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 changes and entries made to the service plan were dated and initialed, service plans were reflective of residents' needs and/or provided clear direction to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1.Resident 1 moved into the facility in 09/2019 with diagnoses including dementia. The resident's current service plan available to staff, dated 03/09/25, and 01/08/25 through 04/08/25 progress notes and temporary care plans (TCPs) were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following was identified: a. The resident had multiple changes and entries on the service plan which were not dated and initialed. b. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: *Activities, including ability to participate and modifications required; and *Number of staff required to assist with repositioning, incontinence care, transfers and evacuation. The need to ensure all changes and entries to the service plan were dated and initialed, and service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (Assistant ED), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings. ?2. Resident 2 was admitted to the facility in 02/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the resident's 03/30/25 service plan, and 02/28/25 through 04/08/25 temporary care plans and progress notes were completed. The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following areas: * Incontinence and toileting assistance; * Bathing assistance; * Activities; * Transfer assistance; * Mealtime assistance; * Behaviors related to telling other residents s/he needed them to help care for him/her; and * Non-drug interventions for pain. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Assistant ED), Staff 2 (RN), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in 08/2021 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the resident's 02/04/25 service plan and 01/08/25 through 04/08/25 temporary care plans and progress notes were completed. The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following areas: * Incontinence care, brief changes and toileting assistance; * Dressing, grooming and hygiene assistance; * Bathing assistance; * Activities; * Transfer assistance, ambulation and wheelchair use; * Mealtime, feeding assistance and food textures; * Wandering and entering other resident rooms; and * Aggression and resistance to dressing/undressing and brief changes. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Assistant ED), Staff 2 (RN), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25. The staff acknowledged the findings.

C-260 Service plan General 1) Service plans for sampled residents 1,2 & 3 have been reviewed/updated for accuracy. 2) Re-education has been provided to ALD/MCD on process for dating/initialing updates made to service plans along with service plan accuracy. 3) Routine review of resident care related documentation will continue to assure changes are noted timely and updates made as well as dated and initialed to a residents service plan as applicable. 4) Reviews will be conducted daily as part of the continued QA routine at the community 5) ALD/MCD with ED oversight

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' needs and/or provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 2 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: a. Resident 2 was admitted to the facility in 02/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the resident's 03/30/25 service plan, temporary care plans, and progress notes were completed. The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following areas: * Toileting; * Bathing; * Ambulation; * Dressing; and * Non-drug interventions for pain. b. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the resident's 05/27/25 service plan, temporary care plans, and progress notes were completed. The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following area: * Toileting. On 06/18/25, the need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

1.) Memory Care Director/Designee has updated all sampled resident services plan to focus on person-centered care and current care needs per regulation. 2.) Memory Care Director/Designee will have all memory care resident service plans reviewed and updated by 08/02/2025. 3.) Memory Care Director/Designee will update service plans by 08/02/2025. After AOC, Memory Care Director/Designee will update service plans quarterly and as needed. 4.) Memory Care Director/Designee.

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 411-054-0036 (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 short term changes in condition had documented progress monitored at least weekly through resolution and provided clear resident-specific directions to staff as needed for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 02/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 03/30/25 and progress notes dated 02/28/25 to 04/08/25 were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, and/or lacked resident-specific directions to staff in the following areas: * Falls with and without injury; and * Emergency room visits. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, and provided clear, resident-specific directions to staff was discussed with Staff 1 (Assistant ED), Staff 2 (RN), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2021 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 02/04/25 and progress notes dated 01/08/25 to 04/08/25 were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas: * Behaviors, increased aggression and anxiety; * Frequent urination and potential UTI; * Resident to resident altercation; * Feeling ill, cough, cold and increased weakness; and * Medication changes. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, and provided clear, resident-specific directions to staff was discussed with Staff 1 (Assistant ED), Staff 2 (RN), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25. The staff acknowledged the findings.

C-270 Change of Condition and Monitoring 1) Resident’s 2 & 3 were re-evaluated and summary documentation made in progress notes on most recent changes noted in the survey document. 2) Re-education was provided to ALD/MCD and RN on the alert charting process to include RN change of condition assessment (when warranted) and closure notes to include changes, plans/interventions in place and when applicable the effectiveness of the plans in place. 3) Ongoing reviews of alert charting will be conducted to assure adherence to the alert charting routine until new or resumed baseline has been achieved. 4) Audits will be daily 5) ALD/MCD with ED oversight

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 411-054-0050(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 related to an unsampled resident who experienced an incontinent episode and for multiple unsampled residents who received meal service. Findings include, but are not limited to: 1. On 04/09/25 at 3:04 pm, an unsampled resident experienced an incontinent episode in the common living and activity room. Staff 10 (MT) escorted the resident to the bathroom. Bodily fluid was observed on the vinyl chair the resident vacated. Two CGs were present in the room and did not attempt to clean the chair. At 3:11 pm, this surveyor approached Staff 11 (CG) and requested she clean the chair so the other residents in the area did not attempt to sit on or clean the chair. She stated she did not know where cleaning supplies were located. The surveyor instructed her to contact the housekeeping or maintenance department. At 3:20 pm, the incident was reviewed with Staff 2 (RN) and Staff 3 (Regional Director of Health Services) who stated they would immediately address the situation and make sure the area was cleaned appropriately. 2. Observations of meal service were conducted from 04/08/25 through 04/10/25 and the following was identified: * Caregiving staff were observed serving food and feeding a resident without wearing a protective covering over potentially contaminated clothing; and * Hand hygiene for residents did not occur, despite multiple unsampled residents observed eating with their hands. The need to maintain effective infection prevention and control protocols was reviewed with Staff 1 (Assistant ED), Staff 3 and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

C-295 Infection Prevention & Control 1) Re-education completed with Caregiving and meal service staff on proper infection control, use of protective aprons during meal service and location of cleaning supplies to assure understanding. 2) Observations will be made routinely of staff during cares and meal service to assure ongoing compliance with infection control protocols. 3) Ongoing observations will be conducted at least quarterly of all CG and those helping with food service/feeding. 4) ALD/MCD with ED oversight.

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 related to 1 of 2 sampled residents (#2) and one unsampled resident who received meal service. This is repeat citation. Findings include, but are not limited to: Observations of the lunch meal service on 06/17/25 identified hand hygiene for a sampled resident (#2) and an unsampled resident did not occur, despite the residents being observed eating with their hands. On 06/18/25, the need to maintain effective infection prevention and control protocols was reviewed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

1.) Re-education was completed with all memory care staff reviewing citation and universal precautions, hand washing, sanitation, etc. 2.) Memory Care Director/Desginee has implemented hand washing/sanitation into the activities program prior to meals. The community has set up a station in the dining room for hand washing for residents. 3.) Memory Care Director/Designee will monitor daily for effectiveness. 4.) Memory Care Director/Designee.

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

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure medications that were administered as a PRN to treat a resident's behavior had written, resident-specific parameters and non-pharmacological interventions were documented as tried with ineffective results prior to administering the medication for 1 of 1 sampled resident (#1) who was prescribed and administered PRN medication to treat a behavior. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia. Resident 1's MARs, dated from 03/01/25 through 04/08/25 and physician’s orders were reviewed, and the following was identified: The resident had three PRN psychotropic medications which were prescribed to treat agitation and/or anxiety: *Lorazepam 0.5 mg every four hours; *Risperidone 0.25 mg once per day; and *Haldol 5 mg every four hours. The symptom presentation for the three medications was described as “yelling, cursing, getting into staff space.” The medications lacked clear, resident-specific parameters for administration. The resident was administered lorazepam (for anxiety) on 04/07/25. There was no documented evidence that non-pharmacological interventions were tried with ineffective results prior to administering the medication. The need to include resident-specific parameters for PRN medications which addressed behavior, and to document non-drug interventions were tried with ineffective results prior to administering PRN medication for behavior, was reviewed with Staff 1 (Assistant ED), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

C-330 Systems: Psychotropic Medication 1) Resident 1’s MAR sheet was reviewed and missing information added. 2) Review conducted of remaining residents with PRN Psychotropic orders was conducted to verify presence of required information. 3) Re-education provided to MCD/ALD and RN on the required information to be present for PRN psychotropics for residents unable to identify need/request. 4) Routine auditing of new/continuing orders will be conducted to assure ongoing compliance. 5) Daily for new orders, monthly for ongoing orders. 6) ALD/MCD/RN with ED oversight

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0065 (1-3) Administrator Qualification and Requirements (1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below: Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 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 employ a full-time administrator scheduled to be on site in the facility at least 40 hours per week. Findings include, but are not limited to: Survey entered the facility on 04/08/25 at 8:45 am and requested to speak with the administrator. Staff 1 (Assistant ED) stated that she did not know who currently held the license as administrator for the facility. On 04/08/25 at 12:55 pm Staff 1 confirmed the facility did not have an administrator and did not have an approved exception for an administrator designee. The need to employ a full-time administrator was reviewed with Staff 1, Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

C-350 Administrator Qualifications & Requirements 1) Current Administrator is Andrea Terrell and information sent to the state on 4/8/25. 2) Administrator coverage assistance is provided by the Home Office 3) Routine review of current Administrators will continue to be conducted for ongoing compliance. 4) At least monthly from the Home Office and with a change in administrator.

OAR 411-054-0065 (1-3) Administrator Qualification and Requirements (1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below: Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 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 and care elements that staff were providing to each resident as outlined in each individual care plan and service plan for 3 of 3 sampled residents (#s 1, 2 and 3) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: The facility's ABST was reviewed during the survey 04/08/25 through 04/10/25. Review of Residents 1, 2 and 3’s ABST revealed multiple ADLs were not reflective of the residents' evaluated care needs. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was reviewed with Staff 1 (Assistant Executive Director), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

C-362 Acuity Based Staffing Tool ABST time 1) ABST tool for sampled residents was updated to accurately reflect ADL. 2) Review of ABST tool info for remaining residents was conducted to verify accuracy 3) Re-education provided to the ALD/MCD and ED on ABST tool use and content to assure understanding 4) ABST tool will be routinely audited for accuracy 5) At least weekly, with new move ins, significant changes of condition and at least quarterly with service plan updates. 6) ALD/MCD with ED oversight

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 completed prior to a resident moving into the facility, updated and reviewed no less than quarterly at the same time the service plan was updated and/or with a significant change of condition for 3 of 3 sampled residents (#s 1, 2 and 3) and multiple unsampled residents. Findings include, but are not limited to: The facility’s ABST data was retrieved at 7:00 am on 04/08/25 and reviewed during the survey 04/08/25 through 04/10/25. The following was identified: a. Resident 1’s ABST evaluation was not updated and reviewed at least quarterly with his/her service plan update on 03/09/25, or with significant changes of condition. b. Resident 2, who moved into the facility 02/28/25, and four unsampled residents, who moved into the facility 04/08/25, 03/12/25, 03/01/25 and 02/02/25 respectively, did not have an ABST evaluation completed prior to moving into the facility. c. Resident 3’s ABST evaluation was not updated and reviewed with his/her service plan update. The need to ensure residents’ ABST evaluations were completed prior to move-in and updated with significant changes of condition and no less than quarterly with the service plan update was reviewed with Staff 1 (Assistant ED), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

C-363 Acuity Based Staffing Tool-Updates and Staffing Plan 1) ABST tool for sampled residents was updated to accurately reflect ADL. 2) Review of ABST tool info for remaining residents was conducted to verify accuracy 3) Re-education provided to the ALD/MCD and ED on ABST tool use and content to assure understanding 4) ABST tool will be routinely audited for accuracy 5) At least weekly, with new move ins, significant changes of condition and quarterly with service plan updates. 6) ALD/MCD with ED oversight

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 completed prior to an unsampled resident moving into the facility and updated and reviewed no less than quarterly for multiple unsampled residents. Additionally, the facility failed to accurately capture care time that staff were providing for 1 of 2 sampled residents (#2) whose ABST was reviewed. This is a repeat citation. Findings include, but are not limited to: The facility’s ABST data was retrieved at 9:15 am on 06/17/25 and reviewed during the survey from 06/17/25 through 06/18/25. The following was identified: * An unsampled resident, who moved into the facility on 06/12/25, lacked an ABST evaluation completed prior to moving into the facility; * 11 unsampled residents’ ABSTs were not updated at least quarterly; and * Review of Resident 2’s ABST revealed multiple ADLs were not accurately capturing care time that staff were providing. On 06/18/25, the need to ensure residents’ ABST evaluations were completed prior to move-in, updated no less than quarterly, and accurately captured care time staff were providing was reviewed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

1.) Memory Care Director reviewed all memory care resident's ABST minutes for accuracies on 6/17/2025. 2.) Memory Care Director/Deignee will update quarterly and as needed to ensure ABST is reflecting current care needs. 3.) Memory Care Director/Deignee will update quarterly and as needed. 4.) Memory Care Director/Designee.

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 411-054-0105 (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 observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to deficiencies in this report.

1.) Refer to plans for all outlined tags. 2.) Memory Care Director/Designee to review POC weekly and as needed to ensure plan is being executed. 3.) Memory Care Director/Designee to review POC weekly and as needed. 4.) Memory Care Director/Designee.

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 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: ? Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 04/08/25 and 04/09/25 showed the following areas to be in need of cleaning or repair: * Multiple carpet stains were noted in the hallways and common areas. The stains varied in size and included white, red and black stains. Carpet stains were noted in the memory care director’s office as well; * Multiple scuffs, gouges and scratches were noted to the laminate flooring in the dining room. Scratches were several inches in length at the minimum; * Ceiling lights in the dining room and hallway had numerous dead insects and debris gathered in the light fixtures; * Strong odors of stale urine and a sour smell were noted in the common area bathroom and the hallways near the entrances to the memory care unit; * The common area bathroom had brown stains along the base of the toilet and on the nearby tile; * Spills, scrapes, splatters and debris were noted in/on the drawers, cupboards, walls and windowsills in the dining room. The curtains in the dining room had multiple spills and splatters with black/brown/white discolorations; * Room 6 had dark carpet stains, missing and/or discolored caulking along the shower edges and around the toilet base; * Room 21 had missing and/or discolored caulking at the shower edge and at the base of the toilet. Large cracks in the ceiling and at the wall corner were noted. The cracks were pulling apart creating a small gap; * A dusty vent was located in the common area on the lower wall; and * Multiple wall corners throughout the facility had chunks of missing plaster. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Assistant ED) on 04/09/25. She acknowledged the findings.

C513 Doors, Walls, Elevators, Odors 1) Carpets have been cleaned in hallways, common areas and MCD office. Noted scuffs gouges and scratches have been repaired. Dead insects cleaned out of light fixtures. Cleaning conducted of all common area bathrooms completed. Dining room has been cleaned. Room 6 carpet has been cleaned and caulking repaired for room 21. Vents have been cleaned. Wall corners have been repaired. 2) Review of cleaning schedules and ongoing observations for identifying ongoing needs conducted with SCU staff, maintenance and housekeeping departments. 3) Ongoing observations of the SCU unit including common areas, offices and resident apts will be conducted to assure ongoing compliance. 4) MCD will conduct weekly walk throughs of the SCU unit, offices and residents apts to identify any areas of cleaning or needed maintenance repair. MCD will conduct weekly reviews of cleaning schedules to assure it is being completed. 5) MCD with ED oversight.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility on 06/17/25 through 06/18/25 showed the following areas in need of cleaning or repair: * Multiple carpet stains were noted in the hallways and common area. The stains varied in size and included white and red stains. Carpet stains were noted in the memory care director’s office as well; * Ceiling lights in the dining room and common area had numerous dead insects and debris gathered in the light fixtures; and * Room 6 had missing and/or discolored caulking along the shower edges and around the toilet base. On 06/17/25, the areas in need of cleaning and/or repair were shown to and discussed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

1.) On 6/17/2025 all toilets were re-caulked. Common hallways carpets were cleaned with the carpet cleaner on site. Light fixtures were cleaned in the common areas of bugs/debris. 2.) Memory Care Director/Designee has implemented a cleaning checklist for her team to follow daily. Memory Care Director/Designee will monitor community daily/as needed to ensure cleaning items are completed. Professional carpet cleanning has been scheduled monthly from an outside vendor. Carpet dying vendor scheduled for July to correct coloring issues to carpet. 3.) Memory Care Director/Designee to monitor daily/as needed. 4.) Memory Care Director/Designee.

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

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by: ?Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: On 04/08/25, observations of the memory care unit showed resident one-bedroom apartments contained wall heaters. The heaters were located where residents could potentially come into incidental contact with them. The wall heaters located in the bedrooms of the four one-bedroom apartments in the memory care unit were tested on 04/08/25. The surface temperatures exceeded 120 degrees. Staff 1 (Assistant ED) and Staff 3 (Regional Director of Health Services) indicated they would have the heaters disabled. Staff 1 and Staff 12 (Maintenance) did additional temperature checks with the surveyor on 04/10/25, after new grates were installed. Staff 12 indicated extenders would be put in place to gain another one to two inches between the grate and the wall heater to ensure all temperatures consistently remained under 120 degrees. The need to ensure all wall heaters and/or grates did not exceed 120 degrees was discussed with Staff 1, 3 and 12 on 4/10/25. The staff acknowledged the findings.

C-540 Heating and Ventilation 1) Extenders will be put in place to reduce risk of resident injury 2) Re-education provided to MCD and maintenance on requirements and oversight measures to assure understanding. 3) Ongoing checks will take place to assure temps remain within range. 4) Weekly 5) MCD/Maintenance with ED oversight

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. 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 limited to: Refer to: C295, C350, C513 and C540.

Z-142 Administration Compliance 1) See individual POC statements for C295, C350, C513 & C540 2) Administrator will review POC adherence through weekly reviews with applicable department heads.

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. This is a repeat citation. Findings include, but are limited to: Refer to C295, C363, and C513.

Refer to POC for C295, C363, and C513.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: ? Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C260, C270 and C330

Z-162 Compliance with Rules Health Care 7) See individual POC statements for C295, C350, C513 & C540 8) Administrator will review POC adherence through weekly reviews with applicable department heads.

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. This is a repeat citation. Findings include, but are not limited to: Refer to C260.

Refer to POC for C260.

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 individualized nutrition and hydration plans were developed and included in the service plan for 1 of 3 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1’s service plan dated 03/09/25 and temporary care plans dated 03/09/25 through 04/08/25 were reviewed. The service plan was found to be lacking information and staff instructions related to an individualized nutrition and hydration plan, including preferences and appropriate snack and meal options. The need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was reviewed with Staff 1 (Assistant ED), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

Z163-Nutrition and Hydration 1) Resident 1 has been re-evaluated and service plan reviewed to assure presence of the individualized nutrition and hydration plan is present. 2) Review conducted of remaining SCU residents service plans to assure individualized nutrition and hydration plan is present. 3) Re-education provided to MCD/RN on requirements as noted above to assure understanding. 4) Routine reviews will be conducted of resident nutrition/hydration needs and service plan accuracy 5) MCD to observe at least one meal a day and continue with review of resident care related documents to assure timely awareness and updates made r/t any changes in resident need. 6) MCD/RN with ED oversight.

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 individualized nutrition and hydration plans were developed and included in the service plan for 1 of 2 sampled residents (#5) whose records were reviewed. Findings include, but are not limited to: Resident 5’s service plan dated 05/27/25 and temporary care plans were reviewed. The service plan was found to be lacking information and staff instructions related to an individualized nutrition and hydration plan, including preferences and appropriate snack and meal options. On 06/18/25, the need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was reviewed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

1.) Memory Care Director/Designee has updated all sampled resident services plan to focus on diet and hydration preferences for each resident. 2.) Memory Care Director/Designee will have all memory care resident service plans reviewed and updated by 08/02/2025 with diet and hydration preferences listed. 3.) Memory Care Director/Designee will update service plans by 08/02/2025. After AOC, Memory Care Director/Designee will update service plans quarterly and as needed. 4.) Memory Care Director/Designee.

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: