OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were promptly investigated to rule out abuse or immediately reported to the local Seniors and People with Disabilities (SPD) office if abuse could not be ruled out, and/or incidents of abuse or suspected abuse were immediately reported to the local SPD office for 2 of 2 sampled residents (#s 1 and 2) who had injuries of unknown cause and/or incidents of abuse or suspected abuse. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2021 with diagnoses including Alzheimer’s disease and anxiety disorder. The resident’s clinical record from 10/21/25 through 01/20/26 was reviewed. The following was identified: a. There was no documented evidence the following injuries of unknown cause were investigated to rule out abuse or suspected abuse and immediately reported to the local office if the investigation could not reasonably conclude the injuries were not the result of abuse: * 11/04/25 – Skin tear on left elbow; and * 01/03/26 – Skin tear on right elbow. Staff further documented the resident was unable to provide a statement as to what happened regarding both injuries. An interview with Staff 2 (Administrator) on 01/21/26 at 1:55 pm confirmed the above incidents had not been reported to the local SPD office. Survey requested the facility report the injuries of unknown cause. (either here or at the beginning of the next paragraph) On 01/22/26 at 9:53 am, the facility provided documentation that the incidents were reported to the local SPD office. b. There was no documented evidence the following incidents were immediately reported to the local SPD office: * 11/17/25 – Resident-to-resident altercation; and * 12/14/25 – Resident-to-resident altercations. (plural?) Survey requested the facility report the incidents. Confirmation was received on 01/22/26 at 9:53 am the above incidents were reported to the local SPD office. The need to investigate all injuries of unknown cause to determine whether or not abuse could be reasonably ruled out, and to report all incidents of abuse or suspected abuse and injuries of unknown cause to the local SPD office when needed, was discussed with Staff 1 (General Manager), Staff 2 (Administrator), Staff 3 (RN), Staff 4 (Senior General Manager), and Staff 5 (Regional RN) on 01/22/26 at 3:00 pm. They acknowledged the findings. 2. Resident 1 moved into the MCC in 05/2025 with diagnoses including dementia. The resident’s clinical record from 10/20/25 to 01/20/26 was reviewed, and the following was identified: Staff documented the following injuries of unknown cause: * 11/04/25 – blister on resident’s left ear; and * 01/08/26 – multiple scratches on resident’s right hip. Staff further documented the resident was unable to state what happened regarding both injuries. Facility incident reports received at 10:20 am on 01/21/26 did not include documentation abuse was reasonably ruled out. At 2:55 pm on 01/21/26, Staff 2 (Administrator) confirmed the lack of documentation that abuse was reasonably ruled out for both injuries of unknown cause. The need to ensure injuries of unknown cause were immediately investigated to rule out abuse and/or reported to the local SPD office if abuse could not be ruled out was discussed with Staff 1 (General Manager), Staff 2, Staff 3 (RN), Staff 4 (Senior General Manager), and Staff 5 (Regional RN) at 1:50 pm on 01/22/26. They acknowledged the findings. Survey requested the above injuries of unknown cause be reported to the local SPD office, and confirmation was received at 9:52 am on 01/22/26.

1. -All incidents in examples given were reported to APS for resident 1 on 1/21/26. -All incidents in examples given were reported to APS for resident 2 on 1/21/26 - Review of investigations for resident 1 and 2 completed by Administrator with Senior GM. Investigations amended appropriately to meet documentation standards. 2. Administrator received education/training on 01/22/2026 on ruling out abuse/neglect documentation during incident investigations to include manadatory reporting of injury of unknown cause(s) and all suspected abuse and neglect immediately to APS. Administrator registered for OHCA ALF/RCF rules webinar: incident investigations and root cause analysis that is scheduled on 02/26/2026 and "Role of the nurse" course also through OHCA scheduled for 02/17/2026-02/19/2026. Administrator will provide detailed documenation in the incident investigation and if Administrator is not able to reasonably rule out abuse and/or neglect, administrator will report any injury of unknown cause imediately to APS. 3. Administrator will evaluate this with each incident and report accordingly. General Manager will evaluate this on a monthly basis. 4. Administrator and General Manager will monitor investigation documentation, incident reporting, and check that documentation is completed appropriately and/or reported per regulation.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. 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 observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 residents (#s 1 and 2) who had significant changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 05/2025 with diagnoses including dementia and was identified in the acuity interview as having a modified diet (soft and bite-sized food and nectar-thick liquids) and hospice services. The resident’s clinical record from 08/06/25 to 01/20/26 was reviewed, and the following was identified: Staff documented the following weights: * 08/06/25 – 184.2 pounds; * 09/04/25 – 185.8 pounds; * 10/05/25 – 175.4 pounds; * 11/24/25 – 177 pounds; * 12/11/25 – 177.8 pounds; * 01/05/26 – 171.6 pounds; and * 01/22/26 – 172.4 pounds (taken during survey). From 09/04/25 to 10/05/25, the resident lost 10.4 pounds, or 5.5% of his/her bodyweight. This severe weight loss constituted a significant change of condition, requiring an RN assessment that included findings, resident status, and interventions made as a result of the assessment. At 1:36 pm on 01/22/26, Staff 4 (Senior General Manager) stated no RN assessment had been completed for the significant weight loss. She further stated the facility RN at the time of the significant weight loss was no longer employed at the MCC. The resident was observed eating lunch (cut up meatloaf, mashed potatoes, cut up fruit, and a cookie) on 01/20/26 at 12:03 pm, breakfast (scrambled eggs, hashbrowns, and cut-up fruit) on 01/21/26 at 9:51 am, and lunch (cut up meatloaf, mashed potatoes, and cut up fruit) on 01/21/26 at 12:57 pm. S/he consumed 75% of lunch on 01/20/26, 50% of breakfast on 01/21/26, and 100% of lunch on 01/21/26. Staff were observed at all three meals intermittently cueing the resident for swallowing safety. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (General Manager), Staff 2 (Administrator), Staff 3 (RN), Staff 4, and Staff 5 (Regional RN) at 1:50 pm on 01/22/26. They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2021 with diagnoses including Alzheimer’s disease. During the acuity interview on 01/20/26 at 9:25 am, Resident 2 was identified for weight loss. The resident's clinical record from 10/21/25 through 01/12/26 was reviewed, and the following was identified: Staff documented the following weights: * 12/05/25 – 143.6 pounds; * 01/05/26 – 131 pounds; and * 01/21/26 -- 133.8 pounds (taken during survey). From 12/05/25 to 01/05/26, the resident lost 12.6 pounds, or 8.77% of his/her bodyweight in 30 days, which was considered a severe weight loss and required an RN assessment that included findings, resident status, and interventions made as a result of the assessment. In an interview on 01/21/26 at 2:45 pm Staff 2 (Administrator) stated nursing coverage was being provided by a regional RN at the time of the weight loss, and an RN assessment had not been completed for the weight loss. Observations made revealed Resident 2 consumed less than 50% of lunch on 01/20/26 at 12:45 pm and 90% of breakfast on 01/21/26 at 8:35 am. On 01/20/26 at 12:55 pm, Staff 10 (MT) was observed requesting a milkshake for Resident 2 from the kitchen. An interview with Staff 10 at 1:55 pm confirmed Resident 2 consumed 100% of the milkshake provided. The need to ensure the facility RN completed a timely assessment for the significant change of condition related to weight loss and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (General Manager), Staff 2, Staff 3 (RN), Staff 4 (Senior General Manager), and Staff 5 (Regional RN) on 01/22/26 at 3:00 pm. They acknowledged the findings.

1. -RN completed assessment on 1/20/26 for Resident 2 reviewing weight loss and interventions currently in place for resident. Resident is no longer at the facility. -Resident 1's weight loss interventions reflected in service plan. Administrator and RN will continue to monitor Resident 1's weights monthly of which RN will perform assessment for significant change of condition as needed. 2. Facility implemented monthly weight tickler so that changes of conditions related to weight loss and/or gain are triggered timely and RN will perform change of condition assessment. Inservice with direct care team will also occur to train staff what constitutes a change of condition regarding weight loss and/or gain and when and how to report to RN. 3. Administrator and RN will evaluate monthly to ensure compliance by audting weight tickler and ensuring any change of condition assessments occurred. 4. Administrator will be responsible to follow up with RN on appropriate assessments needing to be completed. RN will be responsible for completing appropriate assessments and to ensure monitoring.

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 411-054-0060 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 the facility RN, a PT, or an OT conducted a thorough assessment of a supportive device with restraining qualities for 1 of 1 resident (#1) who had side rails. Findings include, but are not limited to: Resident 1 moved into the MCC in 05/2025 with diagnoses including dementia and was identified in the acuity interview as requiring two staff for transfers and bed repositioning. The resident’s clinical record from 10/20/25 to 01/20/26 was reviewed, staff were interviewed, and observations of the resident were made. The following was identified: Observations of the resident’s apartment at 8:42 am on 01/21/26 showed the resident had a hospital bed with bilateral quarter-length side rails in the up position. There was no documented evidence the side rails had been assessed by the facility RN, a PT, or an OT. At 12:00 pm on 01/21/26, Staff 2 (Administrator) confirmed the lack of documentation. The need to ensure a thorough assessment was completed by the facility RN, a PT, or an OT for residents who had supportive devices with restraining qualities was discussed with Staff 1 (General Manager), Staff 2, Staff 3 (RN), Staff 4 (Senior General Manager), and Staff 5 (Regional RN) at 1:50 pm on 01/22/26. They acknowledged the findings.

1. RN completed side rail assessment on 1/21/26 for Resident 1. 2. Inservice completed on 02/09/2026 for staff education on regulation for restraints and supportive devices to include reporting to community RN if devices containing a restraining quality arrive in the community. Administrator registered for Role of the Nurse in CBC through OHCA to be completed by 2/19/26 as well. Community RN received this OHCA training in December when they were hired. Community RN has completed an audit to ensure all assessments, if applicable, have been completed for any residents with supportive devices with restraining qualities. 3. This will be evaluated on a quarterly basis with resident service plan updates and/or with change of condition evaulation. 4. Administrator will be responsible for tracking devices requiring RN assessment and follow up with RN on completion of assessments. RN will be responsible for completing appropriate assessments.

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 411-054-0037 (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 ensure the acuity-based staffing tool (ABST) accurately captured care time staff provided to residents for 2 of 2 residents (#s 1 and 2) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 11/2025 with diagnoses including dementia. The resident’s clinical record from 10/20/25 to 01/20/26 was reviewed, interviews with staff were conducted, and observations of the resident were made. The following care areas, listed as “PRN” on the resident’s 01/19/26 ABST and service plan, did not include time required for staff to provide the care: * Repositioning; * Supervising, cueing, or supporting while eating; * Providing non-drug interventions for pain management; * Cueing or redirecting due to dementia; * Ensuring non-drug interventions for behaviors; and * Providing additional care services, including coordinating with hospice. At 10:19 am on 01/22/26, Staff 2 (Administrator) confirmed staff provided the above services, and there was no time allotted for "PRN" care areas on the resident’s ABST. The need to ensure the ABST included care time for all care areas staff were providing to residents was discussed with Staff 1 (General Manager), Staff 2, Staff 3 (RN), Staff 4 (Senior General Manager), and Staff 5 (Regional RN) at 1:50 pm on 01/22/26. They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2021 with diagnoses including Alzheimer’s disease. Observations of the resident were made, interviews with the staff were conducted, and the 01/12/26 service plan and Resident 2’s ABST data was reviewed. The following care areas, listed as “PRN” on the resident’s 01/12/26 ABST and service plan, did not include time required for staff to provide the care: * Time spent cueing or redirecting due to cognitive impairment or dementia; * Time spent ensuring non-drug interventions for behaviors; and * Time spent monitoring behavioral conditions or symptoms. An interview with Staff 4 (Senior General Manager) on 01/22/26 at 12:33 pm confirmed areas on the resident service plan with “PRN” did not allocate time for the care being provided on the ABST. The need to ensure resident ABST evaluations captured care time for the care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (General Manager), Staff 2 (Administrator), Staff 3 (RN), Staff 4, and Staff 5 (Regional RN) on 01/22/26 at 3:00 pm. They acknowledged the findings.

1. For Resident 1, PRN times were re-evaluated and updated to be routine to include evaluated time per task. Resident 2 is not longer at the facility. 2. Training was performed with Administrator on ABST rules and regulations to ensure that all tasks whether occasional or routine be reflected in the service plan as routine daily, weekly, and/or monthly therefore eliminating PRN usage of service tasks. Training to be done with direct care to ensure they are accounting for "additional tasks" in our proprietary ABST tool so that Administrator can evaluate and account for potential as needed and/or unscheduled tasks by implementing time per task in service plan. Audit will be completed to ensure that all PRN times are removed from service plan and are re-evaluated to include routine times per task if applicable. 3. Administrator will evaluate this twice weekly, with quarterly evaluations, upon move in, and/or change of conditions when running the ABST. 4. Administrator will be responsible for updating and maintaining ABST.

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 411-054-0090 (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 in fire and life safety procedures within 24 hours of admission. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 6 (Maintenance Director) on 01/22/26 at 11:55 am. There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission. The need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission was discussed with Staff 1 (General Manager), Staff 2 (Administrator), Staff 3 (RN), Staff 4 (Senior General Manager), and Staff 5 (Regional RN) on 01/22/26 at 3:00 pm. They acknowledged the findings.

1. All residents received fire and life safety education and instructions on 1/21/26. 2. Power of attorney and/or resident signs the Resident Handbook upon or prior to move in that includes Resident Fire Life and Safety instructions and education. 3. This will be evaluated by General Manager to ensure completion of Resident Handbook Acknowledgment signature page. 4. Administrator and General Manager will provide monitoring that fire training is completed withing 24 hours of admission.

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 411-054-0200 (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 interior of the building was observed on 01/20/26 at 10:38 am. The following was identified needing cleaning or repair: Chairs, couches, and recliners located throughout the common areas of the memory care were noted to be visibly worn, with vinyl peeling and/or stains located on the seats. A walk-through showing areas needing cleaning and repair was conducted with Staff 1 (General Manager) and Staff 2 (Administrator) on 01/21/26 at 10:15 am. They acknowledged the findings.

1. Affected furniture will continue to be removed and replaced within the compliance period. 2. Cedar Mill Memory Care recently transitioned to Merrill Gardens. Merrill Gardens has a system in place to perform regular and reoccuring site visits of which furniture will be checked and plan will be submitted timely to replace any future affected furniture. Additionally, Administrator will report any affected furniture in between site visits so that Merrill Gardens and Administrator can develop a plan to replace furniture as soon as possible and/or problem solve. 3. This will be evaluated weekly by Administrator and quarterly by Merrill Gardens Regional Team. 4. The Administrator will be responsible to ensure that these corrections are implemented and monitored.

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 411-057-0140(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 observation, interview, and record review, it was determined the facility failed to follow the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C362, C422, and C513.

Refer to plan of correction for C231, C362, C422, and C513.

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 observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C280 and C340.

Refer to plan of correction for C280 and C340.

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: