OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the required postings were in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times. Findings include, but are not limited to: The facility was toured on 03/17/25, and it consisted of five separate and distinct cottages. The following postings were not posted in each of the cottages as required: * Copy of most recent re-licensure survey, including all revisits and POC; * The Ombudsman Notification Poster; * The LGBTQIA2S+ Rights and Protections; and * The LGBTQIA2S+ Nondiscrimination Notice. The need to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.

1. The most recent survey, Ombudsman Notification Poster, Resident Rights including LGBTQIA2S+ Rights and Protections along with the Nondiscrimination Notice, and most recent licensing survey have been posted in the community. 2. The Executive Director will receive additional training on required postings in the community. 3. The Executive Director or Designee will audit postings monthly to verify they are current and posted in the appropriate locations. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by:

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure medical and other records were kept confidential. Findings include, but are not limited to: During the relicensure survey from 03/17/25 through 03/20/25 observations were made of a printer and fax machine used to communicate resident health information to and from the facility located in a resident use laundry room. Multiple unsampled resident's confidential information was observed on the fax machine and/or printer during the survey. On 03/17/25, observations of medical and/or other records were left on a counter next to the fax machine while two residents were in the laundry room. The documents were gathered and given to Staff 2 (General Manager) who stated she would discuss the concern with Staff 1 (ED). On 03/19/25 and 03/20/25 additional documents were observed on the printer and/or fax machine throughout each day. The findings were reviewed with Staff 1 and Staff 2 on 03/20/25 at approximately 11:54 am. They acknowledged the findings.

1. The fax machine and copy machine will be relocated to an area that is not accessible to residents. 2. See Number One. 3. Daily until relocation is completed. 4. The Executive Director will be responsible for ensuring compliance.

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

OAR 411-054-0050(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 designate an individual to be the facility’s “Infection Control Specialist”, and to establish and maintain infection preventions and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 resident (#7), whose records were reviewed. Findings include, but are not limited to: a. In an interview on 03/20/25, Staff 1 (ED) acknowledged the facility did not 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. b. Resident 7 was admitted to the facility in 03/2023 with diagnoses including dementia, aphasia, dysphagia, retention of urine and multiple sclerosis. During the acuity interview on 03/17/24, Resident 7 was reported to require a high degree of care, including a soft mechanical texture diet requiring assistance with meals. During the survey from 03/17/25 through 03/20/25, the surveyor obtained permission and observed the facility staff provide personal care and feeding to Resident 7. The resident was noted to require total care assistance from staff. On multiple instances, direct care staff donned gloves without first performing hand hygiene, did not change single use gloves between tasks, and performed feeding without wearing a protective barrier over clothing to prevent the potential for cross contamination. On 03/17/25 at 12:49 pm, Staff 31 (MT) was observed to drop a tube of prescription cream on the floor, the MT proceeded to pick up and administer the medication to the resident without changing gloves prior to administering the cream. c. On 03/17/25 and 03/18/25 during lunch service, the survey team observed staff transporting meals within Barlow cottage from the kitchenette to residents’ rooms without proper plate covering. Additionally, the survey team observed an uncovered tray of brownies that were taken into a resident’s room. d. Observations of lunch service on 03/18/25 and 03/19/25, revealed multiple direct care staff in Diamond cottage served food and provided direct feeding to residents having donned gloves without first performing hand hygiene and without donning a protective barrier over potentially contaminated clothing. The need to ensure the facility designated an individual to be the facility’s “Infection Control Specialist” and to establish and maintain effective infection prevention and control protocols was reviewed with Staff 1, Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), Staff 10 (Wellness Director), and Staff 40 (Operations Specialist) on 03/20/25 at 11:04 am and again at 11:54 am. They acknowledged the findings.

infection control, designated person, handwashing and glove use, covering food, aprons designated person in place, additional training for care staff and dining 1. The community has designated an infection control speciailist. 2. The Dining Services Staff and Direct Care Staff will receive additional training on hand washing, proper plate covering when delivering meals, and wearing aprons when serving meals or assistng residents with direct feeding. 3. The Executive Director will be responsible for ensuring compliance.

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 411-054-0090 (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 conduct fire drills in accordance with the Oregon Fire Code. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 09/2024 through 02/2025 identified the following: * The facility was not evacuating residents from the simulated fire area; therefore, there was no documentation of: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. * Additionally, the facility failed to document the staff members on duty and participating in the drill in two of the three drills completed. On 03/19/25 at 12:00 pm, Staff 6 (Maintenance Director), confirmed residents were not evacuated or relocated during fire drills. On 03/19/25 at 12:00 pm, the need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 1 (ED), Staff 2 (General Manager), Staff 3 (Business Office Manager), Staff 6 and Staff 40 (Operations Specialist). They acknowledged the findings.

1. The Community completed a fire drill that included resident evacuation and documentation. 2. The Maintenance Director and Executive Director will receive additional training on the Fire and Life Safety Training and Drills Flowchart and the Fire and Life Safety Ass Staff In-Service & Training Documentation. 3. Completion of Drills and Documentation will be reviewed monthly per the QA - Maintenance Review Schedule. 4. The Executive Director will be responsible for ensuring 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 re-instruct residents, at least annually, on 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. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 09/2024 through 02/2025 revealed no documented evidence of annual fire safety re-instruction for residents. On 03/19/25 at 12:00 pm, Staff 1 (ED) confirmed the facility did not have a system for re-instructing residents, at least annually, on fire and life safety expectations. On 03/19/25 at 12:00 pm, the need to re-instruct residents, at least annually, on 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 per the OFC requirements was discussed with Staff 1, Staff 2 (General Manager), Staff 3 (Business Office Manager), Staff 6 (Maintenance Director) and Staff 40 (Operations Specialist). They acknowledged the findings.

1.The Community will complete the Fire and Life Safety Annual Resident Safety Training for all Residents. 2. The Maintenance Director and Executive Director will receive additional training on Resident Safety Training. 3. Fire and Life Safety Annual Resident Safety Training Documentation will be reviewed annualy per the QA - Maintenance Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

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

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the RCF common use areas, entrance and exit ways were made of hard, smooth material, were accessible and maintained in good repair and all chemicals and other toxic materials were safely stored in a locked storage. Findings include, but are not limited to: During a tour of the facility from 03/17/25 through 03/19/25. The facility consisted of five separate and distinct cottages and the following was identified: a. Three of the cottages had interior courtyards, Astor, Barlow, and Crown. Astor and Barlow had patios attached to some resident rooms. All the courtyards and patios did not have a threshold that was accessible for residents who used wheelchairs or walkers. Additionally, the wooden ramp access to the back courtyard in the Crown cottage was not in good repair. During an interview on 03/18/25 at 1:38 pm, Resident 1 reported s/he had difficulty getting over the front entrance threshold of the Barlow cottage in his/her wheelchair. b. Cleaning chemicals and disinfectants were found unlocked in housekeeping closets in the Astor cottage and Crown memory care cottage. The closets were easily accessible to residents. Upon reinspection on 03/18/25 and 03/19/25, the housekeeping closet was found unlocked in Astor. The need to ensure all exterior pathways and accesses to the RCF common use areas, entrance and exit ways were made of hard, smooth material, were accessible and maintained in good repair and all chemicals and other toxic materials were safely stored in a locked storage was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.

1. Thresholds have been installed on doors to allow residents with wheelchairs or walkers to have access. The housekeeping door handles have been changed to one that automatically locks. 2. The Housekeeping and Direct Care Staff will receive additional training on keeping housekeeping closets locked at all times. 3. Thresholds and self-locking door handles will be reviewed quarterly per the QA - Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure when an electronic code must be entered to use an exit door, it was clearly posted for residents, visitors and staff use and all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 03/17/25. The facility consisted of five separate and distinct cottages, two ALF and three MCC units. The following was identified: a. The main entrance to Barlow, the enhanced ALF, had a code for entry and it was not clearly posted for resident use. During survey, it was identified not all residents knew the code. b. The following areas were in need of repair: * In Astor, the sink in the staff/visitor bathroom was separating from the wall with a large crack present; * In Barlow, the mirror in the resident’s shower room was broken, and the inside laundry room door was lacking trim; * In Crown, the call light cord was missing, and the shower head holder was broken in the resident’s main shower room; and * In Crown, resident room 44, the shower head holder and window blinds were broken; and * In Diamond, the paint was lifting off the wall above the door trim near the common area. The lack of electronic code to an exit door being clearly posted for residents, visitors and staff use and ensuring all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.

1. The access code posted for Barlow. All Common areas will receive repairs as indicated in the SOD. 2. The Maintenance Director and Executive Director will received additional training on the QA Quarterly Building Inspection. 3. Common areas will be reviewed quarterly per the QA - Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents' rights of privacy and dignity for multiple sampled and unsampled residents whose medical information was maintained in the facility. Findings include, but are not limited to: Refer to C 200.

Refer to C 200.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(1)(e) Optimize Settings: Independence, Activities (1) Residential and non-residential HCB settings must have all of the following qualities: (e) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the individual chooses to interact. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the setting optimized, but did not regiment, individual initiative, autonomy, self-direction and independence in making life choices for multiple sampled and unsampled residents who resided in the Barlow cottage. Findings include but are not limited to: Refer to C 513a.

Refer to C 513a.

OAR411-004-0020(1)(e) Optimize Settings: Independence, Activities (1) Residential and non-residential HCB settings must have all of the following qualities: (e) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the individual chooses to interact. This Rule is not met as evidenced by:

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the setting was physically accessible to individuals. Findings include, but are not limited to: Refer to C 510a.

Refer to C 510a.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual resident had privacy in his/her own unit for multiple sampled and unsampled residents who resided in the MCC cottages. Findings include, but are not limited to: During the re-licensure survey, dated 03/17/25 through 03/20/25, the environment was toured and interviews with staff and residents were completed. The following were revealed: a. Multiple residents who resided in the Diamond and Emerald cottages shared an apartment. The bathrooms in the shared apartments were observed to lack a locking mechanism that would ensure privacy to the resident in his/her own unit. On 03/19/25 at 10:00 am, Staff 40 (Operations Specialist) confirmed the bathroom doors of shared units did not have the ability to be locked. b. The doors of resident apartments in the Crown, Diamond, and Emerald cottages were observed to have lever-type handles. These handles had a keyed locking mechanism on the exterior of the door; however, the interior handle had no mechanism that would allow a resident to lock the door from inside the room to ensure privacy. On 03/20/25, Staff 14 (MT/CG), Staff 20 (CG), and Staff 21 (MT) confirmed the doors in Crown, Diamond, and Emerald cannot be locked from the inside. The need to ensure residents were provided with individual privacy in their own unit was discussed with Staff 1 (ED), Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), and Staff 40 on 03/20/25 at 11:18 am. They acknowledged the findings.

1. The door handles on the bathrooms of shared suites have been changed replaced with handles that have a locking mechanism. 2. The Executive Director and Maintenance Director will receive additional training on handles with locking mechanisms to ensure provacy to the resident. 3. Door hanles will be reviewed quarterly per the QA - Quarterly Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

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 their unit for multiple sampled and unsampled residents. Findings include, but are not limited to: During the re-licensure survey, dated 03/17/25 through 03/20/25, resident service plans were reviewed and interviews with residents, family members, and staff were completed. Interviews with Resident 2 and 7 confirmed they were not provided keys to their apartments. Follow-up interviews with Resident 2 and 5’s family members confirmed no key was provided to the resident or the resident’s family. On 03/20/25 at 8:38 am, Resident 2 stated s/he wanted a key for his/her apartment. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1, Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), and Staff 40 (Operations Specialist) on 03/20/25 at 11:18 am. They acknowledged the findings.

1. door handles in the Memory Care will be replaced with handles that have a locking mechanism. Each Resident or Responsible Party will receive a key to the apartment and the service plan will be updated. 2. The Executive Director will receive additional training on providing a key at time of move-in for all residents and documenting on the service plan. 3. The key status will be reviewed with each routine service plan update. 4. The Executive Director will be responsible for ensuring compliance.

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 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to post the LGBTQIA2S+ Rights and Protections and the LGBTQIA2S+ Nondiscrimination Notice. Findings include, but are not limited to: Refer to C152

Refer to C 152.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. 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 152, C 200, C 295, C 420, C 422, C 510, C 513.

Refer to C152, C 200, C 295, C 420, C 422, C 510, C513.

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

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents who resided in the memory care cottages had individually identified residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The facility’s three memory care cottages, Crown, Diamond and Emerald were toured on 03/17/25. Multiple resident rooms in each cottage lacked any individualized identification to assist residents in recognizing their room. On 3/17/25 at 11:40 am, an unsampled resident was observed going into multiple resident rooms and was asking caregivers where his/her room was. Upon further observation, the resident’s room lacked an individual identifier to assist the resident in recognizing his/her room. The need to ensure each resident room was individually identified to assist residents in recognizing their room was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.

1. All memory care apartments now have an individual identifier to assist the resident with recognizing his/her apartment. 2. The Executive Director and Life Enrichment Director will receive additional training on individual identifiers for each memory care resident. 3. Individual Identifiers will be reviewed upon move-in and quarterly per the QA - Quarterly Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: