OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the resident’s move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 11/2025 with diagnoses including mild cognitive impairment of uncertain or unknown etiology, Type 1 diabetes with hyperglycemia, and unspecified dementia mild with psychotic disturbance. The initial evaluation, dated 11/25/25 failed to address the following elements: * Gender identity; * Hobbies, social interests, and leisure activities; * Traditions; * Mental health issues, including history of treatment and effective non-drug interventions; and * Review of risk indicators, including complex medication regimen, history of dehydration, recent losses, and unsuccessful prior placements. The need to ensure the move-in evaluation addressed all required elements was reviewed with Staff 1 (Administrator) and Staff 2 (Wellness Director, LPN) on 01/14/26 at 1:30 pm. They acknowledged the information.

Evergreen Memory Care will ensure move-in, 30-day, quarterly and as needed evaluations address all required elements. Moving forward, all admissions will have a completed Resident Evaluation to address all required elements. Resident #4's evaluation will be updated to address all required elements. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and RSD will be responsible.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 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 the resident’s current status and care needs, provided clear direction to staff regarding the delivery of services, and were implemented for 1 of 4 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. The resident's clinical record from 10/05/25 through 01/12/26 was reviewed, and interviews were completed with staff. Observations made throughout the survey identified the following: a. The service plan, dated 11/06/25, was not reflective of the resident’s current status and/or care needs and lacked clear direction to staff in the following areas: * Fall interventions; * Assistance with transfers; and * Assistance with mobility. b. The service plan was not implemented in the following areas: * Assisting with hearing aids; and * Fall interventions, including using a wheelchair, bed alarm, chair alarm, and cleaning out cups from his/her room. The need to ensure service plans were reflective of the resident's care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure all residents' service plans are reflective of residents' current care need and preferences and provides clear direction regarding the delivery of services. All resident service plans will be updated and updated as needed to include resident changes. These updates will be written to provide clear direction to team members regarding the delivery of services. Service plan for Resident #2 will be updated to reflect residents' current care needs and preferences and will provide clear direction regarding the delivery of services. A "Service Plan Update" form will be used to update a service plan as needed. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. All Staff Meeting will be held February 10, 2026 with topic to include service plans. ED, HSD and RN will be responsible.

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 determine actions or interventions needed following changes of condition, communicate the actions or interventions to staff on each shift, ensure staff instructions or interventions were resident-specific and made part of the resident record, with weekly progress noted until the condition resolved, and ensure the interventions were monitored for effectiveness for 1 of 3 sampled residents (# 2). Resident 2 experienced falls with injuries. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. During the entrance conference interview on 01/12/26, staff identified the resident had a history of falls. The service plan, dated 11/06/25, and subsequent interim service plans (ISP’s) and progress notes, dated 10/02/25 through 01/10/26, were reviewed. Interviews with staff and observations were conducted during the survey. On 01/12/26 at 12:30 pm, Resident 2 presented with full bilateral facial bruising and a laceration on his/her skull, approximately two-three inches in length, with metal sutures closing the laceration. Resident 2 was observed using a walker during the survey. Resident 2’s service plan and ISP’s from 10/28/25 through 01/10/26, instructed staff of the following fall interventions: * Offer help when s/he was moving furniture; * Non-skid strips next to bed; * Ensure s/he was wearing non-skid socks or shoes at all times; * Staff to clean out any cups from his/her room promptly (ISP 11/25/25); * Keep alarm pad in resident’s bed (“Permanent Change in Service Plan” 12/31/25); and * Take resident to the bathroom upon waking up, after meals, between lunch and dinner and before bed (“Permanent Change in Service Plan” 01/08/26). a. The resident had the following falls that lacked monitoring of fall interventions for effectiveness and/or communicating the change of condition and interventions to staff on each shift: * 09/30/25 – Unwitnessed fall with injury to the left “small toe.” There was an incident report form completed with a fall intervention to encourage resident to not wear silk night gowns. During an interview on 01/13/26 at 2:51 pm with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), and Staff 4 (RCC) it was confirmed direct care staff didn’t have access to the incident reports to be informed of the new fall intervention. Staff confirmed their system to notify staff of changes in condition, including fall interventions, was to communicate the changes using an ISP or Permanent Change in Service Plan form. * 10/28/25 - Unwitnessed non-injury fall; and * 10/28/25 - Second unwitnessed fall with abrasion to the right elbow. There was no documented evidence the previous fall interventions were monitored for effectiveness or new interventions were put in place following the two falls on 10/28/25. * 11/25/25 - Unwitnessed fall. Resident stated s/he hit his/her head. There was an ISP instructing staff to clean out any cups from his/her room promptly. Observations on 01/12/26 at 12:30 pm and on 01/14/26 at 9:00 am showed the fall intervention to remove cups with liquids in them on the resident’s table near the bed was not followed. * 12/02/25 - Unwitnessed fall with abrasion to left upper arm. An intervention to place bright tape on the door threshold between the resident's apartment and bathroom was noted on an incident report. There was no documented evidence the intervention, including instructions on who to notify if the tape became dislodged from the threshold, was communicated to staff. * 12/20/25 - Unwitnessed non-injury fall. The incident report noted an intervention: “will collect a UA [Urinalysis].” There was no documented evidence the intervention was communicated to staff, and there was no documented evidence the UA was collected. * 12/25/25 - Unwitnessed fall with abrasion to right forearm. On 12/31/25 (six days later) there was a “Permanent Change in Service Plan” which instructed staff to keep alarm pad in resident’s bed. During an interview on 01/12/26 at 2:30 pm, Staff 7 (Health Services Staff/CG) reported, “I think [s/he] has a bed alarm, but I think it’s only for night-time.” Observations on 01/12/26 through 01/14/26 showed there was not an alarm on the resident’s bed. There was no documented evidence the facility monitored the fall interventions for effectiveness. Resident 2 continued to have the following injury falls, which resulted in emergent medical care from paramedics and/or emergency room visit. * On 01/02/26 Resident 2 experienced another unwitnessed fall with pain to the left hip. * 01/06/26 - Unwitnessed fall with head injury resulting in an emergency room visit and multiple sutures in the resident’s head. An incident report dated 01/06/26 through 01/08/26 had the following description of the incident: “There was water on the floor from a cup that was spilt over ... there was a wheelchair pushed against dresser and [his/her] head was under the wheelchair ... there was blood on the floor and coming from the back of residents [SIC] head.” Staff called 911, and the resident was transported to the hospital. The incident report further noted a “pressure alarm will be used in [his/her] chair in [his/her] room as well as [his/her] bed.” The intervention to use a pressure alarm on his/her chair was not communicated to staff and, based on observations from 01/12/26 through 01/14/26, wasn’t being implemented. There was no documented evidence the facility determined actions or interventions needed to prevent further falls, communicated the use of a wheelchair or chair alarm to staff, or monitored any of the fall interventions to ensure they were being implemented and were effective. This resulted in pain, physical injury, a major deviation in the resident’s health and functional ability, and the resident continued to have two more falls with injuries on the following dates: * 01/10/26 - Unwitnessed fall with bruise to the forehead, bleeding on the front top part of head and was complaining of pain in his/her left hip. The resident was administered a pain medication. * 01/10/26 - Unwitnessed fall with injury to forehead and skin tear to the left elbow. An incident report was completed on 01/12/26 that read: “will ask hospice for a wheelchair.” The incident report from 01/06/26 noted the resident already had a wheelchair in their room, and the use of a pressure alarm on chairs was an intervention that should have already been in use. There was an ISP written on 01/10/26 instructing staff to monitor for pain and latent injuries. However, there was no documented evidence the facility communicated the use of a wheelchair or chair alarm to staff or monitored any of the previous fall interventions to ensure they were being implemented and were effective following the two falls on 01/10/26. There was no documented evidence the facility determined actions or interventions needed to prevent falls, communicated the actions or fall interventions to staff, or monitored any of the fall interventions to ensure they were being implemented and were effective. This resulted in pain, physical injury, and a major deviation in the resident’s health and functional ability. The need to ensure the facility communicated changes of condition to staff on each shift, ensure staff instructions or interventions were resident-specific and made part of the resident record, and ensure the interventions were monitored for effectiveness and were being implemented was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RCC) on 01/13/26 at 2:51 pm and with Staff 3 (RN) on 01/14/26 at 3:14 pm. They acknowledged the findings. b. The following short-term changes of condition were not monitored through resolution: * 01/05/26 - Cephalexin 250 mg capsule (antibiotic for urinary tract infection), give one capsule by mouth three times per day for five days (total of 15 capsules). The resident was administered 10 doses of the antibiotic. An observation of the medication cart on 01/14/26 at 11:40 am showed there were three capsules remaining in the bottle. A progress note dated 01/06/26 indicated the condition was resolved by Staff 2 (Wellness Director/LPN) prior to the resident completing the medication. The facility failed to monitor the resident to determine the efficacy of the medication in treating the resident’s condition. The need to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts and that changes were monitored, with progress noted at least weekly until the condition resolved, was discussed with Staff 1 (Administrator), Staff 2 (LPN), and Staff 4 (RCC) on 01/13/26 at 2:51 pm and with Staff 3 (RN) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure that residents' short term and long term change of conditions are monitored appropriately. Community will determine actions/interventions needed, communicate actions or interventions to team members on all shifts, and monitor changes through resolution with weekly documentation. Resident #2's significant change of condition assessment by RN was completed on January 12, 2026. RN assessments will be completed when applicable. Routine clinical meetings will be held at minimum 5 days/week with ED, HSD and RN. These meetings are a double check to review and identify resident short term and long term change of conditions. Weekly high risk resident meetings will take place to assure compliance. All staff in-service will be held on February 10, 2026. Training topics to include residents' short term and long term change of conditions. ED and HSD will be responsible

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 411-054-0055 (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 observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed and that the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications that the facility was responsible to administer for 1 of 1 sampled resident (#2) who was administered medications. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. The resident’s physician orders, dated 01/11/26, and the 01/01/26 through 01/14/26 MAR were reviewed and identified the following: * Hydrocodone/APAP 5mg/325mg (a controlled substance to manage pain) was administered 13 times without a written order from the prescriber. * Furosemide 20 mg tablet, give two tablets (40 mg total) every day was not administered on 01/11/26 and 01/12/26 because the medication was not available. During an interview and observation on 01/14/26 at 11:40 am with Staff 12 (Health Services Staff/MT), it was confirmed the medication was not available on those dates. The date received on the new medication card confirmed the medication was received on 01/12/26 and the resident began receiving the Furosemide again on 01/13/26. * Cephalexin 250 mg capsule (antibiotic for urinary tract infection) give one capsule by mouth three times per day for five days (total of 15 capsules or doses). The resident was administered 10 doses of the antibiotic. An observation of the medication cart on 01/14/26 at 11:40 am showed there were three capsules remaining in the bottle. The need to ensure medication orders were carried out as prescribed and that the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications that the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure Treatment Administration Records (TARs) will be accurate. Daily audits will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on Febuary 10, 2026. Training topics to include accuracy of TARs. ED, HSD, charge nurse and/or Designee will be responsible.

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 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (# 1) who had documented medication refusals. Findings include, but are not limited to: Resident 1's clinical record and MARs were reviewed during the survey and revealed the resident had multiple medication refusals between 01/01/26 and 01/12/26. The medications refused included: * Lidocaine 4% Patch (for pain); * Oxybutynin 5mg (for overactive bladder); * Senna 8.6 mg (for constipation); * Acetaminophen 500 mg (for pain management); and * Triamcinolone 0.1% ointment (for rash). There was no documented evidence the facility notified the physician when the resident refused consent to their orders. On 01/14/26 at 4:30 pm the failure to notify physicians of the documented medication and treatments refusals was reviewed with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), Staff 3 (RN), and Staff 4 (RCC). They acknowledged the findings. No further documentation was provided.

Evergreen Memory Care will ensure resident medication and/or treatment refusals are communicated to Physician or Practitioner as requested by prescriber. Daily audits will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on Febuary 10, 2026. Training topics to include medication and treatment refusals. ED, HSD, charge nurse and/or Designee will be responsible

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. 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 MAR was kept for 1 of 4 sampled residents (#2) whose MAR was reviewed. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. Review of the resident's MAR, dated 01/01/26 through 01/12/26, identified the following inaccuracies: * The MAR lacked parameters and PRN instructions for Tylenol, hydrocodone, and morphine (all for pain), and for Miralax and senna (both for constipation); * Orders for two discontinued medications (Hydrocodone every 6 hours, discontinued on 01/10/26, and Hydrocodone twice per day, discontinued on 01/10/26) were still on the MAR; * An order dated 01/11/26 for Hydrocodone, give every six hours as needed, was not on the MAR; and * The nursing PRN pain scale parameter for Tylenol to give when pain was 1-4 was given and noted as ineffective when the pain level was documented as 5 and 10. The need to ensure an accurate MAR was kept was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure Medication Administration Records (MARs) will be accurate. Daily audits will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on Febuary 10, 2026. Training topics to include accuracy of MARs. ED, HSD, charge nurse and/or Designee will be responsible.

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 a PRN psychotropic medication was only used for the specific reason for which it was prescribed, after documented non-pharmacological interventions had been tried with ineffective results, and failed to ensure the MAR included instructions for when to contact a health professional for 1 of 1 sampled resident (#2) who was administered a PRN psychotropic medication. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. Review of the resident's progress notes, 01/01/26 through 01/12/26 MAR, and current signed orders identified the following: The resident was prescribed PRN Haloperidol (for agitation) and was administered the PRN on 01/09/26. The medication was noted to be ineffective. There was no documented evidence in the resident’s clinical record that identified the resident was experiencing the specific reason for use (agitation), there were no documented interventions attempted with ineffective results before the PRN was administered, and there were no instructions for when to contact a health professional, including when the PRN was ineffective. The need to ensure a PRN psychotropic medication was only used for the specific reason for which it was prescribed, after documented non-pharmacological interventions had been tried with ineffective results, and to ensure the MAR included instructions for when to contact a health professional was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will ensure non-pharmacological interventions are documented prior to administration of Psychotropic medications. Daily audits of administered PRNs will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on Febuary 10, 2026. Training topics to include non-pharmacological interventions prior to administration of PRN Psychotropic medications. ED, HSD, charge nurse and/or Designee will be responsible.

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 411-054-0070 (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: During the entrance conference on 01/12/26 with Staff 2 (Wellness Director/LPN) and Staff 4 (RCC), the following was identified: * The facility was a one story MCC with four neighborhoods that were connected to each other through corridors and a central resident common area. The neighborhoods were defined as Cascades: rooms 101-114; Rockies: rooms 115-128; Andes: rooms 129-142; and Sierras: rooms 143-156. * The facility had a current census of 48 residents. * Five residents required a two-person assist to transfer and/or for ADL care. Two of the five residents resided in Cascades neighborhood, two resided in Sierras neighborhood, and one resided in Rockies neighborhood. Based on the ABST facility questionnaire, the following was reported by Staff 1 (Administrator) and Staff 2 on 01/14/26 at 2:38 pm: * Seven residents required meal assistance; * 14 residents required support for behavioral symptoms; and * All 48 residents required supports for cognitive impairments. The facility's posted staffing plan, staffing schedule from 01/01/26 to 01/12/26, and total direct care time based on resident acuity and the facility acuity-based staffing tool (ABST) were reviewed. The posted staffing plan: * Day Shift: 6:00 am - 2:00 pm - 4 CGs and 2 MTs; * Swing Shift: 2:00 pm - 10:00 pm - 4 CGs and 2 MTs; and * Night Shift: 10:00 pm - 6:00 am - 2 CGs and 1 MT. The ABST indicated the day shift should have a minimum of 6.5 direct care staff. The staffing schedule showed 33% of the scheduled shifts from 01/01/26 to 01/12/26 were understaffed per the facility’s ABST. During an interview on 01/13/26 at 9:06 am, Staff 12 (Health Services Staff/CG) stated there was not enough staff to meet the needs of the residents. Staff 11 stated when Resident 1 refused a shower there was no other staff to attempt re-approach due to behaviors per Resident 1’s service plan and, therefore, at times, the showers were not completed. In an interview with Staff 4 (Resident Care Coordinator) on 01/13/26 at 10:00 am, she stated the facility was understaffed. Staff 4 revealed there was one staff member per neighborhood. If a staff member was providing shower assistance the neighborhood was left unattended. Cleaning and showers at times were not getting done based on limited staffing. Staff 4 stated overnight shift was particularly difficult as the community had four neighborhoods with three staff members covering. Residents who required two person transfers meant some neighborhoods were left unattended during those tasks. During an interview on 01/13/26 at 12:30 pm, Staff 14 (Health Services Staff/CG) stated she felt the facility was understaffed. Staff 14 stated residents that required a two person transfer often had to wait for transfer until another staff member was available. During an interview on 01/13/26 at 3:00 pm, Witness 1 (Family Member) stated there was not enough staff to meet the needs of the residents. Witness 1 stated the facility previously had more staff scheduled, two Health Services Staff/CG’s and one Health Services Staff/MT for every shift, but that had changed due to new ownership. Witness 1 stated residents were often left alone if the Health Services Staff/CG had to attend to a specific resident’s care needs as there was no one else there. In an interview with Staff 15 (Health Services Staff/CG) on 01/14/26 at 8:20 am, he stated that he felt like the section he worked in (Andes) could use an extra person because it was a “heavier section.” He didn’t always have an extra person around for two- person transfers and he had to wait sometimes, causing a resident to have to wait until after breakfast to get out of bed. Subsequently, the resident must sometimes eat his/her meal in bed instead of going to the dining room. The lack of staff also made it difficult to supervise everyone and complete required housekeeping and ADL tasks. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2, and Staff 4 on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will accurately capture care time and care elements team members provide to residents and will staff accordingly with ABST. Residents' corresponding ABST evaluations will be updated and updated as needed. Weekly audit of the Health Services schedule will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to ensure compliance and evaluate internal system to keep in compliance. ED and HSD will be responsible

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 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to accurately capture care time and care elements that staff were providing as outlined in the individual service plan for 1 of 4 sampled residents (#2) whose ABST was reviewed. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2025 with diagnoses including dementia. Observations and interviews with Health Services Staff (#’s 7, 10, and 12) identified the resident was being assisted with toileting, mobility, and transfers during the survey. The resident’s evaluation and service plan, dated 11/06/25, and subsequent service plan changes instructed staff to assist with toileting and with hearing aids and noted s/he was a moderate assist level with decision making. The ABST evaluation, last updated on 11/24/25, identified the following care time and care elements had zero minutes assigned: * Mobility; * Transfers; * Toileting; * Interests, hobbies, social, leisure activities; * Cognition including decision making ability; * Communication including assistive devices for hearing; and * Non-pharmaceutical interventions for pain. The need to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director, LPN), Staff 3 (RN), and Staff 4 (RCC) on 01/14/26 at 3:14 pm. They acknowledged the findings.

Evergreen Memory Care will accurately capture care time and care elements team members provide to residents. Residents' corresponding ABST evaluations will be updated and updated as needed. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to ensure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and HSD will be responsible.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 the environment was clean and in good repair. Findings include, but are not limited to: The facility consisted of a common area in the center, with four neighborhoods off the common area, including: Cascades, Rockies, Sierras, and Andes. The interior of the environment was toured on 01/12/26 at 11:00 am. The following was noted: Cascades Neighborhood: * Kitchenette had areas with gouged dry wall and missing paint; * Handrail in the kitchen alcove area had multiple areas of chipped/missing paint, creating a non-cleanable surface; and * Chipped paint and gouges on resident unit doors, including 109 and 112. Rockies Neighborhood: * Chipped paint and gouges on resident unit doors, including 124 and 128; * Alcove area opposite kitchen had sections of missing paint; * Dining room chair with vinyl torn from armrests; * Kitchenette had areas with gouged dry wall and missing paint; and * Sticky tape residue was noted in two square patterns in front of the laundry area. Sierras Neighborhood: * Chipped paint and gouges on resident unit doors, including 147, 150, and 153; and * Kitchenette had areas with gouged dry wall and missing paint. Andes Neighborhood: * Kitchenette had areas with gouged dry wall and missing paint; * Alcove area opposite kitchen had areas of chipped paint; * An area of the dining room floor had pulled up or was missing vinyl; * Chipped paint and gouges on resident unit doors, including 132, 137, and 139; and * Apartment 138 bathroom had a hole in the drywall near the sink, two walls had areas of missing paint, and there was brown/black matter around the base of the toilet. On 01/13/26, during a walk-through with Staff 16 (Maintenance) and Staff 1 (Administrator), the areas in the neighborhoods that required cleaning and/or repair were reviewed. Staff acknowledged the findings.

Evergreen Memory Care will ensure community's environment is kept clean, in good repair, and free from unpleasant odors. Weekly audits will be completed by Maintenance Director to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurment meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. All staff meeting to be held on February 10, 2026. Training topics to include community's environment, and Maintenance log to report any concerns. All enviromental items identified during survey not in compliance will be corrected. ED and Maintenance Director will be responsible

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure water temperatures in resident common use bathrooms and adjacent resident apartments were maintained between 110 and 120 degrees F. Findings include, but are not limited to: During an environmental walk-through and temperature check of resident common use bathrooms and adjacent resident room bathrooms, the following temperatures were noted: Rockies Neighborhood: * 01/12/26 at 11:00 am, 51.9 degrees F in common use bathroom; * 01/13/26 at 8:48 am, 49.6 degrees F in common use bathroom; * 01/14/26 at 10:30 am, 51.8 degrees F in Resident 127’s apartment; and * 01/14/26 at 10:30 am, 49.2 degrees F in Resident 128’s apartment. Sierras Neighborhood: * 01/12/26 at 11:00 am, 53.2 degrees F in common use bathroom; * 01/13/26 at 9:30 am, 50.9 degrees F in common use bathroom; * 01/14/16 at 10:35 am, 51.8 degrees F in Resident 156’s apartment; and * 01/14/16 at 10:35 am, 52.3 degrees F in Resident 155’s apartment. The water temperatures in the common use bathroom and adjacent resident apartments were found to be cold to the touch. The temperatures were reviewed and discussed with Staff 6 (Maintenance Assistant) on 01/12/26 at 2:45 pm. Staff 6 verified the cold temperatures. During an interview on 01/14/26 at 10:35 am, Staff 16 (Maintenance) stated he would contact a plumber to address the low water temperatures.

Evergreen Memory Care will ensure water temperatures maintain a rage of 110 - 120 degrees F. Weekly audits will be completed to assure compliance. Audits will be reviewed in Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. ED and Maintenance Director will be responsible

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own bathroom for 1 of 4 sampled residents (#3) and multiple un-sampled residents who shared bathrooms. Findings include, but are not limited to: The resident units consisted of single and double occupancy (shared) units. Resident 3 resided in a double occupancy room that shared a bathroom. Multiple un-sampled residents were noted to share a bathroom. The shared bathrooms were without a locking mechanism on the inside of the bathroom door to ensure privacy when in use. During an interview on 01/14/26 at 9:37 am, Staff 16 (Maintenance) and Staff 1 (Administrator) confirmed that multiple shared bathroom doors lacked locking mechanisms to ensure privacy while the residents were in the bathroom.

Evergreen Memory Care will ensure residents' right to privacy in shared units. Lockable lever door knobs have been purchased and will be installed to be in compliance. All staff meeting to be held on February 10, 2026. Training topics to include restroom door locks for privacy. ED and Maintenance Director will be responsible

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including gender identity, for 1 of 1 sampled resident (# 4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to C252.

Please refer to POC for C252. Facility

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C360, C362, C513, and C545.

Refer to POC for C360, C362, C513, C545.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C303, and C310.

Refer to POC for C260, C270, C303, C310.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate the residents for activities and develop an individualized activity plan based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4’s activity evaluations were requested on 01/13/26 and service plans were reviewed during survey. No activity evaluations were identified. The facility had not evaluated the residents’: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no individualized activity plan developed for each resident based on his/her activity evaluation which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans which were based on an evaluation of the resident's interests, abilities, and needs was discussed with Staff 5 (Life Enrichment Director) on 01/13/26 at 2:52 pm. Staff 5 acknowledged the findings.

Evergreen Memory Care will ensure activity evaluations address all required elements. Moving forward, all admissions will have a completed Resident Evaluation to address all required elements. All sampled resident's evaluations will be updated to address all required elements. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and RSD will be responsible.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: