OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents' right to be treated with dignity and respect for 2 of 2 sampled residents (#s 2 and 8) and multiple unsampled residents who resided in MC1, one of the facility’s memory care units, and ate their meals in the dining room. Findings include, but are not limited to: The facility was comprised of an assisted living community and two memory care communities: MC1 and MC2. Observations of MC1 dining room were made on 04/14/26 and the following was identified: a. At 11:12 am, Resident 2 was observed sitting at a table in the dining room. The resident had two plates of food: a ham sandwich and a plastic cup of fruit on a ceramic plate, and scrambled eggs and toast on a paper plate. Resident 2 was drinking from a disposable cup. At 11:35 am, Staff 19 (CG) stated that staff used paper plates when residents needed their meals reheated. Staff 19 confirmed the kitchen gave disposable cups for all meals served in the memory care units. This was observed at 11:25 am when Staff 19 was pouring beverages for the lunch meal. A total of seven residents were observed using disposable cups at lunch. b. At 12:34 pm, Staff 19 began assisting Resident 8 with eating his/her lunch. The staff member was quiet and was not observed to talk with the resident while providing assistance. Resident 8 was sitting in a chair with his/her head bent down, keeping his/her eyes closed. Staff 19 stopped assisting Resident 8 at 12:37 pm, when an unsampled resident stated s/he wanted to go back to their apartment. At that time, Staff 19 turned her attention to the unsampled resident and stated, “You have to wait until everyone is finished with their dinner.” The staff member picked up the unsampled resident’s hearing device and stated, “You have to finish dinner.” The resident replied, “I can’t eat, I’m sick to my stomach.” Staff 19 began feeding the unsampled resident who was observed to wince when the utensil would get close to his/her mouth. The unsampled resident said, “I’ve got to go home.” Staff 19 continued to try to feed the resident and then asked, “Are you okay?” The resident replied, “No, I want to go to bed.” Staff 19 told him/her, “Just wait a few minutes for the food to go down”, and gave the resident a bite of food. Staff 19 got up from the dining room table and walked out of the dining room. The unsampled resident was assisted to his/her apartment by Staff 27 (MT) at approximately 1:10 pm. When Staff 19 returned to the dining room, she started cleaning up. Resident 8 had not been assisted to eat by any other staff member and had not attempted to get anything to eat or drink independently since 12:34 pm. At 1:03 pm, Staff 19 took the resident’s plate and put it in the microwave. A paper plate was not used to re-heat the meal as she reported was the process previously. Staff 19 continued to assist Resident 8 to eat at 1:04 pm. Twenty-six minutes passed while the resident sat at the dining room table and waited for someone to continue to assist with the remainder of his/her lunch. At 1:04 pm, when Staff 19 sat next to Resident 8, she did not announce herself. The staff member put food on a fork and touched the resident’s lips with the utensil. Resident 8 was visibly startled and stated, “Oh!” Staff 19 giggled. The need to ensure residents’ right to be treated with dignity and respect was reviewed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Dining practices were corrected. Staff were re-educated on announcing presence, engaging throughout feeding, and timely assistance and overall dignity in the dining room. Disposable dishware discontinued unless clinically indicated. 2. System Fix: A Dining Dignity Protocol was implemented requiring engagement, proper communication, and supervision during meals and overall dignity practices. 3. Monitoring: 3x weekly x4 weeks, then monthly, using dining room observation dining tool. 4. Responsible Party: Administrator Resident Care Coordinator Food Services Director

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

OAR 411-054-0028 (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 incidents of abuse or suspected abuse were immediately reported to the local Department office for 1 of 1 sampled resident (# 2) who was reviewed for suspected abuse, and failed to ensure injuries of unknown cause were immediately investigated by the facility, and if the investigation could not reasonably rule out abuse, the local Department office was notified for 1 of 2 sampled residents (# 2) who were reviewed for injuries of unknown cause. Findings include, but are not limited to: Resident 2 moved into one of the facility’s memory care communities in 09/2025 with diagnoses including mild cognitive impairment. The resident’s clinical record, dated 01/04/26 through 04/13/26, was reviewed and the following was identified: a. The following incidents of suspected abuse were documented: * An incident report dated 02/27/26 identified that another resident told staff that Resident 2 had been sexually assaulted by a male caregiver; and * An incident report dated 03/19/26 reported that Resident 2 stated, "[s/he] did not want to sleep with 'him' again referring to a caregiver." On 04/15/26 at 4:15 pm, Staff 1 (Administrator) and Staff 2 (ED) confirmed that neither incident had been immediately reported to the local Department office. Documentation of the incident dated 02/27/26 showed that the caregiver was put on leave until the facility conducted an investigation. Staff interviewed both Resident 2 and his/her family relating to the incident dated 03/19/26. Documentation showed that the resident began talking about a time when s/he lived in California. Documentation that the facility notified the local Department office of the 02/27/26 and 03/19/26 incidents of suspected abuse was provided on 04/15/26 at 6:12 pm. b. The following injuries were identified: * A progress note dated 03/05/26 identified the resident had a “small wound on the top of [his/her left] ?? what .” On 03/07/26 staff noted that Resident 2 did not know how s/he obtained the wound; and * A progress note dated 03/21/26 identified the resident had a scratch to the back of the heal. There was no documented evidence the facility had conducted an immediate investigation of the injuries to rule out abuse or suspected abuse. There was no documented evidence the facility had reported the injuries of unknown case to the local Department office. Documentation that the facility notified the local Department office of the injuries of unknown cause was provided on 04/17/26 at 10:03 am. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local Department office and to ensure injuries of unknown cause were immediately investigated by the facility, and if the investigation could not reasonably rule out suspected abuse, the local Department office was notified was discussed with Staff 1, Staff 2, Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Resident #2 the event was reported to appropriate authorities; full investigations completed and documented. 2. System Fix: Mandatory reporting training reinforced with clear immediate reporting expectations. 3. Monitoring: New Incident Reports and Progress Notes to be reviewed by Interdisciplinary Team daily in Clinical Meeting. 4. Responsible Party: Administrator, Licensed Nurses, Resident Care Coordinator.

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 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and preferences, provided clear direction to staff regarding the delivery of services, including a written description of who should provide the services and what, when, how, and how often the services shall be provided, were implemented, and/or were readily available to staff for 4 of 7 sampled residents (#s 1, 2, 6, and 8) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 6 moved into the assisted living community in 11/2023 with diagnoses including?bipolar disorder and type 2 diabetes mellitus. During the acuity interview on 04/13/26 Staff 3 (RN) and Staff 26 (MT) reported that service plans available to staff for assisted living residents were stored in a binder in a cabinet at the caregiver station in the middle of the unit on the second floor. At 3:30 pm on 04/13/26 the surveyor found a service plan for Resident 6 dated 09/11/25 in the Service Plan binder. On 04/14/26 at 9:30 am Staff 1 (Administrator) provided a copy of the resident’s most recent service plan, dated 03/07/26, which she endorsed had just been printed. Resident 6’s service plan available to staff and the current service plan were reviewed, observations were made, and interviews with staff and the resident were conducted. The service plan available to staff was not reflective of the resident’s needs, and did not provide clear direction to staff in the following areas: * Transferring and sit-to-stand use; * Incontinence care; * Mobility; * Safety checks; and * Behaviors related to sit-to-stand lift refusals. Caregivers throughout the survey reported varied understanding regarding what Resident 6 required for transferring, and whether a sit-to-stand lift was required for safety or was offered to the resident based on his/her preference. In an interview on 04/16/26 at approximately 2:30 pm Staff 4 (RCC) reported that her understanding of the resident’s needs was that the sit-to-stand lift use for Resident 6 was a safety requirement, and that caregivers had been instructed to not transfer the resident if s/he refused to use the lift. On 04/16/26 at 1:00 pm, the need to ensure service plans were reflective of the residents’ needs, provided clear direction to staff, and were implemented, was discussed with Staff 1, Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant). They acknowledged the findings. 2. Resident 1 moved into one of the facility’s memory care communities in 04/2025 with diagnoses including?Alzheimer’s disease. The resident’s 03/05/26 service plan was reviewed and the following was identified: a. The following was not reflective of the resident’s current care needs: * Sleeping routines; * Eating routines; * What services hospice provides; * Meal assistance; and * Resident's need for dentures during mealtimes. b. There was conflicting information relating to how often staff were to provide safety checks. c. Toenail care was not being implemented. Resident 1’s 03/05/26 service plan reflected staff were to preform toenail care “after each bath/shower.” On 04/15/26 at 11:12 am, the resident exited his/her apartment and was observed to not have socks or shoes on. Resident 1’s toenails were long and appeared to be approximately ¾ of an inch longer than the end of his/her toes. Staff 17 (CG) said she thought that a podiatrist cut the resident’s toenails. On 04/16/26 at 12:50 pm, Staff 21 (CG) confirmed that staff were to cut Resident 1’s toenails but they only had small fingernail clippers and she needed the large toenail clippers. Staff 21 stated she did not use the small clippers as she “didn’t want to hurt [the resident].” The need to ensure service plans were reflective of the residents’ current needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings. 3. Resident 2 moved into one of the facility’s memory care communities in 09/2025 with diagnoses including mild cognitive impairment. The resident’s 03/30/26 service plan was reviewed and the following was identified: a. The following was not reflective of the resident’s current care needs: * The use of glasses; * Eating in the dining room; * Toileting assistance; * Sleep schedule and the need to provide snacks during the night hours; * Behavior interventions; and * Transfer assistance. On 04/14/26, Resident 2 was observed to not wear glasses, to eat meals in both the dining room and in his/her apartment, and transfer independently. b. There was conflicting information relating to the following: * The service plan reflected Resident 2 was receiving PRN psychotropics, but MARs, dated 03/01/26 through 04/13/26, reflected a scheduled psychotropic medication; and * The information in the service plan reflected the resident’s desire to lose weight, but the resident had documentation beginning on 01/04/26 of a significant weight loss and interventions had been implemented for Resident 2 to gain weight. c. The following was not being implemented: * Nutritional shakes with lunch and dinner; * Interventions for the resident's suicidal ideations; and * The resident requiring only female caregivers. On 04/14/26 at 12:29 pm, Staff 19 (CG) prepared a room tray for Resident 2. There was no nutritional shake brought to the unit from the kitchen, and Staff 19 did not include a nutritional shake when giving the resident his/her lunch in the resident’s apartment. On 04/16/26 at 9:59 am, Staff 10 (Lead Cook) and Staff 11 (Cook) verified that although they were aware that Resident 2 needed nutritional shakes with lunch and dinner, they were not aware s/he moved from MC2 to MC1 on 03/20/26. They continued to send the shakes to MC2. Progress notes, dated 02/12/26 through 04/10/26, identified two separate times when Resident 2 experienced suicidal ideations. A Temporary Service Plan was implemented on 02/12/26 to direct staff on how to care for the resident when this occurred. The information was not transcribed onto the 03/30/26 service plan. The intervention of having female only caregivers was documented on an incident report dated 03/19/26. This information had not been transcribed onto Resident 2’s 03/30/26 service plan. On 04/16/26 at 10:12 am, Staff 27 (MT) stated that both male and female caregivers could work with Resident 2. d. The service plan was not readily available to staff. Per acuity interview on 04/13/26, staff reported that the residents’ service plans who resided in MC1 were located in a cupboard in the dining room. On 04/14/26 at 11:59 am, Staff 19 (CG) told Staff 29 (MT), “I don’t have a key to this,” while pointing to a cupboard in MC1’s dining room. Staff 29 tried to open the cupboard with a couple of keys but was unable to unlock it. At 12:06 pm, Staff 19 confirmed the residents’ service plans were in the locked cupboard in the dining room and stated the reason why the cupboards were locked was because there were hot chocolate packets that the staff did not want the residents “to get into.” However, the cupboard where the hot chocolate packets were located was observed to be unlocked. At 12:07 pm, Staff 29 unlocked the cupboard and placed the service plan binder on a table where other binders were located in the unit’s dining room. Staff 29 confirmed that only MTs had keys and if a MT was not on the unit, CGs would have to use the walkie-talkie to request a MT to open the cupboard. The need to ensure service plans were readily available to staff, reflective of the residents’ current needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings. 4. Resident 8 moved into one of the facility’s memory care communities in 11/2023. On 04/14/26 at 11:43 am, Staff 29 (MT) brought Resident 8 into the dining room and Staff 19 (CG) helped the resident to sit at the table saying, “Come on, Grandma.” Staff 19 confirmed the resident was not her grandparent but was told that Resident 8 preferred to be addressed by “Grandma”. On 04/16/26 at 10:06 am, both Staff 12 (CG/Front Desk) and Staff 27 (MT) confirmed Resident 8 preferred to be called “Grandma”. Staff 12 reported that the resident responded better by smiling and engaging when s/he was referred to as “Grandma”. She stated that Resident 8 was more serious when staff called him/her by their official name. There was no direction to staff relating to the resident’s preferred name in Resident 8’s 03/24/26 service plan. Staff 27 reviewed the resident’s service plan and confirmed there was no direction to staff to call the resident “Grandma”. She reported that if Resident 8’s family was visiting and staff did not call the resident “Grandma” they would correct staff and say, “[S/he] would really like it if you called [him/her] Grandma.” The need to ensure service plans were reflective of the resident’s current needs and preferences and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Resident #1, #2, #6, #8 have been reviewed by the Interdisciplinary Team to ensure their service plans reflect the resident’s current care needs and provide clear direction regarding delivery of services for all areas of care. 2. System Fix: Resident service plans will be reviewed and updated at their next evaluation to ensure the service plans are reflective of each resident’s care needs and provide clear direction to staff for the provision of care. Education provided to staff on Service Plan and Temporary Service Plan process. 3. Monitoring: Interdisciplinary Team will review that the service plans are being updated quarterly and when there is a change in condition. Audit details to be reported at Quarterly QA meeting. 4. Responsible Party: Administrator, Resident Care Corrdinator, Licensed Nurses

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, communicated to staff on each shift, and were monitored at least weekly until the condition resolved for 2 of 6 sampled residents (#’s 2 and 4), who were reviewed for changes of condition. The findings include, but are not limited to: 1. Resident 4 moved into the assisted living in 01/2023 with diagnoses including chronic Stage 3 kidney disease, hypertension, and edema. The resident’s clinical record from 01/13/26 through 04/13/26 was reviewed during the survey. The following short-term changes of condition were identified: On 3/23/26 the following medications were discontinued: * Saccharomyce S Boul 250 mg capsule (for acid reflux); * Triamcinolone cream (for dermatitis); * Cetirizine HCL 10 mg tablet (for allergies); * Duloxetine 60 mg capsule (antidepressant); * Magnesium Oxide 400 mg tablet (restless legs); * Omeprazole 20 mg capsule (for acid reflux); * Ropinirole 5 mg tablet (for restless legs); and * Valsartan 80 mg tablet (for hypertension and blood pressure). There was no documented evidence the facility determined actions or interventions needed, communicated actions or interventions to staff on each shift and monitored the resident following discontinuation of the above medications or treatments. The need to ensure the facility determined actions or interventions, communicated the action or intervention to staff on each shift and monitored the change of condition at least weekly until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 2:35 pm. They acknowledged the findings. 2. Resident 2 moved into one of the facility’s memory care communities in 09/2025 with diagnoses including mild cognitive impairment. The resident’s clinical record, dated 01/04/26 through 04/13/26, was reviewed and the following short-term changes of condition were identified: * An incident report dated 03/19/26 reported that Resident 2 stated, "[s/he] did not want to sleep with 'him' again referring to a caregiver"; and * In a progress note dated 04/09/26, staff reported the resident fell. There was no documented evidence the facility determined actions or interventions needed, communicated those actions or interventions to staff on each shift, and monitored the resident through resolution. The need to ensure the facility determined actions or interventions, communicated the action or intervention to staff on each shift and monitored the change of condition at least weekly until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Residents #2 & #4 short term condition changes will be recapped by the Licensed Nurse to ensure issues have been resolved and no furter actions/interventions are needed. Service Plans will updated as needed. 2. System Fix: Change in Residents condition will be monitored and identfied through the 24-hour chart review and follow-up process. During morning clinical meeting the clinical team will review short term change of condition and determine approprite actions/interventions and will use the temporary serivce paln process to communicate the Residents needs to staff for monitoring. Licensed Nurse will monitor short term change of condition weekly for needs and resolution. 3. Monitoring: Change in resident’s acute condition will be monitored and identified through the 24-hour chart review and follow-up process. Acute Changes in conditions will also be discussed at morning clinical meetings to determine any need for Licensed Nurse weekly notes. Weekly Audit x2, then Monthly 4. Responsible Party: Administrator, Licensed Nurses, Resident Care Coordinator

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

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to coordinate care with on-site healthcare providers, including ensuring staff were informed of new interventions and the service plan adjusted for 1 of 1 sampled resident (#6) who received services from an outside behavior support services provider. Findings include, but are not limited to: Resident 6 moved into the assisted living community in 11/2023 with diagnoses including bipolar disorder and type 2 diabetes mellitus. Review of the resident’s progress notes, dated 01/15/26 through 04/13/26, identified the resident received behavior support services on-site from an outside provider. On 04/15/26 at 8:45 am the surveyor requested all behavior professional (BP) notes from the last 90 days. On 04/16/26 at 8:55 am Staff 1 provided a BP note dated 03/19/26. No other documentation was provided. The progress notes documented visits from the BP on 03/22/26, 03/26/26, and 04/07/26, which included the following recommendations and comments: * 03/26/26 – “Behavioral health saw resident and recommended when trying to get resident to get up to get [his/her] briefs changed or trying to toilet [him/her] that we don’t tell [him/her] [s/he’s] ‘supposed to’ or that it will be a refusal if [s/he] doesn’t because that will make[him/her] more defensive and more likely to refuse care in the future. They recommend being patient and letting [him/her] know we are doing it because we care about [him/her].” * 04/07/26 – “LPN, RN, Admin [Administrator] unavailable to speak with today. BP would like to talk about concerns Re [regarding]: chronic UTI [urinary tract infection]/hygiene, and the sit-to-stand issue.” There was no documented evidence the facility informed staff of new interventions, that the service plan was adjusted as required. These findings were reviewed with Staff 1, Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 1:00 pm. They acknowledged the need for the facility to coordinate care with on-site healthcare providers.

1. Correction: Resident #6 had a Temporary Service Plan created to ensure implementation of recommendations from outside provider and was added to Service Plan. 2. System Fix: Resident visits from outside providers to go through triple check process, to ensure recommendations implemented. 3. Monitoring: Wellness Director or designee will review all Outside Provider visit notes to ensure recommendations are initiated on appropriate TSP for staff review and signatures. 4. Responsible Party: Administrator, Licensed Nurse, Resident Care Corrdinator

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for several unsampled residents. Findings include, but are not limited to: 1. On 04/15/26 at 2:30 pm, Staff 25 (MT) was observed counting medications with another MT who removed oral medications from multiple medication bottles, touching the oral medications with her bare hands and painted fingernails. The need to ensure MT’s maintained infection prevention and control protocols during medication administration was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 6 (RN Consultant) on 04/16/26 at approximately 5:00 pm. They acknowledged the findings. 2. The facility was comprised of an assisted living facility and two memory care communities referred to as MC1 and MC2. The following was identified during meal service: a. On 04/14/26 at 11:35 am, Staff 19 (CG) was observed getting the MC1 dining room ready for lunch which included setting out silverware and napkins, and filling cups with beverages and placing them onto the tables. There was no hand hygiene or donning gloves observed prior to Staff 19 touching the items and she was not wearing an apron, over her potentially contaminated clothing. In addition, Staff 19 was touching her face and hair and carrying the cups by the top, where residents would be drinking from. At 12:27 pm, Staff 19 and Staff 29 (MT) was observed serving lunch to residents in the MC1 dining room. It was confirmed that both staff member provided personal care to residents. Neither staff member was observed wearing an apron over there potentially contaminated clothing or performing hand hygiene. At 12:34 pm, both Staff 19 and Staff 29 donned aprons and gloves. Six residents had already been served their lunch in the dining room prior to staff donning the aprons and gloves. At approximately 12:30 pm, while Staff 19 was cutting an unsampled resident’s food, the resident’s hearing device fell to the dining room floor. The staff member picked it up, placed it on the table and continued to cut the food. There was no hand hygiene observed between picking the device up and resuming cutting the resident’s food. Immediately after cutting up the unsampled resident’s lunch, Staff 19 was observed taking four lunch plates and all of the desserts out of the insulated food cart, uncovered all of the food, and placed it on a utility table to the left of a cupboard. She placed a lunch plate, condiments, beverage and a dessert on a plastic tray. Staff 19 carried the tray down the hall and delivered it to a resident’s apartment. She did not place a covering on any of the items prior to transporting the tray from the dining room to the resident’s apartment. Three of the plates continued to be uncovered until 1:32 pm, approximately one hour, when the surveyor exited the unit. There were no observations made of the food being re-covered or discarded. b. On 04/16/26 at 12:50 pm in the kitchenette located on MC2, there were three dishes of beef, rice, vegetables, and multiple dishes of dessert observed sitting uncovered on the counter. There were three CGs observed in the dining area. One CG was assisting an unsampled resident with lunch, wearing gloves but no apron over her potentially contaminated clothing. At 12:55 pm, she entered the kitchenette to cover the remaining dishes of lunch and put them in the refrigerator. No hand hygiene was observed. Staff 21 (CG) was observed in the kitchenette, not wearing an apron over her potentially contaminated clothing. The need to ensure caregiving staff maintained infection prevention and control protocols during meal times was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Staff retrained on infection control standards regarding medication handling and food safety. 2. System Fix: Staff retrained on infection control standards including medication handling and food safety. 3. Monitoring: Weekly dining and med pass rounds x4 weeks, then monthly. RN Consultant to provide monthly audit of IP practices in the dining room and during med pass. Infection control standards related to med pass will be monitored by pharmacy during quarterly visit. 4. Responsible Party: Administrator, Licensed Nurses, Resident Care Coordinator, Nurse Consultant Pharmacy

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 6 sampled residents (#s 1 and 4) whose orders were reviewed. The findings include, but are not limited to: 1. Resident 4 moved into the assisted living in 01/2023 with diagnoses including chronic stage 3 kidney disease, hypertension, and edema. The resident’s current orders and MARs from 03/01/26 through 04/13/26 were reviewed during the survey. a. The following medications were not carried out as prescribed: * Potassium Chloride 10 mEq ER tablet was not administered from 03/24/26 - 03/30/26; * Cyclobenzaprine 5mg tablet, take one tablet twice per day for muscle spasms was not administered from 04/10/26 (second dose) - 04/13/26; * Lidocaine Patch daily for pain was not administered from 04/10/26 -04/13/26; * Polyethylene glycol take 17 gm daily for bowel care was not administered 04/10/26-04/13/26; * Senna 8.6 mg tablet, take one tablet, twice per day for bowel care was not administered from 04/10/26 -04/13/26; * Pregabalin 50 mg capsule take three times per day was not administered 04/10/26 (third dose) - 04/13/26; * Ropinirole tablet 1 mg tablet at bedtime for restless legs was not administered from 04/10/26 -04/13/26; and * Trazadone 50 mg, an antidepressant, give one tablet at bedtime was not administered from 04/10/26 -04/13/26. b. There were no signed physician or other legally recognized practitioner orders in the resident’s facility record for the following medications: * Oxycodone 5 mg tablet, take one tablet three times per day; * Tylenol 325 mg take two tablets every four hours ,as needed for pain; * Albuterol HFA inhaler every four hours, as needed for shortness of breath; * Antacid Suspension take two tablespoons by mouth every six hours, as needed, for stomach upset; * Fleet glycerin Suppository 2 gm daily, as needed, for bowel care; and * Naloxone HCL Spray for suspected opiate overdose, as needed. The need to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 2:35 pm. They acknowledged the findings. 2. Resident 1 moved into one of the facility’s memory care unit in 04/2025 with diagnoses including?Alzheimer’s disease and was admitted onto hospice services on 04/07/26. The resident’s clinical record, including MARs, physician’s orders, and progress notes were reviewed during the survey. The surveyor requested signed physician’s orders on 04/16/26 at 9:27 am. At 11:02 am, signed orders were received but per the documentation on the orders, the facility received them via fax on 04/16/26 at 10:33 am, during the time of the survey. There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders in the resident’s facility record for all medications and treatments the facility was responsible to administer. The need to ensure the facility had written, signed physician or other legally recognized practitioner orders in the resident’s record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Orders were clarified with Physician and implemented correctly for residents #1 & #4. 2. System Fix: Medication orders will go through a triple check process and will be brought to daily clinical meeting. A review of the orders portal in Point Click Care for any new or discontinued orders will be completed by . Interdisciplinary Team Medication orders will be verified with signed orders in house. 3. Monitoring: Weekly medication orders audits x4 weeks, then monthly. 4. Responsible Party: Licensed Nurse.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were kept accurate and included resident-specific parameters for PRN medications for 1 of 6 sampled residents (# 2) whose medications were reviewed. Findings include, but are not limited to: Resident 1 moved into one of the facility’s memory care community in 04/2025 with diagnoses including?Alzheimer’s disease. The resident’s clinical record including MARs, dated 04/01/26 through 04/13/26, and physician’s orders were reviewed during the survey. The following inaccuracies were identified: a. The following PRN medications were transcribed onto the MAR without current orders for administration: * Acetaminophen (for pain); * Barrier cream (for skin); * Polyethylene glycol (for constipation) to administer for no bowel movement in three days; * Polyethylene glycol to be administered for no bowel movement in five days; * Antacid (for upset stomach); * Hydrocodone (for pain); * Loperamide (for diarrhea); and * Ondansetron (for heart burn). b. The following PRN bowel medications used for constipation lacked instruction to staff on the sequential order of administration: * Polyethylene glycol, once daily; and * Senna, twice daily. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Resident #1 MARs were reviewed and orders were clarified to include PRN parameters. 2. System Fix: During Morning clinical meeting Interdisciplinary Team will review orders pending through the portal. LN or designee will follow-up until orders can be confirmed. 3. Monitoring: Weekly MAR audits x4 weeks, then monthly. Pharmacy Consultant or designee will audit for resident specific instructions/parameters during their quarterly audit. 4. Responsible Party: Administrator Licensed Nurses Resident Care Coordinator.

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 411-054-0070 (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 and record review, it was determined the facility failed to have two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: The facility was divided into three distinct and segregated areas: two memory care units, Memory Care 1 and Memory Care 2, and an assisted living unit on the second floor. At the time of the survey, the facility was home to 69 residents: 16 in Memory Care 1, nine in Memory Care 2, and 44 in the assisted living unit. Documentation provided by the facility on 04/14/26 indicated that one resident in Memory Care 2 and one resident in the assisted living unit required multiple-person transfers. The facility’s posted staffing plan identified the night shift, 10:30 pm to 6:30 am, was staffed with four direct care staff: one caregiver in each of the memory care units, one care giver in the assisted living unit, and one medication aide that floated between the three units. The facility failed to have a minimum of two direct care staff available in each of the units where a resident required the assistance of two direct care staff for scheduled and unscheduled needs. These findings were discussed with Staff 1 (Administrator) on 04/15/26 at 8:45 am. She acknowledged the findings.

1. Correction: Staffing assignments corrected to ensure adequate staffing for night shift for individuals who require the assistance of 2 direct care staff. 2. System Fix: All shifts reviewed, and scheduling safeguards implemented to ensure adequate staffing when residents in an area may require the assistance of 2 direct care staff. 3. Monitoring: Daily staffing review x60 days. 4. Responsible Party: Administrator Resident Care Coordinator

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 411-057-0140(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 licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C231, C295, and C360.

See Plan of Correction for C200, C231, C295 and C360

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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C303, and C310.

See Plan of Correction for C260, C270, C303 and 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 observation, interview, and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2, and 8) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, sampled and unsampled residents were observed needing assistance and encouragement from staff to initiate, attend, and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms, sat in the common areas, or ambulated in the unit. Resident 1, 2, and 8’s service plans were reviewed, and observations were made of the residents. The following was identified: Though the service plan included some information about activity preferences, there was no documented evidence of an evaluation that addressed the following required elements: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. On 04/16/26 at 10:16 am, Staff 8 (Activities Lead) verified neither she nor her staff had evaluated the residents who resided in the two memory care units as it pertained to activities. She also confirmed that an individual activity plan had not been developed. The need to develop individualized activity plans that were based on a thorough evaluation of the resident's activity interests, abilities, and needs was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Individualized activity plan evaluation have been completed for resident's #1, #2, & #8. to ensure that they are appropriate for their activity preferences. 2. System Fix: Resident Service Plans/ Activity Plans will be reviewed and updated at their next evaluation to ensure the Service Plans are reflective of each resident’s activities needs and provide clear direction to staff for the provision of personalized activities. Education provided to staff on service planning and providing individualized activities in Memory Care. Activities Evaluation section updated in Point Click Care to ensure individualized activity plans for each resident. Will complete each resident upon next evaluation. 3. Monitoring: Interdisciplinary Team to review for accuracy after each resident evaluation is completed. 4. Responsible Party: Interdisciplinary Team including Activities Coordinator

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: