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 residents' current care needs and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 11/2024 and had diagnoses including hypertension and arthritis. The resident's current service plan, dated 11/05/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, and did not provide clear instruction to staff in the following areas: * Breakfast in apartment; * Transfers and toileting assistance; * Shower assist and assistive device; and * Mobility using walker vs wheelchair, vs electric scooter, with instruction for staff. The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator) on 12/11/24. They acknowledged the findings. 2. Resident 2 moved into the facility in 06/2024 and had diagnoses including osteoarthritis and heart failure. The resident's current service plan, dated 11/07/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas: * Compression stockings; * Leg braces; * Two person transfers with gait belt; * Toileting assist; * Shower assist and equipment; * Hobbies and interests; * Edema of lower extremities, including instructions for staff; * Weight monitoring; and * Leg spasm/cramping pain, including non-drug interventions. The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and/or were implemented was discussed with Staff 1 (Administrator), Staff 3 (Health Services Director), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator) on 12/11/24. They acknowledged the findings. 3. Resident 3 moved into the facility in 12/2011 with diagnoses including vascular dementia and anxiety disorder. The resident’s service plan dated 11/08/24 was reviewed, observations were made, and interviews were conducted. The resident's service plan was not reflective of the resident’s needs and preferences and did not provide clear direction to staff in the following areas: * Transfer assistance; * Meal assistance; * Interventions for behaviors related to spitting out food and screaming when touched; * Communication related to repetitive phrases that were not always meaningful, e.g. “Let’s go” and “That’s enough”; and * Resident preference for leaving apartment door open. The need to ensure service plans were reflective of residents' current needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 4 (Resident Services Coordinator) on 12/12/24. They acknowledged the findings. 4. Resident 4 moved into the facility in 05/2021 with diagnoses including atrial fibrillation and kidney disease. Resident 4’s current service plan, dated 07/12/24 and temporary service plans were reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident’s needs or did not provide clear direction to staff in the following areas: * Toileting; * Use and assistance with walker and wheelchair; * Transfer ability and number of staff needed to assist; * Assistance needed with activities of daily living; and * Edema management. The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 3 (Director of Health Services), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator) on 12/11/24. They acknowledged the findings.

C260 - Service Plan's for residents 1 - 4 have been updated with the indicated area's of deficiency: Resident 1: Added additional information for breakfast in her apt, transfers status, toileting, shower assistance and devices uses, mobility instructions for staff re:walker vs. wheelchair vs electric scooter. Resident 2 : Compression stockings, leg braces, two person transfers, toileting assistance, shower assistance, hobbies & interests, edema instructions, weight monitoring, and leg spasms - non-pharm interventions. Resident 3 : transfer assistance, meal assistance, interventions for behaviors, communication and repetative phrases, resident preference for leaving door open. Resident 4: toileting, walker vs wheelchair, transfer ability, ADL assistance, edema management. Total audit for all Service Plan's for completeness will be completed per Service Plan schedule and all will be done by our date of compliance (2/10/24). RSC and Admin responsible to ensure completion. Weekly Audit meeting to be conducted on a continued basis for continued improvement. Responsible: RSC, Admininistrator, RN

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

OAR 411-054-0070 (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 interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident and to compensate for staff duties beyond direct resident care. Findings include but are not limited to: During the acuity interview on 12/09/24, staff identified four residents that required the assistance of two staff people for care related to transfers and ADL needs. Throughout the survey additional residents were identified as needing 2-person assistance. The facility posted staffing plan for December 2024 indicated the facility was staffing night shift with 1 MT and 1 CG. During a group interview on 12/10/24 at 1pm, an unsampled resident reported “a couple times a week on night shift I had to wait 20 minutes or longer”, after pressing their call pendent for assistance. On one occasion, after pressing his/her call pendent at approximately 1am, the CG reported to the resident the MT was at the other licensed building on the campus, which was why the response was so long. During interviews with multiple staff from 12/09/24 through 12/12/24 the following information was reported: * There is “not enough staff on noc shifts, MT’s on noc shift are really busy doing medications and when an emergency happens, such as a resident needing an ambulance or first aide, the MT cannot finish their rounds”; * “A lot of calls pendants are pressed between 3am and 4am”; * “When day shift starts, noc shift is frequently still finishing their rounds due to something unexpected happened at night and the MT got behind”; * At times on night shift, staff have to call for assistance from another separate and distinct licensed building; and * When a MT calls out on night shift, the MT has to cover the other separate and distinct licensed building. On 12/12/24, Staff 1 (Administrator) reported that the facility occasionally used one MT to cover a night shift between the facility and another separate and distinct facility on the campus, leaving one CG in the facility. In an interview on 12/12/24, Staff 1 and Staff 4 (Resident Services Coordinator) acknowledged there were seven residents in the facility who required 2-person assistance. The need to ensure sufficient staffing to meet the scheduled and unscheduled needs of the residents was discussed with Staff 1 and Staff 4 on 12/12/24. They acknowledged the need for additional staffing.

C360 - ABST has been updated to be more reflective of our current residents scheduled and unscheduled needs. Additional caregiving hours has been added to the current staffing plan for NOC shift. We will continue to adjust our ABST and staffing plan as resident's needs change - per Service Plan schedule and upon changes of condition/move in's and outs. Responsible for assuring compliance: RSC,Staffing Coordinator, Administrator.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to residents. Findings include, but are not limited to: A review of the facility’s ABST revealed the care times and care elements documented for cares provided by staff were not accurate for Residents 1, 2, 3, and 4. The need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1 (Administrator) and Staff 4 (Resident Services Coordinator) on 12/12/24. They acknowledged the findings.

C362 - ABST audit will be completed by date of compliance. ABST updated as indicated to capture cares provided to residents 1 - 4. Moving forward, resident specific care times have been added to the pre-care plan conference documentation to enable caregivers are able to give feedback on changes of duration of cares. Updates as per Service Plan schedule and changes of condition. Responsible for compliance: RSC, Administrator

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 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 14 and 20) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 12/11/24 and revealed the following: a. Staff 14 (CG), hired on 10/03/24, lacked documented evidence of competency within 30 days of hire in the following required topics: * General food safety, serving, and sanitation. b. Staff 20 (MT), hired 10/04/24, lacked documented evidence of competency within 30 days of hire in the following required topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; and * General food safety, serving, and sanitation. On 12/11/24, the need to ensure staff had documented evidence of competency demonstration within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 7 (Staffing Coordinator). They acknowledged the findings.

C372 - Staff 14 has completed their food handlers card and is up to date on training complaince. Staff 20 has completed the following training: Role of Service Plan's in providing individual care, providing assistance with ADLs, and general food safety (food handlers card). Staff training audit completed by 2/10/2024 - Staffing Coordinator Any staff behind on their trainings will be brought current by 2/10/2024 or removed from the floor. Responsible for compliance: Staffing Coordinator, Administrator

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired direct care staff (#21) demonstrated competency of skills in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training was reviewed with Staff 1 (Administrator) on 03/18/25 and revealed the following: Staff 21 (CG), hired on 01/21/25, lacked documented evidence of competency within 30 days of hire in the following required topics: *Role of service plans in providing individualized care; *Providing assistance with ADLs; *Changes associated with normal aging; *Identification, documentation, and reporting changes of condition; *Conditions that require assessment, treatment, observation, and reporting; and *General food safety, serving, and sanitation. In an interview on 03/18/25, Staff 1 reported Staff 21 would be pulled from the floor until documented evidence of competency was completed. On 03/18/25, the need to ensure staff had documented evidence of competency demonstration in assigned duties, within 30 days of their hire date, was discussed with Staff 1 (Administrator) and Staff 3 (Resident Services Coordinator). They acknowledged the findings.

C 372 - 1. Competency Checklist has been completed for employee selected during survey. 2. On going we have updated our process to include uploading of the Competency Checklist to their digital employee records prior to an employee being independent on the floor. Administrator or Staffing Coordinator will give the final "ok" for the employee to be scheduled independantly. 3. Weekly check in's with the Staffing Coordinator regarding staff training Wednesday's at 1:00 pm 4. Staffing Coordinator, Administrator

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

1. We will be completeing all compliance tags as soon as possible with a date of completion being 5/2/2025 2. See below for continued compliance 3. Quarterly review of all compliance areas via Environmental Walk through and Home Office State Survey prepardness visits. 4. Plant Ops, Staffing Coordinator, Administrators, ED

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure outside surfaces were maintained in good repair. Findings include, but are not limited to: On 12/09/24, the outdoor areas of the facility were toured, and the following was identified: * The interior courtyard had multiple concrete sidewalks had shifted and were uneven. The uneven sidewalks created a potential fall hazard for residents; and * Throughout the courtyard and exterior pathways, multiple two inch drop-offs measured from the sidewalks to the ground were observed. The drop offs created a potential fall hazard for residents. On 12/09/24, the need to ensure exterior sidewalks and outside surfaces were maintained in good repair was discussed with Staff 1 (Administrator) and Staff 8 (Director of Plant Operations). They acknowledged the findings.

C610 - - Interior courtyard sidewalks and around building sidewalks have been leveled per industry standards. - 2 inch drop offs from concrete to garden beds have been filled in with appropriate landscaping material to reduce the drop offs. - Ongoing Quarterly Enviornmental tool will be utilized to capture needed maintenance issues and added to our TELs system for completion. Responsible for completion: Director of Plant Operations, Admin

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure 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 was clean and in good repair. Findings include, but are not limited to: On 12/09/24, a tour of the interior and exterior of the facility identified the following: Interior: a. Carpet stains were observed near and/or inside: * Hallways; * The dining room; * Men’s public restroom; * Laundry room; and * Resident rooms, including but not limited to: #18, #19, #25, #28, #33, #36, #37, and #38. b. Multiple doors, door frames, and walls throughout the facility had chipped paint, scuffs, scrapes, and/or worn off finishes; c. Multiple chairs in the dining area had scrapes, and/or worn off finishes; d. Multiple handrails throughout the facility had gouges and/or worn off finishes; and e. Between 12/09/24 through 12/12/24, a strong pervasive urine odor was detected in the hallway near room 33. Exterior: *Multiple walls and doors throughout the exterior of the facility had debris and spider webs; *Multiple exterior window frames had peeling finishes; *Multiple exterior window screens were torn, allowing for potential pests to enter the building; and *The concrete pathway near the exterior kitchenette door was observed with an accumulation of black matter. On 12/09/24, the need to be free from unpleasant odors, and the interior and exterior areas in need of cleaning and repair was discussed Staff 1 (Administrator) and Staff 8 (Director of Plant Operations). They acknowledged the findings.

C613 - Interior - All common area carpeted area's have been deep cleaned by outside provider. On going carpet cleaning scheduled.Doors & door frames repaired per professional recommendation and will continue per touch up schedule. Dining room chairs have been repaired or replaced. Handrails have been sanded and finished. Exterior - Outside areas cleared of debris and spider webs. Windows - Director of Plan operations has reached out to our window treatment supplier for next steps for the peeling finishes for the window & screen replacements. To be completed by compliance date. Outside walkway by kitchen powerwashed and cleaned. On going improvement will be captured using the Quarterly Environmental Audit Tool and TELs system to catch needed environmental improvements and maintenance. Responsible party - Director of Plant Operations and Administrator.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure 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 was clean and in good repair. Findings include, but are not limited to: On 03/18/25, a tour of the interior and exterior of the facility identified the following: Interior: a. Carpet stains were observed near and/or inside: * Hallways; * The dining room; and * Resident rooms, including but not limited to: #33 and #38. b. Multiple doors, door frames, and walls throughout the facility had chipped paint, scuffs, scrapes, and/or worn off finishes; and e. A strong pervasive odor was detected in the hallway near room 33. Exterior: *Multiple exterior window frames had peeling finishes; and *The concrete pathway near the exterior kitchenette door was observed with an accumulation of black matter. On 03/18/25, the need to be free from unpleasant odors, and the interior and exterior areas in need of cleaning and repair was discussed with Staff 1 (Administrator). She acknowledged the findings.

C 613 1. a. carpet stains below hand sanitizer dispensors have been touched up by outside vendor. * Regular carpet cleaning of high traffic areas added to maintenance schedule. Med Techs given access to our TELS system to better capture areas of concern in a timely manner. * Professional odor control devices installed by outside vendor. * Each room listed has been deap cleaned by our maintenance crew. Laundry of residents with unpleasent urine odors changed from weekly to daily. B. Door frames have been painted and have been added to the TELS system for a regular touch up schedule. * outside vendor to install scuff resistant coating to all doors in AL2 in the hopes of reducing further occurrence of uncleanable surfaces or doors being not in good repair. c. Each room listed as having a strong pervasive odor have been deep cleaned. Laundry Service changed from weekly to daily for those with ongoing incontinence odors. * All window frames have been repainted, repaired, or replaced as needed. Concrete stains outside kitchen have been professionally cleaned and will be maintained per maintenance schedule. Staff trained to no longer set trash bags directly onto the contrete. 4. Plant Ops, Maintenance crew, TELS system, Admin, ED

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