OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide administrative oversight to ensure the quality of care and services rendered in the facility. Due to the number of citations and system failures, there was risk of serious harm which could affect the health and safety of residents. Findings include, but are not limited to: During the change of ownership survey, conducted 01/13/26 through 01/16/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the number of citations and system failures. Refer to deficiencies in the report.

1. The Executive Director (ED) and Regional Support Team conducted an immediate review of all operational systems, including staffing oversight, service planning, medication management, and complaint response. Areas of non compliance were identified and corrective actions initiated. 2. All residents’ service plans, medication records, and care needs will be reviewed reviewed by the Regional Health Services Director (HSD) and Regional Nurse Consultant (RNC) to ensure accuracy and compliance. 3. Weekly operations review was implemented, covering staffing, service incident reports, medication systems, and resident concerns.A new daily leadership rounding schedule was implemented to ensure visibility and oversight. 4. The Executive Director

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: A review of Resident Council minutes, dated 10/21/25 through 01/06/26, revealed the following resident concerns were expressed on multiple occasions: * Long wait times for medications; * Slow call light/pendant response time; and * Nurse being gone frequently and/or inaccessible to residents. There was no documented evidence the complaints were responded to or resolved. In an interview on 01/14/26 at 11:45 am, Staff 1 (Executive Director) stated that he had a grievance binder where he would document complaints but did not document any resolution or response. The binder contained two complaints, dated 11/2025. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. The ED reviewed all Resident Council minutes and grievance logs and held meetings with family and residents. Outstanding concerns were addressed and resolutions were documented. Call times are being reviewed in the stand up meeting, and the Regional Nursing team is on-site and available for phone consultation. 2. A formal complaint tracking system was implemented, including documentation of receipt, investigation, resolution, and follow up. Staff are being retrained on the complaint policy, including required timelines and documentation. Regular Town Hall meetings are being scheduled. Resident Council minutes will now be reviewed within 48 hours by the ED, with documented follow up. 3. The ED will audit the grievance log in the stand up meeting and reviewed monthly in the QI meeting to ensure resolution. 4. The Executive Director.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 01/13/26 through 01/16/26, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. In an interview on 0/14/26 at 11:45 am, Staff 1 (Executive Director) confirmed there was not currently an ongoing quality improvement program which ensured adequate resident care, services, and satisfaction. The need to ensure the facility developed and conducted ongoing quality improvement programs was reviewed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings. Refer to the deficiencies in the report.

1. A QI committee was re established, including the ED, HSD,and department heads. The meetings are scheduled the third Thursday of each month. 2. QI meetings will review medication systems, service plans, staffing patterns, incidents and resident satisfaction. A QI binder was created to maintain agendas, minutes, data, and action plans. Department heads were trained on QI expectations and reporting requirements. 3. Monthly 4. Executive Director

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#4) with a PRN psychotropic medication which was administered as a chemical restraint. The use of a chemical restraint, the failure to adequately evaluate and service plan regarding resident behaviors, and the failure to determine and document resident-specific parameters and non-pharmacological interventions to attempt prior to administering the psychotropic medication resulted in an immediate risk of harm to the resident. Findings include, but are not limited to: Resident 4 was admitted to the facility in 02/2024 with diagnoses including dementia and anxiety. During the acuity interview on 01/13/26 at 9:20 am, staff stated that Resident 4 would not be able to find his/her way back to the facility if s/he exited, had a history of elopement resulting in injury, staff had to “try to keep [him/her] away from the front door,” and that the resident was administered a PRN psychotropic medication. In an interview on 01/14/26 at 11:45 am, Staff 2 (Health Services Director, RN) confirmed the resident’s history of elopement and stated the resident required accompaniment if leaving the facility. The resident was observed throughout the survey attempting to exit the building by pushing the handles of the locked front entry doors. Staff were not observed near the resident when s/he attempted to exit. The resident’s most recent evaluation and service plan were completed by Staff 2 and dated 10/23/25. The documents were reviewed, and the following was identified: * The evaluation stated “none” in answer to the question “explain any behaviors associated with cognition or psychosocial needs, such as wandering, irritability, agitation”; * The evaluation stated “none” in answer to the question “what interventions are in place to support the resident’s needs”; * The evaluation stated “no” in answer to the question “does resident have a history of wandering or exit seeking behavior”; * The evaluation stated the resident “make[s] no attempt to exit in an unsafe manner” in answer to the question, “Does the resident currently wander or have exit seeking behavior”; * The service plan stated, “resident is not at risk for exit seeking behavior, resident is not a wander [sic] or exit seeking risk”; * The service plan stated the resident had a history of depression and anxiety and received PRN medication for depression, anxiety, or agitation “when appropriate.” The medication referenced, PRN hydroxyzine, was not an active medication for the resident at the time of his/her service plan update, and there was no description of the circumstances that would deem administering the medication appropriate; * The service plan did not include any indication that anxiety presented as exit-seeking behavior; and * The service plan did not include any non-pharmacological interventions for staff to try prior to administering a PRN psychotropic medication. The resident’s 12/01/25 through 01/13/26 MARs and signed physician’s orders were reviewed, and the following was identified: * The resident had a signed physician’s order for clonazepam 0.5 mg, one tablet to be administered by mouth daily as needed for “anxiety (agitation)”; * There was no description on the MAR of how the resident’s anxiety or agitation presented; * There was no indication of non-pharmacological interventions to try prior to administering the medication; and * The medication had been administered six times during the reviewed period. Staff 11 stated that Staff 1 (Executive Director) and Staff 2 had instructed MTs to administer the PRN psychotropic medication to the resident if s/he was “trying to leave” the facility. Staff 2 stated during an interview on 01/16/26 at 11:10 am that the resident was administered the PRN psychotropic medication on 12/27/25 because s/he was pushing on exit doors. The facility’s 24-hour report monitoring sheets were reviewed and showed the following: * On 10/18/25: “clonazepam at 2:16 pm trying to leave”; * On 12/27/25: “trying to go out exit doors, PRN given has calmed down since”; and * On 12/29/25: “heavy on eloping.” PRN clonazepam was administered on 12/29/25. The monitoring sheets had been initialed as reviewed by Staff 2. The use of a PRN psychotropic medication for purposes which had not been documented as a reason for use, and the lack of evaluation and service planning to determine and communicate non-pharmacological interventions to try prior to administering the psychotropic medication, indicated that the medication was used as a chemical restraint. The situation posed an immediate threat to the health and safety of Resident 4, and an immediate plan of correction was requested from the facility at 1:00 pm on 01/16/26. The facility provided an accepted plan of correction on 01/16/26 at 4:48 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was reviewed with Staff 1, Staff 2, Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. An immediate safety plan was implemented for Resident 4 and remains on 1:1 monitoring. Tim Malone, MSW Gero-psychiatric Specialist has assessed the resident and has made recommendations for medication changes and deemed her appropriate for assisted living. RN has assessed, and her behavior and safety plan has been updated. 1:1 remains in effect. Staff were instructed on appropriate use of PRN psychotropics. An elopment drill was peformed 1/28/26. 2. All residents with cognitive concerns, diagnoses of memory impairment or Alzheimer’s and dementia will be assessed by nursing. Service plans will be updated and revised as needed based on cognitive screening and based on results of elopement evaluations. All residents with PRN psychotropics were reviewed for correct indication of use, non-pharmaceutical interventions. All-staff will receive training on appropriate use of PRN psychotropics. 3. HSD will audit MAR weekly for appropriate documentation for PRN psychotropics. 4. ED and RN

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect for 1 of 4 sampled residents (#2) whose clinical record was reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2025 with diagnoses including left hemiparesis with history of stroke. The resident required assistance from staff with all ADL care, including incontinence care, dressing, repositioning in bed, and transfers. In an interview with Resident 2 on 01/13/25 at 4:15 pm, s/he stated that the past few months had been very difficult for him/her as s/he had abruptly lost independence after having a stroke. The resident’s clinical record was reviewed and showed the following: In the 24-hour logs, care staff documented the following, which did not ensure the resident’s right to be treated with dignity and respect: * On 10/28/25: “Calling a lot for nothing” and “Will change [brief] and will [have a bowel movement] right away in new [brief]”; * On 11/28/25: “Heavy screaming and calling [underlined three times]” and “Peoples [sic] familys [sic] are asking us if [s/he] is OK and concerned with all the screaming”; * 11/29/25: “Heavy on calls, unnessary [sic] changes every ten minutes. Very demanding”; * 12/03/25: “Heavy call screaming top of [his/her] lungs” and “Pushing out [bowel movement] every 10 [minutes]”; and * 12/05/25: “[S/he] is forcing [underlined] [him/herself] to have a [bowel movement] directly after change!!!!” The resident report logs on 10/28/25, 11/28/25, 12/03/25, and 12/05/25 were initialed as having been reviewed by Staff 2 (Health Services Director, RN). On 12/04/25, staff noted on an interim service plan the resident was “throwing stuff in [his/her] room to get are [sic] attention. We told [him/her] we would get [him/her] up when we got done getting all the one-person people up so we didn’t fall behind.” The need to ensure residents’ right to be treated with dignity and respect was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. The staff members involved was counseled and retrained on resident rights, dignity, and respectful communication. Resident 2 received follow up from the ED to ensure concerns were addressed and that the resident felt safe and respected. 2. All staff will receive retraining on the Resident Bill of Rights. Leadership implemented routine walking rounds to observe staff resident interactions. 3.Weekly care observations by RN and ED. 4. RN and ED.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear instruction to staff, including a written description of who should provide the services and what, when, how, and how often the services shall be provided, and/or were implemented, for 3 of 4 sampled residents (#s 1, 2, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living community in 12/2025 with diagnoses including?chronic kidney disease stage 3?and lymph node malignancy. Resident 1’s service plan, dated 12/26/25, was reviewed, observations were made, and interviews with staff, the resident, and witnesses were conducted. The 12/26/26 service plan was not reflective of the resident’s care needs and lacked clear instructions to staff in the following areas: * Assistance with meals, including use of scoop plate and built-up utensils, and placement of cups; * Assistance with toileting; * Assistance with transferring; * Communication; and * Inability to use right hand. During the acuity interview on 01/13/26, Resident 1 was identified as requiring two-person assistance with transfers, and one-on-one assistance with feeding “except for finger food.” Resident 1’s service plan stated, “Resident needs finger foods or foods cut up.” Throughout the survey, the resident received multiple items that were not finger foods, such as soup in a bowl and tossed salads, and items that were not cut up, such as sausage patties and omelets. Throughout the survey, the resident was observed variously receiving meals on a regular plate or in a scoop plate and regular utensils or utensils with built-up handles. Record review and multiple staff interviews identified that Resident 1 sometimes required three people to assist with toileting. During breakfast on 01/15/26, at approximately 8:30 am, Resident 1 was observed attempting to reach one of the two full beverage glasses at the top left of his/her plate. When the surveyor asked if s/he could reach them, s/he nodded and continued to attempt to reach a cup but was unsuccessful. There were no staff in the dining room. An interview with the resident on 01/14/26 identified the resident as having significant language impairment, including frequently answering “yes” and “no” to the same question, attempting to self-correct, and then becoming very frustrated that s/he could not communicate his/her intent. During the interview, Witness 2 (Family Member) reported that Resident 1 had aphasia, a language disorder. On 01/16/26 at 5:00 pm, the need to ensure the service plan was reflective of the resident’s current status, provided clear instruction to staff, and was implemented was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3,?Staff 4 (Regional Operations Specialist, and Staff?6 (Senior Regional Nurse Consultant). They acknowledged the findings.? ? 2. Resident 2 was admitted to the facility in 10/2025 with diagnoses including left hemiparesis with history of stroke. The resident’s clinical record was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident's service plan was not reflective of his/her current needs and/or did not provide clear direction to staff in the following areas: * Preferred name; * Behaviors, including screaming; * Use of call pendant; * Assistance required to attend meals in the dining room; * Specific needs and preferences related to meals, including placement of drinks and use of adaptive drinkware and/or straws; * Level of assistance required for all ADLs; * Routines and habits in the morning; * Specific instructions related to toileting and/or incontinence care, including location where care was completed, undergarment or brief use, number of staff required to assist, and frequency of cueing and/or reminders; * Non-pharmacological interventions for pain; * Use of bilateral side rails on bed; * Number of staff required to assist the resident in an evacuation, depending on whether resident is in bed or in his/her manual wheelchair; * Left arm and leg hemiparesis and instructions for propping left arm and leg; and * Wheelchair modifications, including flat surface for left arm and donut cushion. The resident had a history of stroke with residual weakness to his/her left arm and leg. In interviews on 01/13/26 and 01/16/26 the resident and his/her family members expressed frustration that care staff did not appropriately handle the resident and his/her hemiparetic left side, and the family created a handwritten sign and taped it to the wall to provide instructions to care staff. Instructions, which were not on the resident’s service plan, included: * Ensuring the resident had phone and drink within reach (of right, non-hemiparetic side); * Left leg was straight (to prevent contracture) and left foot was propped while in bed; * Left arm was not “smashed”; * A pad with handles and chuck pads were placed underneath the resident; and * Reminders again that the resident was hemiparetic on his/her left side. Review of the 10/13/25 through 01/13/26 24-hour logs showed staff repeatedly documented the resident demonstrated behaviors, including screaming and extensive use of his/her call pendant. In an interview on 01/16/26 at 10:30 am Staff 11 (MT) stated that the resident had used his/her call pendant four times in the past hour, and there had been times that the resident had used the call pendant twenty times within twenty minutes. The resident required full, two-person assistance from staff for all ADL care, including transferring with a Hoyer lift. The resident received incontinence care in his/her bed. The resident’s manual wheelchair had custom adaptations, including a wide arm rest for his/her left arm and a donut cushion to assist with the resident’s buttock pain. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings. 3. Resident 4 was admitted into the facility in 02/2024 with diagnoses including dementia and anxiety. The resident's clinical record was reviewed, the resident was observed, and interviews with staff and the resident were conducted. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: * History of elopement; * Behaviors, including care refusal, moving items in the facility or within other residents’ rooms, and wandering; * Presentation of anxiety and agitation and pharmacological interventions; * Non-pharmacological interventions for behaviors; * Involvement of spouse in shower program; * Evacuation assistance, including escort or monitoring once out of the community; * Routines and habits in the morning; and * History of alcohol abuse and preference for non-alcoholic beverages. The resident was observed to be independent in ambulation and transfers and was consistently observed wandering throughout the facility independently during the survey, from 01/13/26 through 01/16/26. The resident was observed on multiple occasions attempting to exit the facility by pushing on the front doors, which were locked. During interviews with care staff and MTs between 01/14/26 through 01/16/26, Resident 4 was identified as having behaviors, including refusals of showers and assistance after episodes of incontinence, a history of wandering and elopement, with injury occurring after exiting the building, and stealing items from other residents and the facility. Staff stated that Resident 4 required increased assistance from care staff multiple times per week for redirection and activity engagement due to his/her behaviors. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. For residents 1,2, and 4 the service plans have been updated to accurately reflect current needs, risks, and required interventions. Any missing, outdated, or inaccurate information was corrected immediately. 2. A comprehensive review of all service plans is being conducted to ensure accuracy and appropriate staff instructions. Staff are receiving training on the importance of adhering to service plans at the next all-staff meeting. All staff providing care will review and sign the service plans including agency workers. Service plan due dates are being reviewed in the clinical meeting and completion tracked on the whiteboard. 3. Weekly review of service plan completion, and monthly review in the QI meeting. 4. ED and RN.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts for short-term changes of condition, residents were monitored consistent with their evaluated needs at least weekly until the condition resolved, and/or significant changes of condition were evaluated and referred to the facility RN, for 3 of 4 sampled residents (#s 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the assisted living community in 08/2024 with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. Review of the resident’s clinical record identified the following change of condition: On 12/09/25 Resident 3 returned from 11 days at a rehabilitation center with diagnoses of sacral and lumbar fractures. Review of the clinical record and interviews with staff revealed that before going to the hospital on 11/24/25, the resident was independent with walking, ate meals in the dining room, and did not require narcotics for pain. Upon return from the rehabilitation center on 12/09/25, Resident 3 required wheelchair use and/or assistance with walking, frequently ate meals in his/her room, and received hydrocodone/acetaminophen 10 mg (for severe pain) 14 times between 12/09/25 and 01/07/26 for increase in pain, which constituted a significant change of condition. There was no documented evidence the facility evaluated the resident, referred to the facility RN, documented the changes, and updated the service plan for the significant change of condition. In an interview on 01/14/25 Staff 2 (Health Services Director, RN) reported that a significant change of condition assessment had not been completed because the resident was “pretty much at baseline” when s/he returned to the facility. The need to ensure the facility determined and documented resident-specific interventions as appropriate for changes of condition, communicated interventions to staff on all shifts, and monitored the resident until the condition resolved was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3, Staff 4 (Regional Operations Specialist, and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 10/2025 with diagnoses including left hemiparesis with history of stroke. The resident’s clinical record was reviewed, the resident was observed, and staff and the resident were interviewed. The following was identified: a. The resident moved into the facility on 10/24/25 and his/her initial service plan noted s/he had a wound on his/her right groin. The wound was monitored via home health care coordination in the resident’s progress notes at least weekly through 11/21/25. Between 11/21/25 and 01/13/26 there was no documented evidence of monitoring or resolution of the wound. During an interview on 01/14/26 at 1:25 pm, Staff 2 (Health Services Director, RN) stated she believed the wound had closed but was unable to state when this occurred and acknowledged the lack of documentation of monitoring the wound through resolution. In an interview with Staff 2 on 1/14/25 at 9:25, Staff 2 stated that she believed the wound had resolved but had no documented evidence resolution occurred and had not observed the area recently. Staff 2 and Staff 3 (Regional Nurse Consultant, RN) stated that wound monitoring should occur weekly and notes would be placed in the resident’s progress notes by the facility RN. b. On 10/28/25 the facility documented that the resident started an antibiotic to treat a urinary tract infection. There was no documentation of monitoring at least weekly between 10/31/25 and 11/11/25. c. On 11/09/25, the facility stopped administering metoprolol tartrate (for blood pressure control and stroke prevention). There was no documented evidence that staff were instructed on what to monitor, or the resident was monitored, based on evaluated needs, with at least weekly documentation of progress. d. On 11/11/25, the resident received a new order from a speech language pathologist which changed the resident’s liquid texture from thickened liquids to thin liquids. There was no documented evidence the resident was monitored occurred, with progress noted at least weekly through resolution. e. On 11/12/25 and 11/13/25 staff documented that the resident was “screaming for assistance,” not using his/her pendant, and “yelling for assistance” in a way that disturbed other residents in the facility. The resident was previously evaluated and service planned as using his/her call light appropriately and had no documented history of screaming. This constituted a new behavior, and there was no documented evidence of the resident being evaluated, actions or interventions being determined and communicated to staff on all shifts, or monitoring occurring through resolution. Staff continued to document concerns regarding the resident’s behaviors, with notes stating: * 11/28/25: “Heavy screaming and calling” (underlined 3 times) and “[unsampled resident’s] family[‘s] are asking us if [s/he] is OK and concerned with all the screaming”; * 12/03/25: “Heavy call [sic] screaming top of her lungs”; and * 12/05/25: “Constantly screaming.” The resident’s service plan was updated on 12/02/25 and did not include actions or interventions to address the resident’s behaviors or assist the resident when s/he demonstrated distress, and there was no documented evidence of monitoring the resident at least weekly until the change resolved. f. On 11/18/25, home health visit notes stated the resident’s skin concern in his/her groin was spreading. There was no documented evidence that the resident’s skin concern was evaluated, actions or interventions were determined, documented, and communicated to staff on all shifts, or that it was monitored, with progress documented at least weekly. g. The resident’s move-in evaluation, dated 10/24/25, stated that the resident had a history of urinary tract infections. On 11/16/25 staff documented in the 24-hour log the resident was “very confused!!!” The next day, 11/17/25, staff documented the resident was complaining of pain with urination, had a sore throat, and was not feeling well. On 11/21/25 staff documented the resident stated s/he felt a “burning sensation” when urinating. There was no documented evidence the resident’s symptoms were evaluated, actions or interventions were determined, documented, and communicated to staff on all shifts, or the condition was monitored with progress noted at least weekly through resolution. h. On 12/08/25 the resident returned from an emergency room visit with a diagnosis of allergic reaction and a new medication. An interim service plan form was created stating the above information, but it did not include any interventions or instructions to staff on what to monitor. i. On 12/10/25, Staff 2 documented the resident was transported to the emergency room after noting that the resident had a blistered rash under his/her breast with the rash spreading from his/her legs to his/her abdomen and back. There were no instructions to staff regarding monitoring the skin condition or interventions if the resident was attempting to scratch or complained of being itchy. On 12/15/25, Staff 2 documented the rash “appears to be resolving appropriately.” There were no additional notes monitoring the rash or documenting progress until resolution. j. On 01/05/26 and 01/11/26 staff documented in the 24-hour log the resident’s pendant was malfunctioning and resetting itself and the resident’s call light was not working. There was no documented evidence actions or interventions were determined and communicated to staff on all shifts, such as increased checks for the resident, as s/he was incontinent and dependent on staff for all care needs. There was no evidence the change was monitored or resolved. The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition through resolution, with progress documented at least weekly was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3, Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings. 4. Resident 4 was admitted into the facility in 02/2024 with diagnoses including dementia and anxiety. The resident's clinical record was reviewed, and staff were interviewed. The following was identified: a. On 12/01/25, an interim service plan was created stating the resident had demonstrated aggression with staff and had been trying to leave the facility. Staff were instructed to complete “frequent checks” and “monitor behaviors.” The facility documented behavior tracking on a separate log through 12/05/25. There was no documented evidence of monitoring progress at weekly between 12/05/25 and 12/15/25. During an interview on 01/14/26 at 1:25 pm, Staff 2 and Staff 3 (Regional Nurse Consultant, RN) acknowledged monitoring of the short-term change of condition did not occur at least weekly through resolution. b. On 12/11/25, an STM/ISP was created indicating the resident had experienced a possible injury fall while out of the facility with his/her spouse. Staff were instructed to monitor the resident for bruising or complaint of pain or discomfort. There was no documented evidence the condition was monitored at least weekly between 12/11/25 and when the condition was resolved by Staff 2 on 12/22/25. c. On 12/27/25 and 12/29/25 the 24-hour log notes stated Resident 2 was “trying to go out exit doors” and was “heavy on eloping.” There was no documentation in the resident’s evaluation or service plan that this was the resident’s baseline and, therefore, constituted a short-term change of condition. There was no documented evidence the facility determined actions or interventions, communicated those actions or interventions to staff on all shifts, and monitored the condition, with weekly progress noted until resolution. d. Resident 4’s weight records were reviewed and revealed the following: * 09/01/25: 129 pounds; * 10/01/25: 128.8 pounds; * 11/01/25: 127.6 pounds; * 12/01/25: 112 pounds; and * 01/01/26: 120 pounds. Between 11/01/25 and 12/01/25, the resident experienced a 15.6 pound weight loss, or 12.2% of his/her total body weight, in 30 days. This constituted a significant change of condition. There was no documented evidence the facility evaluated the resident, referred to the facility RN, documented the change, or updated the service plan as needed. During an interview on 01/14/26 at 1:25 pm, Staff 2 verified the significant weight loss was not evaluated or referred to the facility nurse. Staff 2 stated there was no process for staff to notify the RN when a significant weight change occurred. Throughout the survey, from 01/13/26 through 01/16/26, the resident was observed wandering throughout the building most of his/her waking hours. The resident was observed to eat 75-100% of his/her meals. Upon survey request, the resident’s weight was obtained on 01/15/26 at 4:15 pm. The resident’s weight was documented as 129.6 pounds. The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition, with progress documented at least weekly through resolution, and the need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change, and updated the service plan as needed, was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3, Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. The RN completed full change of condition reviews for Residents #2, #3, and #4. Missing assessments, monitoring notes, and service plan updates were completed. Weely monitoring initiated for all significant changes and all short-term changes of condition were evaluated, interventions were determined, and written instructions were communicated to staff on all shifts. 2. Staff have received follow up training on the 24 hour communication process and are aware of conditions that require short term monitoring and what conditions require immediate referral to the RN. The clinical team is reviewing documentation daily in the clinical meeting ensuring follow up on all short-term and significant changes of condition and ensuring appropriate instructions to staff for monitoring. The RN completes weekly audits of all residents with active short term changes. All skin conditions are being tracked on the whiteboard for weekly follow up. 3. Daily review in the clinical meeting, weekly review by the RN and audits monthly in the QI meeting process. 4. RN and ED.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 sampled residents (#3 and 4) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 3 moved into the assisted living community in 08/2024 with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. During the acuity interview on 01/13/25, staff reported Resident 3 had a recent hospital and rehabilitation stay, returning with a diagnosis of vertebral fracture. Review of the clinical record and interviews with staff revealed that before going to the hospital on 11/24/25, the resident was independent with walking, ate meals in the dining room, and did not require narcotics for pain. Upon return from the rehabilitation center on 12/09/25, Resident 3 required wheelchair use and/or assistance with walking, frequently ate meals in his/her room, and required a narcotic for pain. The facility failed to complete an RN assessment for this significant change of condition. In an interview on 01/14/25 Staff 2 (Health Services Director, RN) reported that a significant change of condition assessment had not been completed because the resident was “pretty much at baseline” when s/he returned to the facility. Staff 3 (Regional Nurse Consultant, RN) acknowledged in an interview on 01/15/25 that Resident 3’s decline in mobility constituted a significant change in condition for which an RN assessment was required. The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition was discussed with Staff 1 (Executive Director), Staff 2, Staff 3, Staff 4 (Regional Operations Specialist), and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings. 2. Resident 4 was admitted into the facility in 02/2024 with diagnoses including dementia and anxiety. Resident 4’s weight records were reviewed and revealed the following: * 09/01/25: 129 pounds; * 10/01/25: 128.8 pounds; * 11/01/25: 127.6 pounds; * 12/01/25: 112 pounds; and * 01/01/26: 120 pounds. Between 11/01/25 and 12/01/25, the resident experienced a 15.6 pound weight loss, or 12.2% of his/her total body weight, in 30 days. This constituted a significant change of condition. There was no documented evidence an RN assessed the significant change of condition. In an interview on 01/14/26 at 1:25 pm, Staff 2 acknowledged that she had not reviewed the resident’s weights or completed an assessment of the significant weight gain. Throughout the survey, from 01/13/26 through 01/16/26, the resident was observed wandering throughout the building most of his/her waking hours. The resident was observed to eat 75-100% of his/her meals. Upon survey request, the resident’s weight was obtained on 01/15/26 at 4:15 pm. The resident’s weight was documented as 129.6 pounds. The need to ensure the RN assessed all residents with a significant change of condition was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

POC 1. Significant changes of condition were completed for residents 3 and 4. The RN documented findings, interventions, and updated the service plans. Staff on all shifts were provided written and verbal instructions regarding the updated interventions. The RN reviewed all recent weights and ensured accuracy of documentation going forward. 2. The RN reviews all 24 hour logs daily to identify any potential changes of condition requiring assessment. A new weight tracking process was implemented. A 24 hour reporting system was implemented to ensure staff can reach a nurse at all times. All staff are receiving training on changes of condition that must be reported immediately to the RN. Significant changes of condition are monitored on the whiteboard to ensure weekly progress noted. 3. Clinical meeting several times per week. 4. RN and ED.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#2) whose ADL care was observed and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to: a. On 01/13/25 at 1:15 pm, Staff 15 (CG) and Staff 20 (CG) were observed providing incontinence care for Resident 2. Staff were observed donning gloves and then assisting the resident in rolling to his/her side to remove a soiled brief and provide peri-care, following a bowel movement. Staff proceeded to assist the resident in donning a clean brief and pants without removing their soiled gloves or performing hand hygiene. After providing incontinence care, staff were observed reaching to adjust the resident’s pillow while still wearing soiled gloves. The surveyor stopped the process and requested staff perform hand hygiene and don clean gloves prior to continuing to provide assistance to the resident. b. Observations of meal service were conducted from 01/13/25 through 01/15/25. Caregiving staff were observed at times serving food to residents without wearing a protective covering over potentially contaminated clothing. c. On 01/13/26 at 12:39 pm, an open cart with uncovered salads and desserts was observed sitting in the middle of the hallway. During an interview on 01/14/25, Staff 1 (Executive Director) stated the facility’s infection control specialist was Staff 2 (Health Services Director, RN). He acknowledged that caregiving staff should be wearing aprons when serving food. The need to maintain effective infection prevention and control protocols was reviewed with Staff 1, Staff 2, Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. The RN/Infection Control Specialist (ICS) completed a return demonstration competency with all staff members involved including removing soiled gloves after contaminated tasks, performing hand hygiene, donning clean gloves before touching clean surfaces or resident belongings, keeping food covered at all times, leaving open food unattended in hallways or common areas, and proper transport and storage of meal items. 2. All staff (caregivers, medication aides, dietary staff, and nurses) will receive retraining on infection prevention and control, including hand hygiene, glove use and PPE sequencing, cross contamination prevention and safe food handling and transport. The ICS will maintain documentation of all observations and corrective actions. 3. Several times a week infection control rounds to observe meal service and resident care. 4. RN and ED.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to: During the change of ownership survey, conducted 01/13/26 through 01/16/26, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 302 – Tracking Control Substances; * C 303 – Medication and Treatment Orders; * C 310 – Medication Administration; and * C 330 – Psychotropic Medications. The need to ensure a safe medication and treatment system was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

Refer to * C 302 – Tracking Control Substances; * C 303 – Medication and Treatment Orders; * C 310 – Medication Administration; and * C 330 – Psychotropic Medications.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#3) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: Resident 3 moved into the assisted living community in 08/2024 with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. Resident 3 had the following order for a PRN medication classified as a controlled substance: * Hydrocodone/APAP 10-325 mg tab one tablet every four hours as needed for severe pain, seven to ten pain scale. Resident 3's Controlled Substance Disposition Logs and 12/01/25 through 01/13/26 MAR were reviewed. The following discrepancies were identified: a. On four occasions, 12/18/25 at 3:00 am, 12/22/25 at 11:49 am, 12/24/25 at 8:44 pm, and 12/30/25 at 12:15 pm, staff signed on the drug disposition log that the hydrocodone/APAP was taken out of the locked storage to administer; however, the MAR lacked documentation that the resident received the medication. b. On 12/13/25 the hydrocodone/APAP was entered on the MAR as having been administered, but the Controlled Substance Disposition log had no corresponding documentation that the medication had been taken out of locked storage. c. On 12/30/25 the Controlled Substance Disposition log documented the hydrocodone/APAP was removed at 18:40; the MAR for that date documented no hydrocodone/APAP as being administered. d. The MAR documented hydrocodone being administered on 12/31/25 at 18:39, with no corresponding documentation in the Controlled Substance Disposition log that the medication had been taken out of locked storage. These findings were discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings.

1. A full audit of Resident #3’s controlled substance records was completed immediately, including: Controlled Substance Disposition Logs, MAR documentation, remaining medication counts. All discrepancies were reconciled and corrected. Staff involved in the missing or mismatched documentation were counseled and educated on proper documentation on both the MAR and controlled substance log, accurate removal and administration recording. 2. Return demonstration competencies are being completed for all med-techs. The RN is completing weekly control substance audits looking at: controlled substance counts, any missing signatures, mismatched entries, or incomplete documentation, and proper medication disposal. 3. Weekly control substance audits, and monthly review of documentation in the QI meeting. 4. RN and ED.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and that written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible for administering, for 3 of 4 sampled residents (#s 2, 3, and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the assisted living community in 08/2024 with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. Resident 3’s 12/01/25 through 01/13/26 MAR and corresponding prescriber orders were reviewed. The following was identified: The resident had signed physician orders dated 12/05/25 for multiple medications, including the following medications that were not included in Resident 3’s MAR: * Hydrocodone-Acetaminophen Oral Tablet 5-325 mg one tablet by mouth every four hours as needed for moderate pain, four to six pain scale; and * Melatonin oral tablet 5 mg 1 tablet by mouth at bedtime for inability to initiate sleep. Staff 11 (MT) confirmed in an interview on 01/15/25 at 2:00 pm that the facility did not have these two medications for the resident. On 01/15/25 at 2:00 pm, Staff 3 (Regional Nurse Consultant, RN) reported that “a mistake was made and the orders were not transferred to the MAR.” Staff 3 self-reported this to the local Seniors and People with Disabilities (SPD) office immediately, and documentation of the report was provided to the surveyor at 2:36 pm on 01/15/25. The need to ensure medications and treatments were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3, Staff 4 (Regional Operations Specialist), and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings. ?2. Resident 2 was admitted to the facility in 10/2025 with diagnoses including left hemiparesis with history of stroke. The resident’s signed physician’s orders, dated 10/24/25 through 01/13/26, and MAR/TAR were reviewed, and staff were interviewed. The following was identified: a. The resident had signed orders dated 10/24/25 and moved into the facility on 10/27/25. The orders included: * Metoprolol succinate 24 hour extended release (ER), 25 mg tablet (for blood pressure control and stroke prevention). The order did not contain directions for use, such as frequency or dosage. * Metoprolol tartrate 25 mg tablet (for blood pressure control and stroke prevention), take one and a half tablets by mouth at bedtime. The facility provided documentation of communication from Consonus Pharmacy on 10/27/25 requesting order clarification, asking “Is the patient taking the metoprolol ER? There are no directions. We have keyed the metoprolol tartrate order for now. Please let us know if this should be different.” There was a documented reply from the resident’s physician dated 10/27/25 which stated, “metoprolol succinate one daily.” During an interview on 1/14/25 at 4:25 pm, Staff 2 (Health Services Director/RN) stated she interpreted the physician’s order as stating that the resident should not be taking metoprolol tartrate and should only be taking metoprolol succinate, though acknowledged this was not clearly defined The resident’s MAR showed that the resident was never administered metoprolol succinate per the physician’s order dated 10/27/25. The resident was administered metoprolol tartrate 10/27/25 through 11/03/25. The facility provided additional documentation which showed the same communication from Consonus Pharmacy, again dated 10/27/25, which asked, as above, “Is the patient taking the metoprolol ER? There are no directions. We have keyed the metoprolol tartrate order for now. Please let us know if this should be different.” The physician’s reply and order now indicated “[discontinue] metoprolol ER”, referencing the metoprolol succinate ER tablet, signed 11/03/25. The provider signed a separate order on 11/03/25 again stating “[discontinue] metoprolol succinate.” As of 11/03/25, the most current physician’s order stated the resident should be administered metoprolol tartrate, 25 mg, one and a half tablets at bedtime. The resident was not administered metoprolol tartrate on 11/04/25. The resident was administered the medication on 11/05/25 through 11/08/25. On 11/09/25 the medication was marked as discontinued on the resident’s MAR, and the resident was no longer administered the medication after 11/08/25. During interviews on 01/13/26 through 01/15/26, Staff 2 and Staff 3 stated they were unable to identify why the facility discontinued the medication on 11/09/25. The resident had an office visit with his/her physician on 11/10/25 and returned with signed orders which stated metoprolol tartrate 25 mg tablets, one and a half tablets by mouth at bedtime. The resident did not receive this medication as ordered between 11/08/25 and 01/13/26. On 01/13/26 Staff 3 faxed the physician to notify them that the resident had not been receiving metoprolol tartrate as ordered. The facility self-reported the medication error to the office of Aging and People with Disabilities (APD) on 01/15/26. b. Between 12/01/25 and 01/13/26, the resident was not administered the following medications as ordered: * Atorvastatin 80 mg, one tablet every evening (for cholesterol management): three dates; * Cranberry supplement 500 mg, one capsule by mouth every day (for urinary tract care): 22 dates; * Probiotic, one billion cells per capsule, one capsule by mouth every day (for supplement): 20 dates; * Losartan, 50 mg tablet twice per day (for blood pressure control): two dates; and * Lansoprazole, 30 mg tablet, one tablet every morning before breakfast (for gastroesophageal reflux disease): nine dates. c. The resident had new medication orders dated 12/11/25. The document also stated the resident now had a new order for “[Two Liters] of water daily.” There was no documented evidence the order had been followed. d. In the 24-Hour log on 12/09/25, staff documented the resident was complaining of “itching.” Staff documented that resident had “no order for Bendryl – Prednison [Benadryl or Prednisone] not in M[AR].” The log then stated, in another staff member’s handwriting, “Having allergic reaction flair [sic] up again, gave benadril [sic] and took [resident’s] pulse per daughters [sic] request.” The resident was administered the medication without a signed physician’s order. The need to ensure written, signed physician’s orders were present in the resident’s facility record for all medications and treatments the facility was responsible for administering, and all medication and treatment orders were carried out as prescribed, was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3, Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 02/2024 with diagnoses including dementia and anxiety. Resident 4’s 12/01/25 through 01/13/26 MARs and current physician’s orders were reviewed, and staff were interviewed. The following was identified: a. The facility failed to administer the following medication as ordered during the reviewed period: * Vitamin D3/K2 52.5-50 mcg gummy, take one daily (for supplement). The facility was unable to provide documentation of communication with the physician stating that the medication could be discontinued. During an interview on 01/16/26 at 9:25 am, Staff 2 (Health Services Director/RN) stated she had multiple communications between the pharmacy, the facility, and the physician, but was unable to track how, when, or if the medication should have been discontinued. b. The facility failed to provide documentation of a signed physician’s order for the following medication they were responsible for administering to the resident: * Vitamin K 100 mcg phytonadione, one tablet by mouth every day (for supplement). The resident’s record indicated the resident was administered the medication daily during the reviewed period. The need to ensure all medication orders were carried out as prescribed and written signed physician orders were documented in the resident’s facility record was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. MARs for residents 2,3 and 4 were reviewed by the RN and orders clarified with ordering prescribers. Missing medications were made available for administration. Staff were educated on the requirement to ensure signed orders for all medications administered and the importance of following the rights of medication administration. Emergency med-tech meeting was held 1/19/26. 2. The RN completed med-tech competency validations for all med-techs. A med-tech training binder has been implemented to document scheduled and on the spot trainings. All medication staff were retrained on entering and verifying physician orders, following orders exactly as written, never administering medications without a signed order, documenting standards for missed doses and notifying the RN and contacting pharmacy when clarifications are needed. Third checking of orders and routine MAR audits are scheduled during the clinical meeting to ensure orders are processed and MAR is updated appropriately. Routine pharmacy audits are scheduled. A full MAR to Cart to Chart Audit performed by pharmacy 2/2/26 and any concerns are being followed up with. 3. Clinical meeting review several times per week. Weekly RN reconciliation of orders, and monthly review of audits in the QI meeting. 4. RN and ED

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate and complete MAR was kept and/or resident-specific parameters and instructions were included for PRN medications for 3 of 4 sampled residents (#s 1, 2, and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 02/2024 with diagnoses including dementia and anxiety. The resident’s 12/01/25 through 01/13/26 MAR and physician’s orders were reviewed, and staff were interviewed. The following was identified: a. The resident had four PRN medications for pain. The pain medications lacked clear parameters for order of administration: * Diclofenac gel 1%, three times daily; * Hydrocodone/APAP 5-325 mg, every four to six hours; * Acetaminophen 325 mg, two tablets every four to six hours; and * Ibuprofen 200 mg, one tablet every six hours. During an interview on 01/15/26 at 4:35 pm, Staff 9 (MT) stated that s/he was unable to locate Hydrocodone/APAP or Diclofenac gel on the medication cart. When asked which medication s/he would administer if the resident requested pain medication, Staff 9 stated that since the MAR didn’t specify which one to administer first, s/he would use whichever PRN medication had been administered most recently. Staff 2 (Health Services Director, RN) confirmed on 01/16/26 9:15 am that the medications were not available for administration. b. The resident’s MAR lacked a reason for use for the following medication: * Calcium citrate, 250 mg, one tablet daily. The need to ensure the MAR was accurate and complete, and that PRN medications included resident-specific parameters and instructions for administration, was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2025 with diagnoses including left hemiparesis with history of stroke. The resident’s 12/01/25 through 01/13/26 MAR and physician’s orders were reviewed, and staff were interviewed. The following was identified: a. The resident’s MAR lacked a reason for use for the following medications: * Atorvastatin, 10 mg once per day; * Amlodipine, 80 mg every evening; * Lansoprazole, 30 mg every morning before breakfast; * Eliquis, 5 mg twice per day; * Losartan, 50 mg twice per day; * Potassium Chlor ER, 10 mg once per day; * Quetiapine, 25 mg every evening; * Sodium chloride ocular drops, one drop into both eyes every morning before breakfast; and * Calcium chewtab, 500 mg, two tablets every 12 hours as needed. The need to ensure the MAR was accurate and complete was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings. 3. Resident 1 moved into the assisted living community in 12/2025 with diagnoses including chronic kidney disease stage 3 and lymph node malignancy. The?resident’s?12/01/25?through 01/13/26 MAR and corresponding signed physician orders?were reviewed. a.?The following PRN medications for constipation lacked resident-specific parameters, including sequential order of use: * Bisacodyl 10 mg suppository – unwrap and insert one suppository rectally every day as needed; and *?PEG 2240 powder 238 gm – dissolve 17 gm in liquid and drink by mouth every day as needed. b. The following medications lacked a reason for use on the MAR: * Levetiracetam 500 mg – two tablets by mouth two times daily; * Metolazone 5 mg tab – one tablet by mouth every morning; * Potassium Chloride ER 20MEQ M-tab – one tablet by mouth twice daily; * Tamsulosin 0.4 mg capsule – one capsule by mouth every night at bedtime; * Naltrexone 50 mg tab – 0.5 tablet by mouth every morning; and * Alendronate 70 mg tab – one tablet by mouth every night at bedtime. The need to ensure resident MARs were?accurate,?including resident-specific?parameters, orders of administration for PRN medications, and reason for use for all medications and treatments administered, ?was?discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings.

1. PRN parameters and indications of use for residents 1,2 and 4 were updated by the RN. Missing medications were made available. Staff have received training on locating medications and missed medication process. 2. A third check system is in place with final RN review to ensure PRN parameters and indications of use are present for all orders. Staff have received training on PRN parameter documentation, ensuring indications of use are present for all medications administered and verifying medication availability. 3. Several time per week MAR audits in the clinical meeting, and monthly review in the QI meeting, quarterly pharmacist review. 4. RN and ED.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medications that were administered PRN to treat a resident's behavior had written, resident-specific parameters and failed to document non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 2 and 4) who were prescribed and administered PRN medications to treat behaviors. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 02/2024 with diagnoses including dementia and anxiety. The resident had a physician’s order for clonazepam 0.5 mg to be administered one time per day as needed for anxiety. Resident 4’s 12/01/25 through 01/13/26 MARs were reviewed, and staff were interviewed. The resident was administered clonazepam on six occasions during the reviewed period. There was no documentation of resident-specific parameters, such as how anxiety presented for Resident 2, and no documented evidence staff had first attempted non-drug interventions with ineffective results. On 01/16/26 at 11:10 am, Staff 2 (Health Services Director, RN) and Staff 3 (Regional Nurse Consultant, RN), confirmed that there were no resident-specific parameters or non-drug interventions listed, nor was there documentation of non-drug interventions attempted with ineffective results prior to the administration of the PRN psychotropic. The need to ensure resident-specific parameters were documented and to ensure non-drug interventions were attempted prior to administering PRN psychotropic medications was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3, Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2025 with diagnoses including left hemiparesis with history of stroke. The resident’s signed physician orders and 12/01/25 through 01/13/26 MARs were reviewed. The resident had a signed order for quetiapine, 25 mg, 0.5 tablet (12.5mg) by mouth every eight hours as needed for hallucinations or agitation. The medication was administered five times during the reviewed period. On 12/08/25, 12/10/25, 12/24/25, and 12/26/25, the medication administration notes stated the medication was administered for “anxiety.” Anxiety was not listed as a reason for use in the medication order or parameters. On 01/15/26 at 1:35 pm the MAR was reviewed with Staff 11 (MT). She confirmed that there were no resident-specific parameters which described how the resident’s behavior, including agitation, presented. She confirmed there were no instructions indicating non-pharmacological interventions that should be tried, and no documentation that non-pharmacological interventions had been tried, with ineffective results, prior to administering the medication. She stated that she did not attempt or document non-pharmacological interventions prior to administering the medication. The need to ensure resident-specific parameters were available which described how the resident’s behavior presented and to ensure staff attempted non-pharmacological interventions, and documented ineffective results, prior to administering PRN psychotropic medications was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. Residents 2 and 4 MARs were updated to include resident specific behavioral indicators that justify use, person-centered non-pharmaceutical interventions to attempt first and instructions when to contact the provider. Staff were educated on documentation required for administering PRNs and ensuring the medications are given for the right reasons. 2. The RN has completed a full MAR review to update PRN parameters for all psychotropic medications. The RN has provided staff training that includes resident specific parameters that must be present, non pharmacological interventions must be attempted and documented, staff must document the behavior observed and staff must document the resident’s response to the interventions attempted. Training to be provided to all new med-techs and during routine competency testing. 3. PRN psychotropic use will be reviewed in the clinical meeting, and documentation reviewed. Weekly MAR reviews, monthly review of audits in the QI meeting process, and quarterly pharmacy audits. 4. RN and ED.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure there was documented evidence that less restrictive alternatives were attempted prior to using an assistive device with potentially restraining qualities and failed to include the device in the residents’ service plan for 2 of 2 sampled residents (#s 1 and 2) who had a supportive device. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living community in 12/2025 with diagnoses including?chronic kidney disease stage 3?and lymph node malignancy. Observations of the resident’s room showed a half side rail on the side of the bed that was not against the wall. The rail was placed in the up position when the resident was in bed. The resident’s Supportive Device with Restraining Qualities Assessment, dated 12/18/25, was reviewed. There was no documented evidence of: * Other less restrictive alternatives were attempted prior to use of the side rail; and * Use of the side rail was included in the resident’s service plan. The lack of documentation of less restrictive alternatives attempted prior to use of the device with potential restraining qualities and the lack of inclusion in the resident’s service plan was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2025 with diagnoses including left hemiparesis with history of stroke. Observations of the resident’s room on 01/13/26 showed half side rails present on both sides of his/her bed, which was situated in the middle of the room. The resident’s Supportive Device with Restraining Qualities Assessment, dated 10/23/25, was reviewed. There was no documented evidence of the following: * Other less restrictive alternatives attempted prior to use of the side rail; and * Use of the side rail in the resident’s service plan. During an interview on 01/16/26 at 9:25 am, Staff 2 (Health Services Director) acknowledged that no other alternatives were considered prior to use of the side rails, as the resident moved into the facility with the rails present already on his/her hospital bed, and acknowledged the use of the side rail was not included in the resident’s service plan. The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT and included all required elements, including other less restrictive alternatives evaluated prior to the use of the device and use of the side rail was in the resident’s service plan, was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. Resident 1 and 2 side rail assessments have been updated to include less restrictive alternatives attempted and service plans updated for precautions related to use. 2. A full room audit is being completed to identify all supportive devices with restraining characteristics to ensure each device is appropriately assessed and added to service plans with detailed instructions for staff. Staff education on proper use, monitoring, and precautions. Devices are tracked on the whiteboard for routine assessments. 3. Quarterly 4. RN

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to the following: During the acuity interview on 01/13/26 at 9:20 am and upon review of the Department’s Acuity-Based Staffing Tool (ABST) form, completed by Staff 1 (Executive Director), the following was identified: * The ALF was home to 28 residents; * Five residents required multiple person or mechanical assistance with transfers and/or care, including one resident who, at times, required three-person assist with cares; * Two residents required assistance with eating in the dining room; * One resident required care staff support for behaviors including wandering and elopement. a. Staff 1 confirmed that care staff performed duties in addition to direct care for residents and, therefore, were universal workers. Additional duties included: * Serving three meals per day in the dining room; * Delivering three meals per day to residents who requested room trays; * Washing of facility dishes for three meals per day; and * Laundry for all residents. b. Observations of breakfast, lunch, and dinner service in the dining room between 01/13/26 and 01/16/26 showed that two care staff assisted with dining service. This left only one care staff available to assist with medication administration and all other care needs for residents who were not in the dining room. c. Resident council notes dated 10/13/25 through 01/13/26 were reviewed, and residents stated the following complaints related to receiving care and staffing levels: *01/06/25: Laundry service was not being completed, and call light response was slow especially at night. *11/04/25: Long wait times for medications and response to pendants. *10/21/25: Medications administered late and “no one on [the floor, to provide care assistance to residents]” during meal service. d. In an interview on 01/16/26 at 12:37 pm, Witness 1 (Family Member) stated that his/her family member required assistance from two care staff to get out of bed, and the resident’s service plan stated the resident should eat breakfast, lunch, and dinner in the dining room. Witness 1 stated the resident was frequently not provided his/her service-planned needs in the morning. Witness 1 reported that when s/he asked why the resident’s care wasn’t being provided, staff told him/her they didn’t have time. e. On 12/26/25, staff documented in the 24-hour log that “no shower [given to Resident 2] due to rushing of morning.” f. A 24-hour log entry dated 12/20/25 documented, regarding Resident 1, “[Spouse] c/o no showers being given to [him/her]. Did shower today per the task sheet.” The facility was unable to provide documentation that Resident 1 had received a shower between 12/10/25 and 12/20/25. g. During an interview on 01/14/26 at 2:30 pm, Staff 12 (MT/CG) stated that Resident 1, at times, required three-person assistance to provide toileting care. Staff 11 (MT/CG) stated on 01/16/26 at 10:30 am that Resident 1 required three-person assistance with transfers. In the 24-hour log, staff documented on 12/13/25 Resident 1 required “2-3 person [assistance] to toilet” and on 12/20/25 “difficulty transferring on toilet. Took 3 [person assistance] for BM toileting.” The facility’s ABST stated that to meet the scheduled needs of the residents, the facility would need a minimum of 3.2 care staff on day shift, 2.5 care staff on swing shift, and one care staff on the overnight shift. The facility’s posted staffing plan stated the facility staffed three care staff on day shift, three care staff on swing shift, and two care staff on the overnight shift. The facility failed to provide enough staff to meet the scheduled and unscheduled needs of the residents, including increased levels of staffing when care staff were considered universal workers and failed to ensure at least three staff were available at all times to meet the care needs of residents who required three-person transfer or care assistance. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. Resident 1 and 2 were confirmed to require 2-person assist transfers. Staffing assignments were adjusted to ensure appropriate staffing levels. Missed showers and delayed care concerns were addressed with staff, and corrective coaching was completed. Call light response issues were addressed immediately by reassigning staff to ensure continuous coverage during meal service and medication pass. 2. All residents with two person or three person assist needs are being reassessed. A new staffing plan was implemented to ensure adequate coverage for scheduled and unscheduled needs. Staffing was increased to compensate for universal worker duties (meal service, laundry, dishes). The ABST is now reviewed in the clinical meeting and whenever a resident experiences a change of condition. Staff were retrained on prioritizing call light response. 3. Daily review of staffing assignments, call times and ABST review. Monthly review in the QI meeting. 4. ED and RN.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in for one unsampled resident and no less than quarterly, at the same time of service plan update, for eight unsampled residents. Findings include, but are not limited to: The facility’s ABST was reviewed on 01/13/26 and the following was identified: a. One unsampled resident, who moved into the facility in 11/2025, did not have an ABST evaluation completed. b. Eight unsampled residents’ ABSTs had not been updated at least quarterly. In an interview on 01/14/25 at 11:45 am, Staff 1 (Executive Director) stated that he was responsible for updating the facility’s ABST information and had not completed the above-listed updates. The need to ensure residents’ ABST evaluations were completed and updated before move-in and no less than quarterly with the service plan update was reviewed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. The Executive Director completed the missing move in ABST evaluation for the resident who moved in during 11/2025. The RN reviewed the ABST to ensure accuracy and alignment with the resident’s service plan. The eight resident with overdue ABSTs are being updated with the service plan updates to ensure consistency with current needs. 2. The ED and RN are reviewing all remaining residents’ ABSTs to ensure updates and accuracy. The ABST and service plan are being updated at same time to ensure accuracy. The ED 3. Review of ABST in the clinical meeting to reflect census changes and change of condition. Monthly review in the QI meeting. 4. ED and RN.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 13, 15, 16, and 17) completed all required pre-service orientation training, and 2 of 3 newly hired direct-care staff (#s 13 and 16) completed all required pre-service dementia training. Findings include, but are not limited to: Staff training records for the following four newly-hired staff were reviewed on 01/14/26 with Staff 1 (Executive Director): Staff 13 (MT/CG), hired 10/30/25, Staff 15 (CG), hired 11/20/25, Staff 16 (CG), hired 11/12/25, and Staff 17 (Community Relations Director), hired 12/09/25. The following deficiencies were identified: 1. There was no documented evidence Staff 13, Staff 15, Staff 16, or Staff 17 completed the following required pre-service orientation topics: * Approved HCBS course; and * Approved LGBTQIA2S+ course. 2. There was no documented evidence Staff 13, Staff 16, and Staff 17 completed the required approved infectious disease prevention training. 3. There was no documented evidence Staff 17 completed fire safety and emergency procedures training. 4. Staff 13 and 16 lacked documented evidence of the required pre-service dementia training. The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist, and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings.

1. Staff 13, 15, 16 and 17 are completing the required trainings. 2. The Trustwell training checklist was reimplemented which includes all training requirements. A full training audit is being conducted to identify and assign training to all employees. 3. Weekly training audits and monthly review in the QI meeting. 4. ED

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 7 MTs (#s 18 and 19) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire, including medication administration, and failed to ensure 2 of 3 care staff (#s 13 and 16) demonstrated competency in assigned job duties within 30 days of hire. Findings include, but are not limited to: Employee training records were reviewed on 01/14/26 at 4:00 pm with Staff 1 (Executive Director), and the following was identified: a. Staff?18 (MT), hired 10/02/25, and Staff 19 (MT), hired 12/20/24, had been working in the facility independently in their roles, and job duties included administering medications to residents. The facility was unable to provide documentation that their knowledge and performance in administering medications had been reviewed and each had been determined competent to safely administer medications unsupervised. b. There was no documented evidence Staff 13 (MT/CG), hired on 10/30/25, and Staff 16 (CG), hired on 11/12/25, demonstrated competency in the following areas: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and Abdominal Thrust. c. There was no documented evidence Staff 13 demonstrated competency in the following area: * Providing assistance with ADLs. The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist, and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 13, 15, 16, and 17) completed all required pre-service orientation training, and 2 of 3 newly hired direct-care staff (#s 13 and 16) completed all required pre-service dementia training. Findings include, but are not limited to: Staff training records for the following four newly-hired staff were reviewed on 01/14/26 with Staff 1 (Executive Director): Staff 13 (MT/CG), hired 10/30/25, Staff 15 (CG), hired 11/20/25, Staff 16 (CG), hired 11/12/25, and Staff 17 (Community Relations Director), hired 12/09/25. The following deficiencies were identified: 1. There was no documented evidence Staff 13, Staff 15, Staff 16, or Staff 17 completed the following required pre-service orientation topics: * Approved HCBS course; and * Approved LGBTQIA2S+ course. 2. There was no documented evidence Staff 13, Staff 16, and Staff 17 completed the required approved infectious disease prevention training. 3. There was no documented evidence Staff 17 completed fire safety and emergency procedures training. 4. Staff 13 and 16 lacked documented evidence of the required pre-service dementia training. The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist, and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings.

1. Staff 16, 18, 19 and 13 have completed their assigned required trainings. 2. The Trustwell training checklist was reimplemented and includes all training requirements. A full training audit is being conducted to identify and assign training to all employees. 3. Weekly training audits and monthly review in the QI meeting. 4. ED

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure that employees completed Department-approved biennial LGBTQIA2S+ training for 3 of 3 long-term staff (#s 9, 10, and 11) whose training records were reviewed. Findings include, but are not limited to: Training records were reviewed on 01/14/26 with Staff 1 (Executive Director), and the following was identified: There was no documented evidence Staff 9 (MT), Staff 10 (MT), and Staff 11 (CG), hired 03/25/24, 08/29/19, and 11/21/22, respectively, completed Department-approved biennial LGBTQIA2S+ training. The need to ensure staff completed and documented the required annual in-service training was discussed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist, and Staff 6 (Senior Regional Nurse Consultant) on 01/16/26 at 5:00 pm. They acknowledged the findings.

1. Staff 9,10 and 11 have been assigned the required training. 2. A full audit of all employee files was completed to ensure no other staff were overdue for required annual or biennial trainings. The Trustwell training checklist was reimplemented and includes all training requirements. A full training audit is being conducted to identify and assign training to all employees. 3. Weekly training audits and monthly review in the QI meeting. 4. ED

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Six months of fire drill and fire and life safety training records were requested on 01/13/26. The following was identified: a. There was no documented evidence the facility had conducted a fire drill every other month between 07/2025 and 01/2026. The facility was unable to provide documentation of any fire drill completed since 03/2025. b. There was no documented evidence the facility was providing fire and life safety training to staff on alternating months from fire drills. During an interview on 01/15/26 at 8:40 am, Staff 1 (Executive Director) confirmed there was no documentation of the facility completing a fire drill in the previous six months and no documentation of the facility providing fire and life safety training to staff on alternate months. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code and fire and life safety instruction was provided to staff on alternate months Was reviewed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. A fire drill was conducted immediately upon identification of the deficiency, following Oregon Fire Code requirements. The drill included: activation of the fire alarm system, use of an alternate exit route, full evacuation to the designated point of safety, documentation of time, route, staff participation, and any issues encountered. All staff on duty participated and were coached in real time. Fire and life safety training was provided to all staff immediately, covering evacuation procedures, resident assistance expectations, alarm activation, points of safety, staff roles during emergencies. 2. A fire drill and training calendar has been implemented and Trustwell training protocols have been reimplemented. 3. Monthly review 4. ED and maintenance.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were requested on 01/13/26. During an interview on 01/15/26 at 8:40 am, Staff 1 (Executive Director) stated there was no documented evidence that residents had been instructed at move-in or annually. The need to instruct and re-instruct residents on fire and life safety training per the OFC requirements was reviewed with Staff 1, Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), Staff 4 (Regional Operations Specialist), Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

POC 1. All current residents were immediately instructed on the facility’s fire and life safety procedures, including general safety procedures, evacuation methods, resident responsibilities during fire drills, designated meeting places inside the fire safe area and outside the building. A written record of the training, including content covered and resident attendance, was completed and placed in the Fire & Life Safety Binder. All residents admitted within the past 12 months were reviewed. Any resident lacking documented move in fire/life safety instruction received the required training immediately. 2. Fire and life safety instruction has been added to the move in checklist, requiring completion within 24 hours of admission. The Trustwell standardized Resident Fire & Life Safety Training Form was implemented to ensure consistent documentation of training content and attendance. A resident training calendar was created to ensure all cognitively able residents receive annual reinstruction. Staff responsible for admissions and resident orientation were trained on OFC requirements and the new documentation process. All training records will be maintained in the Fire & Life Safety Binder and cross checked with resident files for accuracy. 3. Daily with new admissions (current restriction of admission is in place), and monthly during Quality Improvement meetings. 4. ED and Maintenance Director

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure that when an electronic code must be entered to use an exit door, that code is clearly posted for residents, visitors, and staff to use. Findings include, but are not limited to: Upon entering the facility on 01/13/25, it was observed that the facility had an electronic lock which required a code to be entered by staff, visitors, and residents to enter or exit through the front door of the facility. The code to enter the facility was a clearly posted four-digit code. The code to exit the facility was not clearly posted or immediately recognizable. A framed document was hung on the wall at a 90 degree angle to the electronic keypad, with the document stating in italicized lettering “Cookbook,” with pictures of various kitchen items including a cheese grater, measuring cup, whisk, and pans. Below the pictures of the kitchen items on the document were the words, “My favorite recipe calls for Five cloves of garlic, Four ripe tomatoes, Three sprigs of rosemary, Two bay leaves, and just One pinch of salt.” The facility staff stated this was the code, or “recipe,” that needed to be entered into the electronic keypad in order to exit the facility. In an interview on 01/14/26 at 11:45 am with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), and Staff 4 (Regional Operations Specialist), Staff 3 stated that the exit door code had previously been posted similarly to the entry door code, but had been changed within the past year due to concerns with a resident who was deemed to be an elopement risk. During the interview, Staff 3 stated that requiring the code to be deciphered within the recipe format ensured that residents who required accompaniment when leaving the facility due to cognitive decline had to ask staff for assistance and would, therefore, be accompanied or monitored when leaving the facility. Staff 3 acknowledged that at least one current resident was unable to decipher the code to exit the facility. The need to ensure that when an electronic code must be entered to use an exit door, that code is clearly posted for residents, visitors, and staff to use was reviewed with Staff 1, Staff 2, Staff 3, Staff 4, Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

1. The exit door code was immediately posted in a clear, readable, and plainly visible format directly adjacent to the electronic keypad on 01/16/26. The “recipe” document previously used to obscure the code was removed. All residents, visitors, and staff now have unobstructed access to the posted exit code as required by rule. Staff were educated that exit doors may not include locks or coded systems that delay or prevent evacuation, and that codes must be clearly posted for all users. Residents who may have been unable to decipher the previous “recipe” format were informed of the corrected posting and shown the clearly displayed code. 2. A standardized Exit Door Code Posting Template was created to ensure all exit codes are posted in a clear, direct, and readable manner. The facility implemented a Door Safety & Code Posting Checklist, requiring monthly verification that exit codes are clearly posted. Any future changes to exit door codes must be approved by the Executive Director and require immediate replacement of the posted signage using the standardized template. 3. Daily visual checks by the Executive Director or designee and monthly during the monthly Quality Improvement meeting. 4. ED

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(1)(a)(B) Integrated Settings: Community Life (1) Residential and non-residential HCB settings must have all of the following qualities: (a) The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: (B) Engage in greater community life; This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the assisted living setting supported the same degree of access to the greater community as those not receiving home and community based services (HCBS), including opportunities to engage in greater community life, for 1 of 1 resident (#4) who was unable to exit the facility independently. Findings include, but are not limited to: Resident 4 was admitted to the facility in 02/2024 with diagnoses including dementia and anxiety. The facility was licensed as an assisted living facility and was not licensed as a secured memory care facility. Upon entering the facility on 01/13/25, it was observed that the facility had an electronic lock which required a code to be entered by staff, visitors and residents to enter or exit through the front door of the facility. The code to enter the facility was a clearly posted four-digit code. The code to exit the facility was not clearly posted or immediately recognizable. A framed document was hung on the wall at a 90-degree angle to the electronic keypad, with the document stating in italicized lettering “Cookbook,” with pictures of various kitchen items, including a cheese grater, measuring cup, whisk, and pans. Below the pictures of the kitchen items on the document were the words, “My favorite recipe calls for Five cloves of garlic, Four ripe tomatoes, Three sprigs of rosemary, Two bay leaves, and just One pinch of salt.” The facility staff stated this was the code, or “recipe,” that needed to be entered into the electronic keypad in order to exit the facility. In an interview on 01/14/26 at 11:45 am with Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Regional Nurse Consultant, RN), and Staff 4 (Regional Operations Specialist), Staff 2 and Staff 4 stated that the code to exit the facility was changed in 2025 after Resident 4 exited the facility and was unable to find his/her way back. Staff 2 stated Resident 4 was an elopement risk and needed to be accompanied when leaving the building. She stated that for a time Resident 4 memorized the code to exit the building and did elope, so the facility changed the code to the “recipe” so Resident 4 wouldn’t elope. Staff 2 and 3 acknowledged that Resident 4 could not interpret the code as posted and was not currently able to exit the facility without assistance from staff or family. The staff acknowledged that the facility was not a secured memory care unit, and that residents had the right to enter and exit the facility freely. In interviews with care staff and MTs on 01/14/25 and 01/15/26, staff stated that Resident 4 was not able to leave the facility without staff or family member accompaniment. Staff 14 stated that within the past week the resident had attempted to exit the building, and Staff 14 placed his/her body between the resident and the door to stop the resident from continuing to attempt to exit the facility. The need ensure the assisted living setting supported the same degree of access to the greater community as those not receiving home and community based services (HCBS), including opportunities to engage in greater community life, was reviewed with Staff 1, Staff 2, Staff 3, Staff 4, Staff 5 (Regional Director of Operations), Staff 6 (Senior Regional Nurse Consultant), and Staff 7 (Vice President of Clinical Operations) on 01/16/26 at 5:30 pm. They acknowledged the findings.

POC 1. The exit door code was immediately posted in a clear, readable, and plainly visible format next to the keypad on 01/16/26, removing the “recipe” document that prevented Resident #4 from independently exiting. Resident #4’s service plan was reviewed and updated to reflect their right to access the community, their need for staff support when leaving the building due to cognitive impairment and the specific supports staff must provide to ensure safety without restricting access. 2. The facility implemented a Door Access Compliance Checklist, requiring verification that exit codes are clearly posted, no disguised, coded, or symbolic signage is used and no environmental barriers impede resident access. Any future changes to exit door codes must be immediately updated using the standardized posting template and verified by the Executive Director. 3. Daily spot checks and reviewed monthly in the QI meeting process. 4. ED.

OAR411-004-0020(1)(a)(B) Integrated Settings: Community Life (1) Residential and non-residential HCB settings must have all of the following qualities: (a) The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: (B) Engage in greater community life; This Rule is not met as evidenced by:

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to: Refer to C 340.

Refer to C-340

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by:

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 4 of 4 newly hired staff (#s 13, 15, 16, and 17) whose training records were reviewed. Findings include, but are not limited to: Refer to: C370.

Refer to C-370

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by:

OAR 411-054-0070 (6)(b)(A-C)&10(a-f) Annual and Biennial Inservice for All Staff (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. (b) Exempt from this training requirement are contractors who contract directly with the resident or the resident’s representative, and contractors who do not generally provide services or supports directly to residents, including, but not limited to, contractors for landscaping, pest control, deliveries and building repairs. (c) By December 31, 2024, facilities shall ensure that all contracts entered into with entities described in paragraph (a) of this section shall include language requiring contractors provide Department approved LGBTQIA2S+ training to their employees within 12 months of entering into the contract with the facility and every two years thereafter. (d) For existing contracts in effect January 1, 2025, facilities shall require the contractor provide Department-approved LGBTQIA2s+ training to employees by December 31, 2025, and every two years thereafter. (e) For new contracts created after January 1, 2025, facilities shall require contractors provide the Department-approved LGBTQIA2S+ training to employees within 12 months of entering into the contract with the facility, and every two years thereafter. (f) Facilities must inform contractors that the cost of all LGBTQIA2S+ trainings for contracted employees shall be paid by the contractor. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure that employees completed Department-approved biennial LGBTQIA2S+ training for 3 of 3 long-term staff (#s 9, 10, and 11) whose training records were reviewed. Findings include, but are not limited to: Refer to: C374.

Refer to C-374

OAR 411-054-0070 (6)(b)(A-C)&10(a-f) Annual and Biennial Inservice for All Staff (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. (b) Exempt from this training requirement are contractors who contract directly with the resident or the resident’s representative, and contractors who do not generally provide services or supports directly to residents, including, but not limited to, contractors for landscaping, pest control, deliveries and building repairs. (c) By December 31, 2024, facilities shall ensure that all contracts entered into with entities described in paragraph (a) of this section shall include language requiring contractors provide Department approved LGBTQIA2S+ training to their employees within 12 months of entering into the contract with the facility and every two years thereafter. (d) For existing contracts in effect January 1, 2025, facilities shall require the contractor provide Department-approved LGBTQIA2s+ training to employees by December 31, 2025, and every two years thereafter. (e) For new contracts created after January 1, 2025, facilities shall require contractors provide the Department-approved LGBTQIA2S+ training to employees within 12 months of entering into the contract with the facility, and every two years thereafter. (f) Facilities must inform contractors that the cost of all LGBTQIA2S+ trainings for contracted employees shall be paid by the contractor. This Rule is not met as evidenced by: