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 notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred and failed to report physical injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, for 1 of 4 sampled residents with reportable incidents (# 5). Findings include, but are not limited to: Resident 5 moved into the facility 12/2024 with diagnoses including Alzheimer’s disease. The resident's 12/01/24 to 03/02/25 Observation notes, Temporary Service Plans, incident reports, and Incident Investigations were reviewed, and interviews with staff were conducted. The following was identified: a. Injuries of unknown cause were identified by staff on the following dates: * 12/14/25 – Right big toe; and * 01/01/25 – Left knee. During an interview at 12:50 pm on 03/04/25, Staff 2 (Wellness Director) confirmed there was no documentation that an investigation occurred to rule out suspected abuse and the injuries of unknown cause were not reported to the local SPD office. b. On 01/31/25, Resident 5 was struck in the face by another resident. There was no documented evidence that the incident was reported to the local SPD office. The survey team requested the above incidents be reported to the local SPD office, and confirmation was provided at 8:40 am on 03/06/25. The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office, and that injuries of unknown cause were immediately reported to the local SPD unless an immediate investigation reasonably concluded that the injury was not the result of abuse, was reviewed with Staff 1 (ED), Staff 2 and Staff 4 (Administrative Assistant) on 03/06/25 at 12:40 pm. They acknowledged the findings.

1. Actions that will be taken to correct the rule violation: The Administrator/Executive Director and Wellness Director immediately reported the two injuries of unknown origin (Resident #5) and the Resident-to-Resident incident identified in this finding to APS (3/17). Additionally, Resident #5 was reported as required (. The VP of Clinical Services conducted a re-inservice for both team leaders on Oregon Reporting (3/14/2025) Requirements on 3/14/2025 to reinforce compliance. 2. System Corrections to Prevent Future Violations: • All injuries of unknown origin where abuse or neglect cannot be clearly ruled out will be reported to APS as required, as will any resident-to-resident altercations. • Facility incidents will be closely monitored by facility leadership on a daily basis to ensure all incidents are identified and reported as required. • A monthly report will be prepared and submitted to the QA committee detailing all incidents, including those of unknown origin and resident-to-resident incidents. • Facility staff will receive in-service training on the importance of identifying and reporting such incidents, including those occurring after hours, weekends, and holidays, to ensure continuous compliance. (March 11 and April 8) 3. Evaluation Frequency and Assigned Personnel: • The facility leadership will conduct daily monitoring of incidents to ensure timely reporting. • The QA committee will receive monthly reports and assess compliance for one year April 2025-March 2026; if no further findings are identified the report will revert to "as needed/prn" basis at the direction of the QA committee. • The QA committee will oversee the review of all incidents to verify that proper reporting and investigation procedures are consistently followed. 4. Staff Responsibility for Ensuring Compliance: • The Executive Director is primarily responsible for ensuring the effectiveness of this corrective action plan. • The QA committee will monitor incidents, evaluate trends, and implement any necessary additional corrective actions. • Facility leadership, including the Wellness Director and team leaders, will oversee daily monitoring and staff compliance with reporting requirements.

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 that the facility failed to investigate incidents of abuse or suspected abuse promptly or immediately report to the local Seniors and People with Disability (SPD) office for 1 of 2 sampled residents (# 11) who had a fall with a fracture. This is a repeat citation. Findings include, but are not limited to: Resident 11 was admitted to the facility in 10/2024 with diagnoses including dementia. Interviews with staff and review of the resident's 09/04/25 service plan and 06/11/25 through 09/16/25 interim service plans, progress notes, and incident investigations were completed. The following was identified: On 09/16/2025, during an acuity interview, Staff 2 (Wellness Director/LPN) and Staff 3 (RN) reported that Resident 11 had sustained a fall with a sacral fracture. On 08/22/25, an incident report was completed, indicating that Resident 11 had an unwitnessed fall at 1:30 pm in a common area of the cottage. The resident was unable to state what had happened. After the fall, Resident 11 complained of back and hip pain. On 08/27/25, the resident was sent to the hospital for severe back and hip pain and returned with a diagnosis of a sacral fracture. Staff 3 completed an investigation of the fall with injury on 08/27/25, which was five days after the fall, and had not reported the incident to the local SPD. The facility was instructed to report the injury of unknown cause to the local SPD office on 09/16/25 at 12:31 pm. Proof of reporting was received from the facility on 09/16/25 at 2:49 pm. The need to ensure all incidents and injuries were investigated immediately and, if not, were reported to the local SPD office was discussed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), and Staff 3 (RN) on 09/17/25. They acknowledged the findings.

1. Facility reported this fall with fracture as requested to APS on 9/16/2025. 2. System Corrections to Prevent Future Violations: • All injuries of unknown origin where abuse or neglect cannot be clearly ruled out will be reported to APS as required. • Facility will develop a check list on all falls or injuries of unknown origin that it will use as a tool until the QA committee feels that reports are made when abuse or neglect cannot be immediately ruled out. • Incidents will be reviewed, and the checklist completed during clinical stand up, to ensure that anything needing reporting was reported to APS • Med Techs, which are shift team leaders, will be reminded of the need to immediately investigate to rule out abuse and neglect, as they handle the incident and to discuss with the nurse, if not present, their findings; they will be taught that if we cannot rule out abuse and neglect we will be reporting the incident to APS This inservice will be held 9/25/25 and repeated at the October Med Tech Meeting. All Staff will be reminded of the need to rule out abuse and neglect when they identify a resident incident in our October 14 All Staff Training Meeting. • A monthly QA report will be prepared and submitted to the QA committee presenting these incident audit forms in order to validate reporting is happening as required. 3. Evaluation Frequency and Assigned Personnel: • The facility leadership will conduct daily monitoring of incidents to ensure timely reporting during clinical stand up. • The QA committee will continue to receive monthly reports at its meeting and assess compliance for the rest of the one year period April 2025-March 2026 with the addition of these checklist/audit documents for incidents; if no further findings are identified the report will revert to "as needed/prn" basis at the direction of the QA committee. • The QA committee will oversee the review of all incidents to verify that proper reporting and investigation procedures are consistently followed. 4. Staff Responsibility for Ensuring Compliance: • The Executive Director is primarily responsible for ensuring the effectiveness of this corrective action plan. • The QA committee will monitor incidents, evaluate trends, and implement any necessary additional corrective actions. • Facility leadership, including the Wellness Director and care team leaders, will oversee daily monitoring and staff compliance with reporting requirements.

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 residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 6 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 11/2024 with diagnoses including Alzheimer’s disease and type 2 diabetes. Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 02/25/25, and Temporary Service Plans showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Hospice services, including frequency and the tasks they were responsible for providing; * Current ability to express needs; * Bed bath instructions; * Use and assistance with a tilt-in-space chair; * Alternating pressure mattress instructions; * Meal assistance instructions, including aspiration precautions; * Frequency of offering fluids and snacks; * Level of assistance needed for teeth brushing and oral care; * Frequency of safety checks; * Non-pharmacological interventions for pain; and * Current skin condition and treatment. The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director) and Staff 4 (Administrative Assistant) on 03/06/25. They acknowledged the findings. 2. Resident 4 moved into the facility in 03/2024 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, review of the resident's service plan, dated 01/08/25, and Temporary Service Plans showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Weight gain; * Pain and medication available; * Falls within the past 90 days; * Interventions for refusals relating to ADLs; * Sleeping attire; * How Resident 4 reacts during showers and getting his/her hair wet; * Staff announcing intent to let the resident know when they need to go into his/her unit to negate behaviors; * Triggers that cause Resident 4's agitation towards other residents; and * Person centered behavior interventions. The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant) on 03/06/25. They acknowledged the findings.

1. Actions to Correct the Rule Violation: • Resident #3 and #4 will have their service plans updated to reflect their current needs as identified in this finding. • Any changes will also be reflected in the residents' ABST to ensure accuracy. • The updated service plan will be reviewed by the residents' RP and signed electronically no less than every 90 days or upon a significant change of condition. 2. System Corrections to Prevent Future Violations: An audit will be done to identify any Service Plans that are not compliant with the minimum of a quarterly review and if needed update. All resident service plans that are not in compliance with their quarterly review will be caught up and brought current. After this task is complete facility will ensure: • Each resident’s service plan will be reviewed quarterly to ensure completeness and alignment with their current needs. • Updates will be provided electronically to families if they prefer not to have an in-person meeting. • Facility representatives and the resident representative will document and date all service plan changes. * Facility staff will be in-serviced on the importance of reviewing and acknowledging service plan changes and will be inserviced on the importance of reviewing and signing off on resident care changes present in the 24 hr binder April 2 and 8. 3. Evaluation Frequency and Assigned Personnel: • The RCC and/or the Wellness Director (WD) will conduct random audits on reviewing/signing care plans changes, and present the audit to the QA committee monthly for 3 months and then revert to a quarterly report for one year if no further issues identified. • The QA committee will monitor and evaluate compliance on an ongoing basis. 4. Staff Responsibility for Ensuring Compliance: • The Executive Director (ED) and Wellness Director (WD) will oversee the implementation and ensure the plan remains active and current.

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 residents who had a significant change of condition were evaluated, referred to the RN for assessment and the service plan was updated as needed, and/or failed to ensure residents who experienced a short-term change of condition had actions or interventions determined and documented, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 7 sampled residents (#s 2, 4, 5, and 7) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 03/2024 with diagnoses including Alzheimer’s disease. The resident's service plan, dated 01/08/25, Observation notes, dated 12/01/24 through 03/04/25, Temporary Service Plans, Task Administration Record (alert charting documentation) for 12/2024, and weight records, dated 07/2024 through 02/2025, were reviewed. Staff were interviewed and Resident 4 was observed. a. Resident 4’s weight records were reviewed and revealed the following: * 01/15/25: 131 pounds; * 01/22/25: 133 pounds; * 01/29/25: 137 pounds; * 02/05/25: 140 pounds; and * 02/19/25: 142. 8 pounds. The surveyor requested the resident be weighed during the survey. On 03/04/25 at 10:44 am, Resident 4 weighed 144.4 pounds. Between 01/15/25 and 02/19/25, Resident 4 had a weight gain of 11.8 pounds or 8.26% of his/her total body weight in one month. The weight represented a significant change of condition, and the facility was required to evaluate, to refer to the facility RN, to document the change, and to update the service plan as needed. There was no documented evidence the resident was evaluated, the significant change of condition was referred to the facility nurse, or the service plan was updated as needed. b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution: * 12/13/24: Resident 4 reported being in extreme pain; * 12/16/24: The resident reported continued extreme pain; * 12/22/24: Resident to resident altercation; and * 12/24/24: An increase in Depakote (to treat psychiatric conditions) and Zyprexa (an antipsychotic). The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed; and determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant) on 03/04/25 and 03/06/25. They acknowledged the findings. 2. Resident 7 moved into the facility in 11/2024 with diagnoses including vascular dementia. The resident's service plan, dated 12/31/24, Observation notes, dated 12/02/24 through 03/03/25, Temporary Service Plans, and Task Administration Record (alert charting documentation) were reviewed and staff were interviewed. The following was identified: Resident 7 was involved in a resident to resident altercation on 12/22/24. There was no documented evidence the facility determined actions or interventions, communicated those actions or interventions to staff on all shifts, and monitored the resident through resolution relating to the resident to resident altercation. The need to ensure the facility determined and documented what action or intervention was needed for a short-term change of condition, communicated the action or intervention to staff on all shifts, and monitored the short-term change of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant) on 03/06/25. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 10/2021 with diagnoses including dementia. Resident 2's clinical record was reviewed for changes of condition and identified the following: * A progress note on 12/14/24 indicated the resident was experiencing pain near their buttocks. Staff observed Resident 2’s skin and indicated the right buttock was reddening and beginning to form a pressure wound. “The wound did not appear to be deep or break the skin.” There was no documented evidence of ongoing monitoring or resolution of the resident skin condition. During an interview on 03/04/25, Staff 24 (CG) indicated Resident 2’s current skin condition was stable and intact. On 03/06/25, the need to ensure residents who experienced short-term changes of condition were monitored weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant). They acknowledged the findings. 4. Resident 5 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. The resident's current service plan available to staff, dated 02/25/25, and 12/01/24 through 03/02/25 Observation notes and Temporary Service Plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution: * 12/14/24 – “[Right] big toe is open and bleeding”; * 12/17/24 – Groin “bright red in color and painful”; * 12/29/24 – Weeping yellow discharge in groin with odor; * 01/01/25 – Skin abrasion to left elbow and left knee; * 02/07/25 – Witnessed non-injury fall; * 02/19/25 – Increased transfer assistance required, use of hoyer mechanical lift; and * 02/21/25 – New type of hoyer sling being utilized. The need to ensure the facility determined and documented actions or interventions needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (ED), Staff 2 (Wellness Director) and Staff 4 (Administrative Assistant) on 03/06/25 at 12:40 pm. They acknowledged the findings.

1. Actions to Correct the Rule Violation: • Residents #2, #4, #5, and #7 will have Change of Condition (COC) reviews conducted based on this finding. • When a resident experiences a COC, the Service Plan or TSP will be updated accordingly. Staff will review the updated document for new interventions and care needs. • A copy of the updated document will be placed in the beginning of the 24-hour book, with staff signatures confirming their review. • Weekly charting of TSP interventions will be completed by the MT/RCC daily until the condition resolves. • Monitoring notes will be recorded in the Observation Notes section of the clinical record every shift. • Clinical Stand-Up meetings will direct staff on when a condition has resolved, allowing it to be removed from the 24-hour report log and no longer require daily or weekly notes. 2. System Corrections to Prevent Future Violations: • An in-service training will be conducted with MT/RCCs to reinforce the importance of daily shift charting on TSPs. • Ongoing education will be provided to ensure staff recognize and report necessary changes promptly. • Staff will be reminded that if the nurse is not informed about changes, necessary interventions cannot be implemented. 3. Evaluation Frequency and Assigned Personnel: • A monthly audit will be performed on a sample of TSP and COC events to assess if changes are being charted weekly and if interventions remain current, implemented, and effective. • Findings from these audits will be presented to the QA committee for review for three months April/May/June. • If the QA Committee determines that this plan of correction has resolved the finding, the reporting frequency will shift to quarterly for the remainder of the QA year. 4. Staff Responsibility for Ensuring Compliance: • The RN, Executive Director (ED), and Wellness Director are responsible for ensuring the Plan of Correction remains effective and is continuously monitored.

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 residents who had a significant change of condition were referred to the RN for assessment, and/or failed to ensure residents who experienced a short-term change of condition had actions or interventions determined and documented, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 4 sampled residents (#s 8, 9, 10, and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the community in 12/2024 with diagnoses including Alzheimer's disease and Pick's disease. The resident’s Observation notes dated 06/01/25 through 09/12/25, service plan dated 06/12/25, and Temporary Service Plans (TSPs) and Change in Service Plans dated 06/21/25 through 09/08/25 were reviewed, and interviews with staff were conducted. The following was identified: a. On 07/02/25 the resident experienced a severe weight gain of 10.1% in 90 days, which constituted a significant change in condition. The RN assessment determined the following interventions: * Intake monitoring; * Staff to offer and encourage lower carb/low sugar foods – more protein, vegetables, fruits as tolerated; and * Sugar free snacks and drinks as tolerated. There was no documented evidence interventions had been communicated to staff on all shifts, or that the facility had monitored the resident according to their evaluated needs. On 09/17/25, Staff 3 (RN) reported that although intake monitoring had been communicated and implemented electronically, she was unable to find the TSP that instructed staff to encourage lower carb foods, more protein, vegetables, fruits, and sugar free snacks and drinks, and did not know if these interventions had been implemented. The need to ensure the facility communicated determined interventions for changes of condition to staff on all shifts, and monitored the resident according to their evaluated needs, was discussed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), and Staff 3 on 09/17/25 at 3:15 pm. They acknowledged the findings. b. On 6/21/25 Observation notes reported the resident returned from urgent care with confirmation of a urinary tract infection (UTI). There was no documented evidence the facility determined interventions, communicated interventions to staff, and monitored the resident at least weekly through resolution. In an interview on 09/17/25, Staff 2 (Wellness Director/LPN) reported that he did not know UTIs required documented monitoring. The need to ensure the facility determined interventions for changes of condition, communicated interventions to staff, and monitored the resident according to their evaluated needs, was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN) on 09/17/25 at 3:15 pm. They acknowledged the findings. 2. Resident 9 moved into the community in 03/2024 with diagnoses including dementia and type 2 diabetes. The resident’s Observation notes dated 06/01/25 through 09/16/25, service plan dated 08/19/25, and Temporary Service Plans (TSPs) and Change in Service Plans dated 05/27/25 through 09/12/25 were reviewed, and interviews with staff were conducted. The following was identified: a. An Observation note dated 06/15/25 documented that the resident complained of pain while urinating and reported having difficulty urinating. On 07/01/25, an Observation note stated, “Course of Cefpodoxime is complete — staff report [resident] is continuing to manifest altered mentation and dysuria [discomfort when urinating].” There was no documented evidence that the facility had determined interventions for the change of condition and monitored the resident according to their evaluated needs. In an interview on 09/16/25 Staff 2 (Wellness Director/LPN) stated there was no TSP for this UTI, and no documentation of monitoring of the resident according to their evaluated needs. b. An Observation note dated 08/27/95 documented a rash on the resident’s chest. There was no documented evidence the rash was monitored at least weekly through resolution. The need to ensure the facility monitored changes of condition at least weekly through resolution was discussed with Staff1 (ED), Staff 2, and Staff 3 (RN) on 09/17/25 at 3:15 pm. They acknowledged the findings. 3. Resident 10 was admitted to the facility in 02/2022 with diagnoses including dementia and diabetes. The resident's 06/20/25 service plan and progress notes, interim service plans, and incident reports dated 06/05/25 through 09/16/25 were reviewed. The following short-term changes of condition lacked actions/interventions determined and communicated to staff on all shifts, and/or RN notification of a significant change of condition: * 07/25/25 – Progress notes indicated an open area to the left buttocks. There were no actions or interventions determined and communicated to staff on all shifts. This area was resolved on 08/25/25. In an interview on 09/17/25, Staff 3 (RN) reported that there were already interventions in place on the MAR for staff, and no additional interventions determined at that time. * 09/08/25 – A transcribed hospice visit note identified open wounds to the right buttocks (3x3x0 cm) and left buttocks (2x1x0 cm). On 09/15/25, the right buttock wound measured 8 x 3 cm, and the left buttock wound measured 4 x 3 cm. There were no actions or interventions determined and communicated to staff on all shifts. On 09/17/25, Staff 2 reported that the resident had a history of recurrent pressure ulcers to the buttocks, but that she had not been notified of the wounds, which opened on 09/08/25, and there were already interventions in place on the MAR for staff, and no additional interventions were determined at that time. The need to ensure changes of condition had actions/interventions determined, and the RN was notified of significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), and Staff 3 on 09/17/25. They acknowledged the findings. 4. Resident 11 was admitted to the facility in 10/2024 with diagnoses including dementia. The resident's 09/04/25 service plan and progress notes, interim service plans, and incident reports dated 06/05/25 through 09/16/25 were reviewed. The following short-term changes of condition lacked actions/interventions determined and communicated to staff on all shifts, and monitoring of progress at least weekly through resolution: * On 07/23/25, Resident 11 was reported as stating, “someone ran my foot over and it hurts”. There was no follow-up with actions/interventions determined, and no documented monitoring of progress through resolution. Staff 2 (Wellness Director/LPN) stated that the daughter had told staff that the resident had a history of something running over his/her foot so thought it was not a change of condition. * On 07/09/25, progress notes indicated the resident’s eyes were red, itchy, and puffy, with a complaint of stabbing pain in the right eye. There was no follow-up with actions/interventions determined, and no documented monitoring of progress through resolution. Staff 2 and Staff 3 (RN) reported on 09/17/25 that there were no instructions provided for staff or monitoring of the symptoms. * On 07/11/25, Resident 11 was started on Flonase 50 mcg, two sprays in each nostril daily for allergy symptoms. There was no follow-up with actions/interventions determined, and no documented monitoring for adverse effects of the new medication. The need to ensure changes of condition had actions/interventions determined and communicated to staff on all shifts, and were monitored through resolution, was discussed with Staff 1 (ED), Staff 2, and Staff 3 on 09/17/25. They acknowledged the findings.

1. Actions to Correct the Rule Violation:• Residents #8 #9 continue with weekly RN review of COC through resolution. Resident #10 continues with weekly wound assessment by licensed nurse through resolution. Resident #11's service plan is updated to her COC and an APS report was made 9/16/25 reporting an fall with fracture. 2. System Corrections to Prevent Future Violations • When a resident experiences a COC, the RN will be immediately alerted to the need for a COC and the Service Plan or TSP will be updated accordingly. • A copy of the updated document will be placed in the beginning of the 24-hour book, with staff signatures confirming their review. • Documentation of interventions will be completed by the MT/RCC daily until the condition is resolved, or a permanent change is warranted. • Monitoring notes will be recorded in the Observation Notes section of the clinical record every shift. • Clinical Stand-Up meetings will direct staff on when a condition has resolved, allowing it to be removed from the 24-hour report log and no longer require daily or weekly notes. This process will cumulate in a resolution note by the Licensed Nurse in the residents chart. • An in-service training will be conducted with MT/RCCs to reinforce the importance of daily shift charting on TSPs. • Ongoing education will be provided to ensure staff recognize and report necessary changes promptly. • Med Techs will be reminded in an inservice on 9/25/2025 that if the nurse is not informed about changes, necessary interventions cannot be implemented. Documentation rules will be reviewed thoroughly during this inservice. Furthermore we will work over the next year to make sure our Med Techs participate in the Oregon Care Partners class on Change of Condition. The RN, the LPN and the ED all took this class, either recently or for this POC. It is a good overview of the requirements and will useful for our staff training. It should also be noted that both the RN and the LPN/Wellness Director are participating in Nurse Learn. • During clincal stand up the shift task sheets will be used to review if shift to shift charting is being accomplished on residents on alert. In addition the Wellness Director and/or RN will use the shift task sheet to spot check that alert charting appears in the resident records for each shift, for residents currently on alert; and will discontinue alert charting on residents who’s conditions have resolved or a permenent service plan change has been implemented. If incomplete documentation is identified the staff member involved will be coached to its importance. 3. Evaluation Frequency and Assigned Personnel: • A monthly audit will be performed on a sample of TSP and COC events to assess if changes are being charted weekly and if interventions remain current, implemented, and effective. • Findings from these audits will be presented to the QA committee for review for three months Oct/Nov/December. • If the QA Committee determines that this plan of correction has resolved the finding, the reporting frequency will shift to quarterly untill the QA committee feels it can be reduced. 4. Staff Responsibility for Ensuring Compliance: • The RN, Executive Director (ED), and Wellness Director are responsible for ensuring the Plan of Correction remains effective and is continuously monitored.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 1 of 1 sampled resident (# 4) who experienced significant weight gain. Findings include, but are not limited to: Resident 4 moved into the facility in 03/2024 with diagnoses including Alzheimer’s disease. The resident’s Observation notes, dated 12/01/24 through 03/04/25, Temporary Service Plans, and weight records, dated 07/2024 through 02/2025, were reviewed. Staff were interviewed and Resident 4 was observed. The following weights were recorded by the facility: * 01/15/25: 131 pounds; * 01/22/25: 133 pounds; * 01/29/25: 137 pounds; * 02/05/25: 140 pounds; and * 02/19/25: 142. 8 pounds. The surveyor requested the resident be weighed during the survey. On 03/04/25 at 10:44 am, Resident 4 weighed 144.4 pounds. Between 01/15/25 and 02/19/25, Resident 4 had a weight gain of 11.8 pounds or 8.26% of his/her total body weight in one month. The weight represented a significant change of condition. There was no documented evidence the facility RN conducted a timely assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure a timely RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 3 (RN), and Staff 4 (Administrative Assistant) on 03/04/25 and 03/06/25. They acknowledged the findings.

1. Actions to Correct the Rule Violation: • Resident #4 has had their Change of Condition (COC) evaluation and documentation completed by the RN. • The Facility Executive Director (ED) will ensure that when the Wellness Director identifies a COC requiring RN evaluation, the RN completes the evaluation in a timely manner. 2. System Corrections to Prevent Future Violations: • The Facility ED will actively oversee the COC identification and evaluation process to ensure no delays. • A structured communication process will be implemented to ensure the Wellness Director promptly notifies the RN of necessary evaluations. 3. Evaluation Frequency and Assigned Personnel: • An audit of COCs and their completion will be presented to the QA committee monthly for one quarter. • If no further issues are identified, the audit will transition to a quarterly review for the remainder of the year. 4. Staff Responsibility for Ensuring Compliance: • The Executive Director (ED) is responsible for ensuring this Plan of Correction remains effective and is continuously monitored.

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

OAR 411-054-0045(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 outside providers in order to ensure the continuity of care for 1 of 3 sampled residents (# 3) who received outside services. Findings include, but are not limited to: Resident 3 moved into the memory care community in 11/2024 with diagnoses including Alzheimer’s disease and type 2 diabetes and was identified during the acuity interview as receiving Hospice services. Resident 3's hospice provider notes, 01/03/25 through 02/25/25, observation notes, 12/01/24 through 03/02/25, service plan dated 02/25/25, and temporary services plans dated 01/23/25 through 02/18/25 were reviewed during the survey. The following concerns or recommendations had been documented: * 01/03/25: "Speech ability is reducing, non-verbal assessments for care needs and comfort should be done”; * 01/27/25: “MD order processing error noted, left upper extremity wrist wound care order from 01/23/25 were not processed, I provided a copy, but orders will be changed for the forehead wound, and orders will include routine hand cleansing.” “Please correct error”; * 02/03/25: “Patient was served a meal in bed and voiced being done, no one to one staff intake assist noted please follow up.” “Please pre-medicate [resident] with PRN lorazepam 30 minutes before bathing, [Resident 3] apparently refused bathing yesterday, but no PRN lorazepam was given”; and * 02/21/25: “Maintenance needs to address placement of cable box / modem and power strip.” “Current placement is a fire hazard.” “General pressure relief measures and general barrier cream applications (in place [with] wound) should continue.” Hospice provider notes were documented in the resident’s observation notes; however, there was no documented follow-up to the information left by the provider, or that the resident’s service plan was adjusted to ensure continuity of care. The need to ensure the facility coordinated care with outside providers to ensure continuity of care was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings.

1. Actions to Correct the Rule Violation: • Findings recommended by the Hospice nurse for Resident #3 have been implemented. It should be noted the maintenance repair was put into our work order system on 2/21/25 at 11:14 am and completed by maintenance as a critical issue by 1:31pm according to our electronic repair log - TELS. 2. System Corrections to Prevent Future Violations: • Care Staff will be in-serviced on the importance of implementing and following up on all recommendations from outside providers. Current system is that outside providers provide their report and recommendations to the nursing office where they are input into the electronic record for staff to follow. • 3. Evaluation Frequency and Assigned Personnel: • The Wellness Director or their designee will audit recommendations from outside providers for one quarter and provide a report to the QA committee April, May, June on recommendations by outside providers being implemented. • If no further issues are identified, the audit will revert to an as needed audit or as directed by the QA committee. 4. Staff Responsibility for Ensuring Compliance: • The Executive Director (ED) is responsible for ensuring this Plan of Correction remains effective and is continuously monitored.

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 for 1 of 1 sampled resident (# 3) whose ADL care was observed, and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to: 1. Observations of meal service were conducted from 03/04/25 to 03/06/25. Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing. 2. On 03/04/25 at 11:00 am, Staff 17 (MT) and Staff 21 (CG) were observed providing incontinence care for Resident 3. During the observation, both staff donned gloves without performing hand hygiene, transferred the resident to their bed, and removed their soiled brief. Staff 21 failed to doff soiled gloves, perform hand hygiene, and don clean gloves before touching the resident's body and applying a clean brief for the resident. After incontinence care, Staff 21 touched multiple surfaces and resident personal items in the room with the soiled gloves still on. The need to establish and maintain effective infection control protocols was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings.

1. No Residents were identified as samples for this finding: Actions to Correct the Rule Violation: Facility staff will be re-inserviced on meal service and the use of protective tools to prevent the spread of infection. Aprons will be worn over clothing in both the kitchen and the dining room. Gloves will be worn during food serving and hair nets will be donned during food service in the kitchen area. 2. System Corrections to Prevent Future Violations: Kitchen audits done by the DSM and the ED will include monitoring the use of gloves, hair nets and aprons. 3. Evaluation Frequency and Assigned Personnel: These audits will be presented to the QA committee monthly as done in April May June and July. If further issues are identified and re-training is not effective progressive discipline could be instituted. If no further issues are observed the audits will revert to semi-annual or as directed by the QA Committee. 4. Staff Responsibilty for Ensuring Compliance: ED and FSD are primarily responsible for the effectiveness of this plan of correction.

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 411-054-0070 (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 a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident including fire evacuation standards. Findings include, but are not limited to the following: The following was identified during the entrance conference on 03/03/25 at approximately 11:00 am with Staff 1 (ED) and Staff 2 (Wellness Director): * The MCC consisted of five distinct cottages – Acorn, Blackberry, Clover, Dandelion, and Sunflower. Sixteen residents were living in Acorn, 16 residents were living in Blackberry, 16 residents were living in Clover, 14 residents were living in Dandelion, and 16 residents were living in Sunflower; and * Twelve residents required two-person assist for transfers at all times – two residents resided in Acorn, three residents resided in Blackberry, three residents resided in Clover, two residents resided in Dandelion, and two residents resided in Sunflower. The facility's posted staffing plan and the staffing schedule from 02/23/25 through 03/01/25 were reviewed. The facility's posted staffing plan indicated five CGs and two MTs were scheduled to work the 10:00 pm to 6:15 am shift daily. This equated to one CG in each cottage and two MTs that floated between the five cottages who administered medications and assisted with caregiving duties as needed. Interviews with staff in two of the five cottages reported that it was difficult to meet the scheduled and unscheduled needs of residents when they were the only staff person in the cottage from 10:00 pm to 6:15 am when residents were exhibiting behaviors. The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assist of two care staff for transfers, had behaviors (including resident-to-resident altercations), and resided in five distinct cottages. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents and fire evacuation standards on the overnight shift was discussed with Staff 1 (ED) during the survey. She acknowledged the findings.

1. Action to Correct the Violation: * To insure the abililty of the night shift team in case of evacuation, should a whole campus (all cottages at once) evacuation be required, the facility will institute and train in the use of a one person evacuation chair for 2 person assists. https://www.vevor.com/bathroom-wheelchairs-c_13450/vevor-electric-patient-lift-chair-patient-transfer-wheelchair-180-split-seat 2. System Corrections to Prevent Future Violations: Each 2-person assist will be evaluated for safe transfer by one person using this transfer device and the evaluation noted in their records. * An evacuation list will be maintained in each cottage/unit and if a resident cannot be evacuated with use of this lift chair, the float staff will be stationed in that cottage. If there are more than 2 cottages that have 2 person assist the facility will add an additional staff on the night shift to be there in case of a campus wide evacuation. An evacuation drill on the night shift using this chair in a cottage with 2 or 3 person assists will be held and the time recorded for a whole house evacuation. System Correction to Prevent Future Violations: *For future compliance the facility will not accept new 2 person assists unless there is sufficient help on night shift to aid in whole campus evacuation should the need arise; or will cohabitate the new resident in a cottage already staffed with two staff members. If the facility cannot support the needs of a current resident due to evacuation status they will assist the family to find other care options such as skilled nursing after offering a move to a cottage with the extra staff to support their need. 3. Evaluation Frequency and Assigned Personnel: The QA committee will be presented a list quarterly for 3 quarters on who is a 2 person assist; who can use the device in an emergency, and who cannot. If there are no additional findings and at the direction of the QA committee this audit will revert to an Annual Review 4. Staff Responsible for Ensuring Compliance: The Wellness Director will oversee the evaluation of the device and transfer status of residents; the Facility Services Director will schedule evacuation drills involving residents with the help of the Cottage or Shift team lead; the ED will obtain the evacuation device and insure its availability in each cottage and will present the 2 Person Assist list to QA Committee starting with the April QA meeting

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time that the staff were providing to each resident as outlined in each individual service plan for 3 of 6 sampled residents (#s 3, 4, and 5) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. The resident's service plan, Interim Service Plans, and ABST were reviewed. Staff were interviewed and Resident 5 was observed. The resident's ABST did not accurately capture care time in the following areas: * Medication administration; * Assisting with communication, assistive devices for hearing; * Escorting to and from meals; * Frequency of safety checks; * Transferring in or out of bed or chair; and * Bowel and bladder management. The need to ensure the ABST accurately captured care time was reviewed with Staff 1 (ED), Staff 2 (Wellness Director) and Staff 4 (Administrative Assistant) on 03/06/25 at 12:40 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 11/2024 with diagnoses including Alzheimer’s disease and type 2 diabetes. Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 3's ABST minutes and/or frequencies were not reflective in the following areas: * Assisting with communication, assistive devices for hearing, vision and speech; * Providing treatments (e.g. skin care, wound care, antibiotic treatment); * Repositioning in bed or chair; and * Transferring in or out of bed or chair. The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings. 3. Resident 4 moved into the facility in 03/2024 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 4's ABST minutes and/or frequencies were not reflective in the following areas: * Monitoring behavioral conditions; * Dressing and undressing; * Bathing; and * Cueing or supporting while eating. The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings.

1. Action to Correct Rule Violation: The ABST tool for Residents #3,4, and 5 will be updated to current needs. 2.System Correction to prevent Future Violatons: Nursing/Care department will then re-evaluate the 57 residents who's ABST is beyond the 3 months term and bring them current. 3. Evaluation Frequency and Assigned Personnel: The Executive Director or their representative will audit the ABST spreadsheet monthly and provide a copy to their VP of Clinical Services for audit review. A monthly copy of this spreadsheet recap will be provided to QA committee for review monthly. After 6 months if the finding is corrected the audits will revert to a annual basis. 4. Staff Responsible for Ensuring Compliance ED is responsible for the effectiveness of this plan.

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 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 3 of 4 sampled residents (#s 2, 5, and 6) and an unsampled resident, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to: The facility was a licensed MCC with five distinct cottages. 1. The facility’s ABST was reviewed with Staff 1 (ED) during the survey. The following was identified: a. Resident 2’s and Resident 6’s ABST evaluation did not have evidence it was updated quarterly at the same time as the service plan update. b. Resident 5 experienced a significant change of condition relating to a decrease in mobility on 02/19/25. There was no documented evidence the ABST was updated with the significant change of condition. c. An unsampled resident moved into the facility on 02/25/25 and did not have an ABST evaluation completed as of 03/04/25. 2. The facility’s posted staffing plan and staffing schedule from 02/23/25 to 03/01/25 were reviewed. The following was identified: The posted staffing plan for the facility was as follows: * Day shift: 10 CGs, 5 MTs; * Evening shift: 10 CGs, 5 MTs; and * Night shift: 5 CGs, 2 MTs. Review of the facility schedule and corresponding timecards from 02/23/25 to 03/01/25 revealed the facility failed to staff per the posted staffing plan on three shifts, or 14.28% of the total shifts reviewed. The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly with the service plan, and the need to ensure consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1. She acknowledged the findings.

1. Action to Correct Rule Violation: The ABST tool for Residents #2,5 and 6 will be updated to current needs. The Wellness department will then audit the ABST log and update 57 evaluations that are older than 90 days. 2. System Correction to Prevent Future Violations: Facility will document their efforts to replace staff when there is a call-out on any shift in order to always provide the needed number of staff on each shift. Residents, before they move in will have their ABST created for needs prior to arrival at the facility. 3. System Evaluation and Personnel Assigned to Monitor Executive Director or their designee will audit the ABST spreadsheet at least monthly and provide a copy to their VP of Clinical Services for audit review. A monthly copy of this spreadsheet recap will also be provided to QA committee for review by the Executive Director. For three months April/May/June a report from the payroll dept will be provided to the QA Committee of any days that miss the ABST recommended staffing hours. Additionally a list of new admissions and the date of their ABST will be provided to the committee. If no further episodes of missing needed hours or not creating a ABST prior to admission are identified by these audits the audit report will revert to an annual sampling of ABST hours to actual worked hours report. 4. Staff Responsible for Ensuring Compliance ED is responsible for the effectiveness of this plan

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted with all required elements documented and failed to provide fire and life safety training to staff on alternate months per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records, reviewed between 09/2024 and 02/2025, revealed the following: a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas: * The escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * The number of occupants evacuated; and * Evidence alternate routes were used during fire drills. Multiple staff interviews conducted between 03/04/25 and 03/06/25 indicated residents were not relocated or evacuated during fire drills. b. There was no documented evidence fire and life safety instruction was provided to staff on alternating months from fire drills. The need to ensure fire drills and fire and life safety training was provided and documented as required was reviewed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 5 (Facility Services) on 03/06/25. They acknowledged the findings.

1. Actions to Correct the Rule Violation: Facility staff will conduct and participate in fire drills that include: • Documenting the number of residents who participated. • Utilizing alternative routes if an area is blocked by fire. • Identifying residents who could not participate and those needing assistance. • Recording any problems encountered during the drill. • Conducting unannounced drills on different shifts to ensure comprehensive preparedness. Additionally, on alternate months from fire drills, the facility will provide Fire and Life Safety training during the monthly All Staff meeting. 2. System Corrections to Prevent Future Violations: To prevent further deficiencies in this Life Safety area: • A fire drill with resident participation will be conducted in April. • Life Safety training will commence at the April All Staff meeting and will continue at a minimum of every other month. • Fire drill documentation and a recap will be presented to the QA Committee by the Facility Director each quarter (June, September, December, and March) for one year to ensure all required elements are documented. • If no further findings are identified, the task will revert to an annual report to the QA Committee. 3. Evaluation Frequency and Assigned Personnel: • The fire drill process and documentation will be evaluated quarterly for one year by the QA Committee. • If compliance is maintained, the evaluation frequency will shift to an annual review. • Facility Services and the Executive Director will oversee the evaluation process. 4. Staff Responsible for Ensuring Completion and Monitoring: • Facility Services and the Executive Director are responsible for ensuring that this plan of correction is completed and continuously monitored for compliance.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 03/05/25. There was no documented evidence of a written record of annual re-instruction to residents including content and residents attending, general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire. The need to ensure residents were provided instruction as required by the OFC was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings.

1. Actions to Correct the Rule Violation: The Executive Director will update the Fire Training Form to include a notation as to whether or not the resident should be re-trained annually based on their level of understanding during the first training. The facility will continue to provide Fire Safety training to residents upon admission. Residents who can retain this information will be re-trained at least annually. If a resident does not appear to understand the training or directions, it will be documented in their initial training form that they cannot follow Fire Safety directions. 2. System Corrections to Prevent Future Violations: To prevent further deficiencies in this Life Safety area: • A fire drill with resident participation will be conducted in April • Life Safety training will commence at the April All Staff meeting and will continue at a minimum of every other month. • Facility staff will re-instruct all applicable residents for their annual training and present a list of who was retrained and who could not retain the information to the QA Committee for one quarter April/May/June and then semi-annual after that unless further findings are identified. • Evidence of training or retraining will be maintained in each resident’s hard chart in their Cottage. • A list of residents who cannot retain Fire Safety training information will be maintained by Life Enrichment (Activities) This list will be updated at least annually and as residents admit or discharge. 3. Evaluation Frequency and Assigned Personnel: • The resident training lists will be presented to the QA Committee quarterly until the Committee determines that this plan is a permanent part of the community plan, but for no less than one quarter and semi annually after that. • If compliance is maintained, the evaluation frequency will shift to an semi annual review. • Facility Services and the Executive Director will oversee the evaluation process. 4. Staff Responsible for Ensuring Completion and Monitoring. • Life Enrichment will lead resident Fire Safety training efforts with support from Cottage staff. ED will present monthly and then semi-annual report to QA committee and is responsible for the effectiveness of the POC.

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

OAR 411-054-0105 (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: Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C231 and C270.

REFER TO THE FACILITY PLAN OF CORRECTION FOR C231 AND C270 AND THEIR ACCOMPANYING QA AUDITS.

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 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers, and to provide exit door alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: On 03/03/25 at 1:20 pm, a tour of the facility identified the following: a. There were multiple resident rooms which lacked any device or system to allow residents to communicate needs to staff. A few residents were observed wearing necklace call pendants, and safety checks were performed regularly. However, there were still many residents in apartments with no means of calling for assistance.; and b. The doors to the outside courtyard area had no alarm or other system in place to alert staff when residents exited the building. On 03/04/25, the need to provide a call system that connected resident units to staff center or pagers, and to provide exit door alarms or another acceptable system to alert staff when residents exited was discussed with Staff 1 (ED) and Staff 5 (Facility Services). They acknowledged the findings.

1. Actions to Correct the Rule Violation: Upon identification, Facility Services checked and repaired all door alarms leading to the outside courtyard to ensure they sound upon each door opening and closing. Additionally, while the facility had not previously provided pendant call bells to residents who could not use them, it has always offered portable call bells to any resident free of charge upon request or demonstrated need. To correct this finding, the facility has identified and implemented a wireless system that will be placed in each resident's room near the bed and can be moved between the bed and chair as needed. 2. System Corrections to Prevent Future Violations: The facility has implemented a structured monitoring system to ensure the call bells remain in designated locations. Staff will conduct regular inspections to confirm that the call bells are available in each resident’s room. In the event that a call bell goes missing, cottage staff will immediately notify maintenance for replacement. Maintenance staff will explore alternative installation locations if missing call bells become a recurring issue. 3. Evaluation Frequency and Assigned Evaluators: The facility will conduct a monthly call bell inspections as part of routine cleaning and maintenance rounds. A quarterly report on call bell presence will be presented to the Quality Assurance (QA) Committee in May, August, November, and February. If the QA Committee determines that call bells remain in the rooms as installed, they may instruct that audits be conducted semi-annually instead. However, if missing call bells persist, the Committee will direct Maintenance staff to identify alternative solutions and maintain QA reports until resolved. 4. Staff Responsibility for Implementation and Monitoring: Facility Maintenance/Services and the Executive Director (ED) are responsible for ensuring the successful implementation and ongoing compliance with this Plan of Correction. They will oversee all corrective actions, monitor adherence to the established procedures, and address any recurring issues as needed to maintain compliance and resident safety.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain a setting which ensured individual rights of privacy, dignity, and respect. Findings include, but are not limited to: The memory care community included a mix of single units and shared (two person) apartments. During the survey, there were multiple observations of shared units which lacked any method for maintaining privacy for residents during personal care. This constituted a violation of individual rights to privacy and dignity for residents. On 03/06/25, the need to ensure individual rights of privacy, dignity, and respect were discussed with Staff 1 (ED) and Staff 2 (Wellness Director). They acknowledged the findings.

1. Actions to Correct the Rule Violation Facility will explore options and select one option to provide visual privacy between beds in our bedrooms to enhance the privacy between the two roommates. Space constraints and resident safety will be taken into consideration as a space divider is evaluated and selected as to better ensure resident safety while in their rooms. Maintenance staff will document the number of semi-private rooms that require dividers. The dividers will be installed as they arrive. 2. System Corrections to Prevent Future Violations To ensure ongoing compliance, the facility will implement a tracking system for room privacy compliance. This system will include documentation of residents' preferences regarding room dividers and a process for reevaluating these preferences as needed. Facility staff will be trained on maintaining records of privacy accommodations to ensure adherence to regulations and resident rights. 3. Evaluation Frequency and Assigned Personnel Once all dividers are installed, a completion report will be submitted to the Quality Assurance (QA) committee to verify project completion. Additionally, an annual inspection will be conducted by Facility Services to ensure dividers remain intact and available for all semi-private rooms. 4. Responsible Staff for Implementation and Monitoring: Facility Services, the Resident Care Coordinator (RCC), and the Executive Director are responsible for ensuring that this plan remains in effect. They will oversee the documentation process, the installation and maintenance of dividers, and ongoing compliance monitoring.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to: During an interview on 03/06/25, Staff 7 (Resident Care Manager) confirmed the majority of the residents in each cottage did not have keys to their units and keys were located in the MT area of each cottage. On 03/06/25, the need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant). They acknowledged the findings.

1. Actions to Correct the Rule Violation The facility has provided a key and has documented the provision of this key to the resident or their family member. The facility will install a key holder for each resident in their living area for easy access. One or two keys will be kept in this holder based on room occupancy. 2. System Corrections to Prevent Future Violations To ensure continuous access to room keys, the facility is implementing a standardized key storage and documentation procedure. This includes maintaining a record of key assignments, verifying key availability in designated holders, and monitoring compliance through structured audits. Facility staff will be educated on these procedures to maintain consistency and accountability. 3. Evaluation Frequency and Assigned Personnel A quarterly audit report will be submitted to the Quality Assurance (QA) committee to confirm that room keys remain available in the designated key holders. Audits will be conducted in May, August, November, and February. If the process remains effective, the QA committee may approve reducing the audit frequency to an annual review. 4. Staff Responsibility for Implementation and Monitoring The RCC, Facility Services, and the Executive Director are responsible for ensuring this plan remains viable. They will oversee compliance, address any issues that arise, and report findings to the QA committee.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. 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: C 231, C 360, C 420, C 422, and C 555.

See POC provided for C231, C360, C420, C422, and C555

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 C 231.

REFER TO C231 PLAN OF CORRECTION

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 260, C 270, C 280, C 290, C 295, C 362, and C 363.

Please refer to C260, C270, C280, C290, C295, C362, C363 for outlined Plans of Correction

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 270.

REFER TO FACILITY PLAN OF CORRECTION C270

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(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed, and included in the service plan for 3 of 6 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Review of the current service plans for Residents 1, 3 and 4 revealed the records lacked daily programs for nutrition and hydration, based on each individual resident’s preferences and needs. On 03/06/25, the need to develop individualized nutrition and hydration plans for each resident, and to include these in the residents’ service plans was discussed with Staff 1 (ED) and Staff 2 (Wellness Director). They acknowledged the findings.

1. Actions to Correct the Rule Violation Residents #1, 3, and 4 will have their Hydration and Nutrition plans updated to reflect their preferences and needs. This will be done using the Nutrition Assessment tool provided in our assessment software, ECP. Additionally, an audit will be conducted to identify other residents affected by this finding. Any identified residents will have their Hydration and Nutrition plans updated, and an audit report will be provided to the QA committee. 2. System Corrections to Prevent Future Violations To ensure ongoing compliance, all residents' Hydration and Nutrition plans will be regularly assessed using the Nutrition Assessment tool in ECP. Staff will be trained on the importance of updating these plans to reflect residents' evolving needs and preferences. Documentation procedures will be reinforced to maintain accuracy and accountability. 3. Evaluation Frequency and Assigned Personnel A quarterly audit will be conducted for three cycles (June, Sept, Dec) to validate that all residents have a Nutrition and Hydration plan that accurately reflects their preferences and needs. If no further issues are identified after three quarters, the audit frequency will be adjusted to a PRN (as needed) basis as directed by the QA Committee. 4. Staff Responsibility for Implementation and Monitoring The cottage RCC will complete the audit tool and present to the Nursing Office on scheduled months. The ED will present the findings to QA. The Wellness Director and RN are responsible for ensuring the effectiveness of this plan. They will oversee the audits, implement corrective actions as needed. Their role includes ensuring that all necessary updates are completed and that the system remains compliant with established procedures.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 4 of 6 sampled residents (#s 3, 4, 5 and 6) whose activity plans were reviewed. Findings include, but are not limited to: Residents 3, 4, 5 and 6's most recent evaluations and service plans were reviewed. The records did not address one or more of the required components: * Past and current interests; * 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. There was no individualized activity plan developed based on the evaluation that reflected the resident's activity preferences and needs for Residents 3, 4, 5, and 6. The need to ensure the facility evaluated each resident for activities and developed an individualized activity plan based on the evaluation was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings.

1. Actions to Correct the Rule Violation: The facility will update the individualized Activity Plan for residents #3, 4, 5, and 6 using the assessment provided in ECP, our resident records software - ECP. This update will ensure that each resident’s plan reflects their specific needs and preferences. 2. System Corrections to Prevent Future Violations: A comprehensive whole-house audit will be conducted by the Activity Director. Any resident found to lack an individualized Activity Plan will have their plan updated accordingly. Additionally, training will be provided to staff on the importance of individualized Activity Plans and proper documentation procedures by VP Clinical Services (3/14/2025). 3. Evaluation Frequency and Assigned Evaluators: The Activity Director will conduct quarterly audits to ensure continued compliance with individualized Activity Plans. A report will be submitted to the Quality Assurance (QA) Committee summarizing updates and compliance progress (June 2025). An annual audit will be conducted no later than December 2025 to verify that the plan of correction remains in effect. If no further issues are identified by the QA committee this audit will revert to a PRN basis. 4. Staff Responsible for Implementation and Monitoring: The Executive Director (ED) and the Activity Director are primarily responsible for ensuring that all corrections are completed and monitored. They will oversee the audits, provide necessary training, and report findings to the QA Committee to maintain accountability and compliance.

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:

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight, stability and design to prevent resident injury or aid in elopement. Findings include, but are not limited to: On 03/04/25 at 9:50 am, the facility’s outdoor recreation area was observed, which included five lightweight tables and 19 lightweight chairs. During an interview at 12:05 pm on 03/04/25, Staff 28 (CG) stated that five minutes prior she had witnessed an unsampled resident standing on one of the lightweight chairs near the courtyard gate. She stated the resident had been exit-seeking recently and appeared to have moved the chair to the gate in an attempt to elope. As of 03/05/25 at 9:30 am, all lightweight furniture had been removed from the courtyard. On 03/04/25 at 1:30 pm, the need to ensure all outdoor furniture was sufficient in weight, stability, and design to prevent resident injury or aid in elopement was reviewed with Staff 1 (ED). She acknowledged the findings.

• Actions to Correct the Rule Violation: • The facility immediately removed the patio furniture from the interior/secured courtyard upon identification of the violation. • System Corrections to Prevent Recurrence: • The facility will either secure the furniture so it cannot be moved (e.g., park benches) or replace any furniture that can not be secured with immovable outdoor furniture. Park benches will be fastened down, and picnic tables/chairs will be replaced with an all in one unit that can be bolted to the concrete. • The facility will not purchase or install patio furniture that can be easily moved by residents of Quail Crest. • Facility Services and the Executive Director will oversee and ensure that only compliant, immovable furniture is selected and installed. • Evaluation Frequency and Assigned Personnel: • A Quality Assurance (QA) report will be conducted twice in 2025 (April and November) to validate that the corrective measures remain in place. • If no further issues are identified by QA, future evaluations will occur on an as-needed basis. • Staff Responsibility for Implementation and Monitoring: • The Facilities Services Director is responsible to implement the plan of correction; the Executive Director is responsible for ensuring that this plan remains in effect, is properly enforced, and is reviewed as necessary.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: