OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an elopement and an injury of unknown cause were promptly investigated to rule out abuse and neglect, and reported to the local SPD office when required, for 2 of 2 sampled residents (#s 1 and 3). Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC in 06/2024 with diagnoses including dementia and coronary artery disease. Interviews with staff, and review of the resident's 10/15/24 service plan, 02/13/25 through 05/13/25 interim service plans, progress notes, and incident investigations were completed. * A progress note dated 02/15/25 indicated Resident 1 was being placed on alert due to an elopement that occurred on 02/14/25. There was no other information about the incident located in the resident's record. No investigation was completed, and the incident was not reported to the local SPD office. In an interview on 05/14/25 at 11:45 am, Staff 1 (Memory Care Director), indicated she was not aware of the incident and no investigation was completed. Staff 1 stated she would report the incident to the local SPD office and provided documented confirmation of the report later that same day. On 05/15/25, the need to ensure incidents were investigated promptly to rule out abuse and neglect, and reported to the local SPD office when required, was discussed with Staff 1. She acknowledged the findings. 2. Resident 3 was admitted to the MCC in 01/2025 with diagnoses including Alzheimer’s disease. Interviews with staff, observations of the resident, and review of the resident's 02/14/25 through 05/13/25 interim service plans, progress notes, and incident investigations were completed. Resident 3 needed assistance with all ADL tasks, supervision with transfers, and used a wheelchair primarily for independent mobility on the unit. On 04/08/25 the progress notes and an incident report indicated Resident 3 was identified to have purple and yellow colored bruising to the left side of the torso, 12 inches long by three inches wide. The investigation did not reasonably rule out abuse, and the injury was not reported to the local SPD. The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office, and all injuries of unknown cause were immediately reported to the local SPD office unless an immediate investigation reasonably concluded that the injury was not the result of abuse was discussed with Staff 1 (Memory Care Director) on 05/14/25. She acknowledged the findings. The facility was instructed to report the injury of unknown cause to the local SPD office on 05/14/25, and confirmation of report sent was received from the facility by 3:00 pm on 05/14/25.

1. The action that will be taken to correct the rule violation include: a) Resident number one incident will be investigated and reported to the local SPD office. b). Resident number three incident will be investigated and reported to the local SPD office. 2. The System will be corrected so that this violation does not occur by: a). A Mandatory all staff training taught by NWSDS will be held 6-24-2025 (June 24th 2025) regarding Abuse Reporting and Investigating. b). Incident reports will be reviewed and investigated daily by the Administrator or designee. 3. The area needing correction will need to be monitored by reviewing incident reports in a daily clinical meeting, and reporting incidents as required. 4. The Administrator will be responsible for ensuring corrections are completed/ monitored.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to: During the survey, the MCC was home to 18 residents. These residents did not initiate any activities. Many residents were observed wandering the unit, both inside and in the outdoor courtyard area, and multiple residents spent time watching movies on a screen in the common room. Review of the MCC activity calendar indicated the scheduled activities for the following days were: *05/13/25: 9:00 Coffee with Friends 10:00 Fun and Fitness 1:00 Chef Chat w/Chef Kenny 2:00 Van Trip *05/14/25: 9:00 Coffee with Friends 10:00 Fun and Fitness 10:30 Trivia 1:00 Bingo 2:30 Gardening *05/15/25: 9:00 Coffee with Friends 10:00 Fun and Fitness 10:30 Crafts 2:00 Bible Study with Sharon 3:00 Ice Cream Social 3:30 Current Events During the survey, none of these scheduled activities were observed to take place. On 05/15/25, the need to ensure the facility provided a daily program of social and recreational activities for residents was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. The action that will be taken to correct the rule violation include: a). The facility will be providing a monhtly program of social and recreational activities. 2. The system will be corrected so that this violation does not occur again by, The Assistant Resident Lifestyle Director will be releasing a monthly activity calander by the second to last Thursday of every month and activities will be held daily. Any changes to the schedule will be noted in advance. 3. The areas needing correction will need to be monitored by the Administrator or designee will review attendance logs weekly during 1:1 meeting with the Resident Lifestyle Director. 4. The Assistant Resident Lifestyle Director and the Administrator will be responsible for ensuring corrections are completed/monitored.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required components for 1 of 1 sampled Resident (#3), whose move-in evaluation was reviewed, and evaluation updates were timely and reflective of residents’ current status for 3 of 5 sampled Residents (#s 1, 4 and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2025 with diagnoses including Dementia of Alzheimer’s type, hypertension and coronary artery disease. The move-in evaluation, dated 01/27/25, was reviewed, and there was no documented evidence the following required elements were addressed: * Customary routine: Eating; * Interests, hobbies, social, leisure activities; * Mental Health issues: History of treatment and effective non-drug interventions; * Personality: including how the person copes with change or challenging situations; * Communication: Ability to understand; * Pain: Pharmaceutical and non-pharmaceutical interventions; * Recent losses; and * Pronouns. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Memory Care Director) on 05/15/25 at 11:35 am. She acknowledged the findings. 2. Residents 1 and 5’s records were reviewed during the survey and revealed the following: There was no documented evidence that quarterly evaluations were completed for Residents 1 and 5. In an interview on 05/15/25 at 2:35 pm, Staff 1 (Memory Care Director) acknowledged that quarterly evaluations had not been completed. On 05/15/25, the need to ensure evaluations were completed quarterly, as required, was discussed with Staff 1. She acknowledged the findings. 3. Resident 4 was admitted to the MCC in 05/2023 with diagnoses including dementia. a. Resident 4’s last quarterly evaluation was completed on 11/13/24. The next evaluation was completed 04/07/25. The 04/07/25 evaluation was not completed at least quarterly, as required. b. Observations were made of the resident, and staff interviews were conducted. The resident’s most recent change of condition evaluation dated 04/07/25 was not reflective of Resident 4’s current care needs including: *Diagnosis of dementia; *Effective non-drug interventions for behaviors; *Assistive devices for hearing and vision loss; *Assistive devices for mobility; *Transfers; *Ability to use call system; *Pain; *Skin condition; *Recent losses; and *Elopement risk or history. The need to ensure evaluations were completed at least quarterly and were reflective of the residents’ current status and care needs was discussed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings.

1. The action that will be taken to correct the rule violation include: a). Resident number threes move in evaluation will include and addendum that adressses: Customary routine: Eating; Interests, hobbies, social, leisure activities; Mental Health issues: History of treatment and effective non-drug interventions; Personality: including how the person copes with change or challenging situations; Communication: Ability to understand; Pain: Pharmaceutical and non-pharmaceutical interventions; Recent losses; and Pronouns. b). Resident one and resident fives quarterly evaluation will be completed as required. c) Resident four's assessment will be completed quarterly and the change of condition dated 4-7-2025 will be updated to reflect: Diagnosis of dementia; Effective non-drug interventions for behaviors; Assistive devices for hearing and vision loss; Assistive devices for mobility; Transfers; Ability to use call system; Pain; Skin condition; Recent losses; and Elopement risk or history. 2. The system will be corrected so this violation does not occur again by: a). The Administrator and the licensed nurse will maintain a monthly schedule of upcoming evaluations to ensure completion. b). Changes in conditions will be discussed at daily standup meeting/ clinical meetings, to ensure evaluations are updated timely. c). The Licensed nurse and the Administrator will ensure resident evaluation are conducted prior to addmission, within 15 to 30 days of move in, with any change in condition, and quarterly to activitley reflect the resident needs and preferences. 3. The areas needing correction will need to be monitored by the executive director, mc administrator, licensed nurse will complete weekly audits to ensure compliance. Areas of non compliance will be addressed immediately. 4. The Administrator will be responsible to ensure the corrections are completed/ monitored.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services, and were readily available to staff for 4 of 4 sampled residents (#s 1, 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2025 with diagnoses including dementia of Alzheimer’s type, hypertension and coronary artery disease. Observations of the resident, interviews with staff and review of interim service plans and progress notes dated 02/13/25 through 05/13/25 were completed. There was no service plan available for staff during survey. The interim service plans were not reflective and did not provide direction for staff in the following areas: * Activities; * Behaviors; * Cognition; * Use of hearings aids; * ADL assistance; * Mobility to include assistive devices; * Dentures; * Mechanical soft diet; * Ability to use call system; and *Elopement risk or history. The need to ensure resident service plans were readily available for staff, reflective of current care needs, provided clear direction to staff was discussed with Staff 1 on 05/15/25 at 11:35 am. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 02/2022, with diagnoses including osteoarthritis, diverticulosis, and dementia. Review of Resident 2’s service plan, dated 02/17/25, interim service plans (ISPs), interviews with staff, and observations during the survey revealed the service plan was not reflective of current care needs, or did not provide clear instructions to staff in the following areas: *Hospice services provided; *Use of geri-chair/recliner; *Communication ability; *Activities; and *Nutrition/hydration: altered textured diet (puree) and meal assistance needed. On 05/15/25, the need to ensure service plans were reflective of current resident care needs and provided clear instruction to staff was discussed with Staff 1 (Memory Care Director). She acknowledged the findings. 3. Resident 1 moved into the MCC in 06/2024 with diagnoses including dementia. The resident’s record including the current service plan, progress notes dated 02/13/25 through 05/13/25 were reviewed. Observations were made, and staff were interviewed, the following was identified: a. The service plan available at the time of the survey was dated 10/15/24 and had not been updated quarterly, as required. b. The service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Hospice services; * Shower refusals and interventions; * Increased aggressive behaviors toward staff; * Behavioral interventions for aggression; * Resident to resident altercations including interventions to minimize reoccurrences; * Change in ambulation, walking with unsteady gait, head down; * Falls and current interventions; and * Resident-specific needs during evacuation. On 05/15/25, the need to ensure resident service plans were reviewed quarterly, were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (Memory Care Director). She acknowledged the findings. 4. Resident 5 moved into the MCC in 08/2023 with diagnoses including dementia and Parkinson’s disease. The resident’s record, including progress notes dated 02/13/25 through 05/13/25 were reviewed. Observations were made, and staff were interviewed. The following was identified: a. A behavior support plan (BSP) for Resident 5, dated 10/22/24, was available for staff in the service plan binder. b. There was no documented evidence that the facility had completed a quarterly service plan for Resident 5 as required. During an interview on 05/15/25 at 2:30 pm with Staff 1 (Memory Care Director), it was confirmed that Resident 5’s quarterly service plan was not readily available for staff. The need to ensure service plans were completed quarterly and were available to staff was discussed with Staff 1 on 05/15/25. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Resident number 3's service plan will be completed and available for staff. The service plan will include the following, but not limited to: Activities; Behaviors; Cognition; Use of hearings aids; ADL assistance; Mobility to include assistive devices; Dentures; Mechanical soft diet; Ability to use call system; and Elopement risk or history. b). Resident number 2's service plan will completed and available for staff. The service plan will include the following, but not limited to: Hospice services provided; Use of geri-chair/recliner; Communication ability; Activities; and Nutrition/hydration: altered textured diet (puree) and meal assistance needed. c).Resident number 3's current quarterly service plan will be available to staff, and will include the following directors to staff, but not limited to: Hospice services; Shower refusals and interventions; Increased aggressive behaviors toward staff; Behavioral interventions for aggression; Resident to resident altercations including interventions to minimize reoccurrences; Change in ambulation, walking with unsteady gait, head down; Falls and current interventions; and Resident-specific needs during evacuation. d). Resident number 5's quarterly evaluation will be updated and availble for staff. 2. The system will be corrected so this violation does not occur again by the Administrator or the Licensed nurse will complete the residents service plan prior to addmission, 15-30 days after move in, with any change of codition, and quarterly to activley reflect the residents needs and preferences. 3. The area needing correction will be evaluated by the Licensed Nurse weekly by auditing all current residents service plans and charts ensuring they reflect the current physical and mental needs of the resident. The licensed nurse will ensure all change of conditions are complete and reflective of resident changes. A clinical meeting will occur daily with the Clinical team (ED, MCD, HSD, RCC) and any other applicable parties for additional oversight on completion and timeliness. 4. The Licensed Nurse and The Administrator will be responsible for ensuring the corrections are completed/ monitored.

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 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4 and 5’s most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans. On 05/15/25, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Residents 1, 2, 3, 4, and 5's service plans will be developed by a service planning team including, but not limited to: the resident, legal representitive, any person of the residents choice, facility administrator or designee, and at least one other staff person. 2. The system will be corrected so this violation does not occur again by: a). A service plan calander will be created and updated monthly, and as needed. b). The residents Power of attorney/ the residents guardian will be contacted to schedule a service plan meeting upon move in, 30 days after move in, quarterly, and upon change of condition. 3. The areas needing correction will need to be monitored by the executive director, mc administrator, licensed nurse will complete weekly audits to ensure compliance. Areas of non compliance will be addressed immediately. 4. The Administrator or designee will be responsible for ensuring the corrections are completed/monitored.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had changes of condition had resident-specific instructions or interventions determined and documented, communicated to staff on each shift, and the conditions were monitored at least weekly through resolution for 3 of 4 sampled residents (#s 1, 3, and 4) who experienced short term changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 06/2024 with diagnoses including dementia and coronary artery disease. Observation of Resident 1, interviews with staff, and review of progress notes dated 02/13/25 through 05/13/25, interim service plans and incident investigations were completed. Resident 1’s progress notes identified the following : 02/15/25 – The resident was placed on alert due to an elopement that occurred on 02/14/25; 02/17/25 - “[Resident 1] had been exit seeking quite a bit, [s/he] was at the door to the [Assisted Living] and was trying to push it open.” “[Resident 1] also has been wandering into other residents’ rooms and when asked to exit [s/he] has been getting aggressive with staff”; 02/18/25 – The resident had been getting aggressive with the podiatrist; 02/19/25 – “[Resident 1] locked [him/herself] in [another resident’s] room”; 02/20/25 – The resident was “yelling at other residents and staff, outbursts, banging on the main memory care doors”; 02/21/25 – The resident was placed on alert due to an altercation toward another resident and had obtained a scratch on his/her bottom lip; 02/24/25 – The resident was having aggressive behaviors and while staff were in another resident’s room, the resident had held the door closed, not allowing the staff out; 02/24/25 – Resident 1 was involved in an altercation with another resident and was scratched on his/her lip; 03/11/25 – “[Resident 1] started pushing [the] front two doors constantly and throwing [his/her] body to open the doors and was pacing up and down the hall”; 03/17/25 – The resident had been trying to get into other resident rooms; 03/18/25 – “Resident to care staff altercation”; 03/23/25 – “[Resident 1] went outside and tried to bust the back gate door with [his/her] walker”; 04/07/25 – “[Resident 1] had trapped and cornered staff and grabbed hand/arm very aggressively not letting go”; 04/15/25 – Resident 1 was on alert for an “open wound on calf bone and right foot”; 04/28/25 – “Late entry from 04/25/25, caregivers reported that [Resident 1] was agitated after a fall yesterday”; 05/01/25 – Non-injury fall; 05/04/25 – Non-injury fall; 05/07/25 – Non-injury fall; and 05/08/25 – Resident to resident altercation. The above short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved. The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings. 2. Resident 3 was admitted to the MCC in 01/2025 with diagnoses including Alzheimer’s disease. The resident's interim service plans, progress notes and incident reports dated 02/14/25 through 05/13/25, MARs dated 04/01/25 to 05/13/25 were reviewed, observations were made, and interviews with staff were conducted. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions determined and communicated to staff on all shifts, and/or were not monitored at least weekly to resolution: * 02/13/25 - Return from hospital with decline in mobility, using w/c, swallowing difficulty; * 02/14/25 - Non-injury fall; * 02/14/25 - New medication; * 02/14/25 - Choking episode; * 02/18/25 - Altercation toward staff; * 02/21/25 - Resident to resident altercation; * 02/28/25 - New medications Divalproex (Depakote), Risperidone (for behaviors); * 03/15/25 - Two bruises on right upper arm and mid lower back; * 03/21/25 - Start Furosemide medication (for edema); * 03/22/25 - Fall outside in secured courtyard; * 04/8/25 - Bruising on left side of torso; * 05/1/25 - Room change; and * 5/4/25 - Start of antibiotic eye ointment. The need to ensure all changes of condition had actions or interventions determined and communicated to staff on all shifts, and/or were monitored at least weekly to resolution was discussed with Staff 1 (Memory Care Director) at 12:30 pm on 05/15/25. She acknowledged the findings. 3. Resident 4 was admitted to the MCC in 05/2023 with diagnoses including dementia. The resident's service plan dated 11/13/24, interim service plans, incident reports and progress notes, dated 02/13/25 to 05/13/25, and MARs dated 04/01/25 through 05/13/25 were reviewed, observations were made, and interviews with staff were conducted. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions determined and communicated to staff on all shifts, and/or were not monitored at least weekly to resolution: * 02/8/25 - Decrease in olanzapine dosage (for behaviors); * 02/19/25 - Erythromycin ointment medication (for eye infection); * 02/26/25 - New medication escitalopram (for behaviors); * 04/3/25 - Right ankle fracture; * 04/4/25 - Uncontrolled pain to the right ankle, sent to hospital; * 04/10/25 - Skin tear to right forearm; and * 04/15/25 - Finger abrasion. The need to ensure all changes of condition had actions or interventions determined and communicated to staff on all shifts, and/or were monitored at least weekly to resolution was discussed with Staff 1 (Memory Care Director) at 12:30 pm on 05/15/25. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Resident numbers 1, 3 and 4's changes in condition will be documented, proper interventions determined, communicated to staff, and monitored at least weekly to resolution. 2. The system will be corrected so this violation does not occur again by: a). Daily clinical meetings will be held to review resident medications, resident progress notes, and resident changes with the executive director the administrator, the resident care coordinator and the registered nurse. b). High risk meetings will be held once a week with a weekly progress note input by the registered nurse. 3. The area of correction will need to be monitored by The Administrator/nurse or designee will conduct weekly audits of required clinical documentation and service plans of residents who experienced a change of condition. Areas of non-compliance will be addressed immediately. 4. The Registered Nurse and The Administrator will be responsible for ensuring the corrections are completed/ monitored.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have an Oregon licensed nurse who was regularly scheduled for onsite duties at the facility, who was available for phone consultation, and failed to ensure RN assessments were completed for 3 of 3 sampled residents (#s 1, 3, and 4) who experienced significant changes of condition. Findings include, but are not limited to: 1. During the survey, Staff 1 (Memory Care Director) reported that the facility did not have an RN who was regularly scheduled for onsite duties at the facility and who was available for phone consultation. Staff 1 reported the previous RNs employment with the facility ended on 05/02/25. The need to have an Oregon licensed nurse who was regularly scheduled for onsite duties at the facility and available for phone consultation was discussed with Staff 1. She acknowledged the finding. 2. Resident 3 was admitted to the MCC in 01/2025 with diagnoses including Alzheimer’s disease. During the acuity interview on 05/13/25, staff reported Resident 3 had significant weight loss. Observations of Resident 3 and interviews with staff identified the resident ate independently a mechanical soft diet and had a good appetite. Weight records, dated 01/10/25 through 05/01/25, and progress notes, dated 02/14/25 through 05/15/25, were reviewed and indicated the resident experienced significant weight loss: * 01/10/25: 150.6 pounds; * 02/2025 through 04/2025: No weights were recorded; and * 05/01/25: 133.2 pounds. Between 01/10/25 and 05/01/25 the resident lost 17.4 pounds, or 13% of total body weight in four months. This weight change constituted a significant change of condition. There was no documentation of an RN assessment for the significant change of condition related to the weight loss to include findings, status, and interventions made as a result of the weight loss. The need to ensure an RN assessment was completed for residents who experienced a significant change of condition to include findings, status, and interventions made as a result was reviewed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings. No further information was provided. 3. Resident 4 was admitted to the MCC in 05/2023 with diagnoses including dementia. The progress notes on 04/03/25 identified the resident was found limping, with pain, redness and swelling to the right ankle. The resident was evaluated at the hospital and was diagnosed with a right ankle fracture. The interim service plans, and progress notes indicated Resident 4 became less ambulatory and began using a wheelchair primarily. During survey, the resident was observed in the wheelchair and was able to self-propel using his/her feet. The ankle fracture and resultant decline in mobility constituted a significant change of condition. There was no documented RN assessment completed for the significant change of condition to include findings, status, and interventions made as a result. Staff 1 (Memory Care Director) acknowledged the findings on 05/15/25. 4. Resident 1 moved into the MCC in 06/2024 with diagnoses including dementia and coronary artery disease. Review of the resident's progress notes dated 02/13/25 through 05/13/25 indicated the resident had increased aggressive behaviors. The resident was admitted to hospice on 04/03/25. The increased behaviors and the admission to hospice represented significant changes of condition for Resident 1, for which an RN assessment was required. There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant changes of condition. On 05/15/25 at 3:15 pm, Staff 1 (Memory Care Director) confirmed there was no RN assessment completed. The need to ensure residents who experienced significant changes of condition were assessed by the RN was discussed with Staff 1 on 05/15/25. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Registered Nurse was hired with a start date of June 12th 2025 (6-12-2025. b). Resident number 3's change in codition assessment will be documented including, but not limited to: findings, status, and interventions made as a result to resident number 3's weight loss. c). Resident number 4's change in condition assessment will be documented including, but not limited to: findings, status, and interventions made as a result to resident number 4's ankle fracture. d). Resident number 1's change in condition assessment will be documented including, but not limited to: finding, status, and interventions made as a result to resident nmber 1's hospice admission and aggressive behaviors. 2. The System will be corrected so the violation does not occur again by: a). The registered nurse will complete the "Role of the RN in a community based care community." b). The Administrator will notify the Registered Nurse of all significant changes of condition promptly. The Registered Nurse will complete a full or problem-focused assessment and will document findings and interventions to address the problem area(s) timely. 3. The area of correction will need to be monitored by the administrator, the registered nurse, or designee will conduct weekly audits of requires clinical documentation and service plans of residents who experienced a change of condition. Areas of non compliance will be addressed immediately. 4. The Registered Nurse and The Administrator will be responsible for ensuring the corrections are completed/ monitored.

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

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 4 was admitted to the MCC in 05/2023 with diagnoses including dementia. The current written prescriber orders and MARs dated 04/01/25 through 05/13/25 were reviewed during the survey. Resident 4 had a physician order for hydrocodone-acetaminophen 5-325 mg, one tablet every six hours as needed for pain. Review of the MARs and Controlled Substance Disposition Log revealed the following discrepancies: *There were three times a facility staff signed the Controlled Substance Disposition log indicating the hydrocodone was removed from locked storage but did not document on the MAR that the medication was administered; and *There was one time a facility staff signed the MAR indicating the hydrocodone was administered but did not document on the Controlled Substance Disposition log indicating the narcotic was removed from locked storage. The number of hydrocodone tablets in the prescription bottle matched the Controlled Substance Disposition log. The need to ensure the tracking of controlled substances was accurate was reviewed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Sampled resident #4's MAR and controlled substance drug dispostion log will be updated for accuracy. 2. The system will be corrected so this violation does not occur again by: a). Consonus Pharmacy conducting an inservice for Memory care medication technicians on narcotics logs and MAR accuracy. 3. The area needing correction will need to be monitored through weekly narcotic and MAR audits. 4. The Registered Nurse and the administrator will be responsible for ensuring the violation is corrected/monitored.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to orders for 2 of 3 sampled residents (#s 3 and 4) who had documented medication or treatment refusals. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2025 with diagnoses including Dementia of Alzheimer’s type, hypertension and coronary artery disease. Resident 3's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication and treatment refusals from 04/01/2025 through 05/13/2025. The medications and treatments refused included: * Acetaminophen 325mg (for mild pain); * Aspirin 81mg (for heart health); * Finasteride 5mg (for prostate cancer); * Isosorbide mononitrate 30mg (for coronary artery disease); * Lorazepam 0.5mg (for agitation/anxiety); * Risperidone 1mg (for behavioral problems); * Amlodipine Besylate 10mg (for high blood pressure); * Compression Socks (for swelling to lower extremity); * Divalproex 125mg (for bipolar); * Zinc Oxide 10% topical cream (for skin breakdown); and * Erythromycin ophthalmic ointment (for conjunctivitis). On 05/15/25 at 11:35 am, Staff 1 (Memory Care Director) confirmed there was no documented evidence the facility notified Resident 3's physician of the refusals. On 05/15/25 at 11:35 am the need to ensure physicians or other practitioners were notified each time a resident refused to consent to an order was discussed with Staff 1. She acknowledged the findings. No further documentation was provided. 2. Resident 4 was admitted to the MCC in 05/2025 with diagnoses including dementia. Resident 4's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication refusals from 04/01/25 through 05/14/25. The medications refused included: * Acetaminophen 325 mg at bedtime (for pain); * Aspirin 81 mg daily (for heart health); * Atenolol 25 mg daily for (cardiac); * Centrum Silver Womens 50+ (for supplement); * Fish Oil 1000 mg twice daily (for supplement); * Isosorbide Mononitrate 30 mg daily (for angina); * Multiple Vitamins with minerals (for supplement); * Olanzapine 5 mg at bedtime (for agitation); * Trazodone HCL 50 mg at bedtime (for sleep); and * Vitamin D3 25 mcg daily (for supplement). There was no specific order for when the physician wanted to be notified of medication refusals, and the facility was unable to provide documented evidence that each refusal was reported to the physician. The need to ensure physicians or other practitioners were notified each time a resident refused to consent to an order was discussed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Resident number 3's documented refusals will be faxed to primary care provider or other practicioner. b). Resident number 4's documented refusals will be faxed to the primary care provider or other practicioner. 2. The system will be corrected so this violation does not occur again by: a). An inservice will be held with Memory Care Medication Technicians regarding Physician notifactions when a resident refuses a medication or a treatment. b). Memory medications technicians will be required to take "Documenting Medication" Oregon Care Partners course, for proper medications administration. 3. The area of correction will need to be monitored through a monthly EMAR audit to ensure both documents match. 4. The Administrator or designee will be responsible for ensuring the corrections are completed/ monitored.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. 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 document non-pharmacological interventions had been tried with ineffective results prior to administering a PRN psychotropic medication, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the MCC in 05/2023 with diagnoses including dementia. The resident was prescribed olanzapine 5 mg every day as needed for agitation. The MAR did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation for which staff could consider administering the medication; and There was no documented resident-specific non-pharmacological interventions attempted prior to administration of the medication on four occasions between 04/01/25 and 05/13/25. The need to have written, resident-specific parameters for PRN psychotropic medications, and to have non-drug interventions for staff to attempt and document ineffective results prior to administration of the psychotropic medications, was reviewed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings 2. Resident 3 was admitted to the facility in 01/2025 with diagnoses including dementia of Alzheimer’s type, hypertension and coronary artery disease. The resident was prescribed lorazepam 0.5 mg every four hours as needed for agitation, anxiety and nausea. The MAR dated 04/01/2025 through 05/13/2025 did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation behaviors for which staff could consider administering the medication; and There was no documented evidence resident-specific non-pharmacological interventions were attempted with ineffective results prior to administering the medication on multiple occasions between 04/1/25 and 05/13/25. The need to have written, resident-specific parameters for PRN psychotropic medications, and to have non-drug interventions for staff to attempt and document ineffective results prior to administration of the psychotropic medications, was reviewed with Staff 1 (Memory Care Director) on 05/15/25 at 11:35 am. She acknowledged the findings. 3. Resident 2 was admitted to the facility in 02/2022, with diagnoses including osteoarthritis, diverticulosis, and dementia. Resident 2's MAR, dated 04/01/25 through 05/13/25, was reviewed during the survey. The resident was prescribed the following PRN psychotropic medications: * Lorazepam .5 mg, to be administered “1 tablet by mouth every 4 hours as needed for anxiety or dyspnea”; and * Quetiapine 25 mg, to be administered “1 tablet by mouth every 6 hours as needed for anxiety or agitation” The MAR lacked instructions for the sequential order of use for these medications, and there was no documented evidence of non-pharmacological interventions to be attempted prior to psychotropic administration. Resident 2 did not receive the prn medication between 04/01/25 and 05/13/25. On 05/15/25, the need to provide clear instructions for unlicensed staff regarding the sequential order psychotropic use, and to ensure non-pharmacologic interventions were attempted and documented prior to psychotropic administration was discussed with Staff 1 (Memory Care Director). She acknowledged the findings. 4. Resident 1 moved into the MCC in 06/2024 with diagnoses including dementia and coronary artery disease. A review of Resident 1's MARs, dated 04/01/25 through 05/13/25, and current prescriber orders indicated the resident was prescribed the following: Lorazepam 0.5 mg, take one tablet by mouth every two hours as needed for anxiety or agitation. a. The record lacked resident-specific parameters to direct staff on how the resident displayed anxiety or agitation. b. There was no documentation that non-pharmacological interventions were tried with ineffective results prior to administration of the PRN lorazepam on five occasions between 04/01/25 and 05/13/25. The need to ensure resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administration of PRN psychotropic medications was discussed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). The eMAR for sampled Residents 1,2, 3, and 4 will be updated to ensure PRN psychotropic medications have written, resident-specific parameters and to include instructions to attempt resident specific non-pharmacological interventions prior to medication administration. 2. The system will be corrected so this violation does not occur again by: a). The Licensed Nurse will review medication orders for residents receiving as needed psychotropic medications to ensure each psychotropic medication has resident specific parameters as well as non-pharmacutical interventions prior to administration. The resident's attending physician will be notified for orders needing clarification. 3. The area of correction will need to be monitored quarterly in conjunction with service plan updates. Areas of non compliance will be addressed immediatley. 4. The administrator or designee will be responsible for ensuring the corrected are completed/monitored.

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 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT or OT prior to use, and instruction was provided to caregivers on precautions and correct use of the device, for 1 of 1 sampled resident (#2) who had a supportive device with restraining qualities. Findings include, but are not limited to: Resident 2 was admitted to the facility in 02/2022, with diagnoses including osteoarthritis, diverticulosis, and dementia. In an acuity interview on 05/13/25, Resident 2 was identified as using a geri-chair recliner, which had restraining qualities. Observations during the survey confirmed the resident was in the chair often. There was no documented evidence the geri-chair had been assessed by an RN, PT or OT, or that caregivers had been instructed on precautions and the correct use of the device. On 05/15/25, the need to ensure an assessment was completed by an RN, PT, or OT prior to use of any supportive device with restraining qualities, including precautions and instructions to staff was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). The registered nurse will complete a supportive device with restraining qualities assesment for resident number 2. 2. The system will be corrected so this violation does not occur again by: a). The registered nurse will be required to take the course "Restraint considerations and alternatives" on oregon care partners. 3. The area needing correction will need to be monitored quarterly through evaluation of service needs. 4. The registered nurse and the administrator will be responsible for enuring the violation is corrected/monitored.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have an accurate number of care minutes included on the acuity-based staffing tool (ABST) for each of the 22 care areas, for 4 of 5 sampled residents (#s 1, 2, 3 and 5). Findings include but are not limited to: Review of Resident 1, 2, 3 and 5’s ABST records revealed the residents’ allotted care minutes were not reflective of current needs in one or more of the 22 care areas of ABST. On 05/15/25, the need to ensure the ABST accurately captured the care minutes for all residents, in each of the 22 ADL areas was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Resident numbers 1,2,3, and 5's ABST records will be updated to reflect the residents current care needs. b). All residents ABST records will be updated upon admission, after 30 days of move in, quarterly, and upon change of condition. 2. The system will be corrected so this violation does not occur again by: a). ABST training scheduled with Acuity-Based Staffing Corrective Action Coordinator on (June 26th 2025) 6-26-2025. b). ABST records will be updated upon admission, between 15 and 30 days after move in, quarterly, and upon change of condition, to reflect current resident needs. 3. The area needing correction will be monitored upon admission, within 30 days after move in, quarterly, and upon change of condition. 4. The Licensed nurse and the administrator will be responsible for ensuring the violation is corrected/ monitored.

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 all residents had an ABST evaluation that was updated quarterly for 4 of 6 sampled residents (#s 3, 4, 5 and 6) and two unsampled residents, and 1 of 1 sampled resident (#3) had no ABST evaluation completed prior to admission. Findings include but are not limited to: Review of the facility’s ABST on 05/14/25 revealed there was no documented evidence of: * An updated quarterly ABST evaluation for Residents’ 3, 4, 5 and 6 and two unsampled residents; and * An ABST evaluation completed prior to admission for Resident 3, who was admitted 01/29/25. On 05/15/25, the need to ensure all resident ABST evaluations were updated no less than quarterly, to correspond with the quarterly service plan, and were entered prior to admission was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Resident numbers 3,4,5, and 6 ABST records will be updated quarterly to reflect the residents current needs and the residents current service plan. 2. The system will be corrected so this violation does not occur again by: a) ABST training scheduled for June 26th 2025 (6-26-2025) with Acuity-Based Staffing Corrective Action Coordinator. b). The administrator or designee will update ABST records will be updated upon move in, within 15 to 30 days after move in, quarterly, and upon change of condition. 3. The area needing correction will be monitored upon admission, within 30 days after move in, quarterly, and upon change of condition. 4. The administrator or the licensed nurse will be responsible for ensuring the violation is corrected/monitored.

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and failed to provide fire and life safety instruction to staff on alternate months in accordance with the Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records between 12/2024 and 05/2025 were reviewed and showed: a. Two fire drills were documented as completed in the last six months. b. Fire drills were not conducted on alternating months with fire life safety training. c. Drills were not conducted on alternating shifts to include all three shifts. d. One of the fire drills conducted was lacking the following required components: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Number of occupants evacuated; and * Evidence alternate routes were used was lacking on both fire drills. The need to ensure fire drills were conducted on alternating months from life safety training and all required components were addressed and documented for each fire drill and provide fire and life safety instruction to staff was discussed with Staff 1 (Memory Care Director) on 05/15/25 at 11:35 am. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). There were no corrective actions taken since no specific resident(s) were identified. 2. The system will be corrected so this violation does not occur again by: a). The Maintenance Director or designee will ensure throrough and complete reporting documentation for each evacuation drill conducted. b). The community will conduct fire drills every other month including, but not limited to: Escape route used; Problems encountered, comments relating to residents who resisted or failed to participate in the drills; Evacuation time period needed; Number of occupants evacuated; and Evidence alternate routes were used was lacking on both fire drills c). Staff fire life safety training will be held by the maintenance director or designess every other month, alternating months with the fire drills. 3. The area needing correction will need to be monitored monthly during the safety committee meeting by the administrator, maintenance director and designee. 4. The administrator or designee will be responsible for ensuring the violation is corrected/ monitored.

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 instruct residents within 24 hours of admission and re-instruct at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, designated meeting places outside the building or within the fire safe area in the event of an actual fire and maintain a written record of fire safety training , including content of the training sessions and the residents attending. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 12/2024 through 05/2025 revealed there was no documented evidence of resident instruction within 24 hours of admission or annual fire safety re-instruction. On 05/15/25 at 11:35 am, Staff 1 (Memory Care Director) confirmed the facility did not have a system for instructing residents within 24 hours of admission or re-instructing residents, at least annually on fire and life safety expectations. The need to instruct residents within 24 hours of admission and re-instruct at least annually, on fire and life safety procedures was discussed with Staff 1 on 05/15/25 at 11:35 am. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Within 24 hours of a new admission the maintenance director or deignee will complete fire and ife safety with the resident. b). The maintenance director or designee will complete fire and life safety reinstruction annually. 2. The system will be corrected so this violation does not occur again by: The administrator or designee will schedule annual re-instruction tied during the month of admission or done community-wide. 3. The area needing correction will need to be monitored quarterly through service plan meetings. 4. The Maintenace Director and The Administrator will be responsible for ensuring the violation is corrected/monitored.

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 (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 facility interior was clean and in good repair. Findings include, but are not limited to: Observations of the facility on 05/13/25 through 05/15/25 showed the following areas in need of cleaning and/or repair: * Corners of the walls in the entrance to the dining room and one window frame area had large gouged areas; * Food and debris found on the inside of the handrails in the corridor; * Bathroom door handle in room 114 was broken, and one side of the bathroom countertop was missing the laminate stripping; * There was no caulking around toilet bases in rooms 102 and 114; * Room 114 had a pervasive unpleasant odor throughout the survey; * Cabinet door under the kitchenette sink was missing; * Closet doors where activity supplies were stored were broken; * Window blinds were broken in rooms 102, 109, 110,113, and one blind in the dining room; and * A screen in one of the dining room windows was torn and hanging. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings.

1. The action that will be taken to correct the rule violation include: a). The facility will ensure to clean and/or repair the following: Corners of the walls in the entrance to the dining room and one window frame area had large gouged areas; Food and debris found on the inside of the handrails in the corridor; Bathroom door handle in room 114 was broken, and one side of the bathroom countertop was missing the laminate stripping; There was no caulking around toilet bases in rooms 102 and 114; Room 114 had a pervasive unpleasant odor throughout the survey; Cabinet door under the kitchenette sink was missing; Closet doors where activity supplies were stored were broken; Window blinds were broken in rooms 102, 109, 110,113, and one blind in the dining room; and A screen in one of the dining room windows was torn and hanging. 2. The system will be corrected so this violation does not occur again by: a). supervisor weekly audits with documented review. 3. The area needing correction will need to be monitored through weekly inspections and monthly facility wide audits by the administrator or designee. 4. The administrator or designee will be responsible for ensuring the violation is corrected/monitored.

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 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain hot water temperatures in the building within a range of 110 - 120 degrees Fahrenheit (F). Findings include, but are not limited to: On 05/14/25, at approximately 11:15 am, water temperatures in one public bathroom and three resident rooms were measured using the surveyor's digital thermometer. The water temperatures were outside the required temperature range as follows: * Public restroom in front of building: 108.2 degrees F; * Room 104: 106.7 degrees F; * Room 106: 106.4 degrees F; and * Room 109: 107.2 degrees F. In an interview on 05/15/25, Staff 4 (Maintenance Director) acknowledged the surveyor’s water temperature findings. Staff 4 explained there was currently a malfunction of the hot water system in the building. He took the surveyor to the control room where two hot water tanks stood. The display screen on one of the tanks read “flame not detected-system failure”. Staff 4 stated he had contacted a water service company, and the problem would be addressed promptly. On 05/15/25, the need to maintain hot water temperatures within a range of 110 – 120 degrees F was discussed with Staff 1 (Memory Care Director) and Staff 4. They acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). An outside service technician will be called to assess and repair the water temperature in the public restroom, and through resident rooms. 2. The system will be corrected so this violation does not occur again by: a). the maintenance director or designee will adhear to the TELS/ Maintence IQ schedule for hot water temperature testing. Any deficiencies noted will be addressed immediately. 3. The area needing correction will need to be monitored weekly by the Maintenance Director preforming hot water temperature testing. 4. The Maintenacne Director or designee will be responsible for ensuring the violation is corrected/ monitored.

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: Observations of the MCC environment from 05/13/25 through 05/15/25, revealed there were no functioning exit door alarms or other acceptable system that alerted staff when residents exited into the secured courtyard and into the assisted living facility. On 05/13/25 the lack of an alarming device or other system to alert staff when a resident exited the facility was discussed with Staff 1 (Memory Care Director). She acknowledged the alarms were not working and had Staff 4 (Maintenance Director) purchase and install replacement alarms. From 05/14/25 through 05/15/25, the door alarms were found to inconsistently function when the doors were opened. On 05/15/25, the need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1. She acknowledged the alarms were not functioning properly each time the doors were opened.

1. The action will be taken to correct the rule violation include: a). An outside service technician will be called to assess and repair the water temperature in the public restroom, and through resident rooms. 2. The system will be corrected so this violation does not occur again by: a). the maintenance director or designee will adhear to the TELS/ Maintence IQ schedule for hot water temperature testing. Any deficiencies noted will be addressed immediately. 3. The area needing correction will need to be monitored weekly by the Maintenance Director preforming hot water temperature testing. 4. The Maintenacne Director or designee will be responsible for ensuring the violation is corrected/ monitored.

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

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for unsampled and sampled residents who resided in the MCC. Findings include, but are not limited to: Observations made throughout the duration of the survey revealed that multiple resident apartment entrance doors had “peepholes,” allowing residents to see who was outside before opening the door; however, the peepholes also allowed anyone on the outside to view inside the residents’ apartments. Staff were observed during survey looking through the peepholes of resident rooms. In an interview on 05/15/25 Staff 1 (Memory Care Director) reported that all but one of the one-way vision devices had fallen out of the peepholes and were thrown away. The need to ensure the facility was respecting resident’s privacy preferences related to door viewers was discussed with Staff 1 on 05/15/25. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). The maintenance director will repair/ replace the one way vision device opening, on the resident room doors. 2. The system will be corrected so this violation does not occur again by: a). After the repair/ replace the one way vision devices will not be in the doors, to ensure the resident has full privacy. 3. The area needing correction will be monitored by: a). After the repair/ replace the one way vision devices will not be in the doors, to ensure the resident has full privacy. 4. The Administrator or designee will be responsible for ensuring the correction is corrected/ monitored.

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 residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: Review of records for Residents 2, 3, 4, and 6 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms. The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Memory Care Director) on 05/15/25. She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). The licensed nurse will complete an assessment on resident numbers 2,3,4, and 6 to document the residents ability to utilize a key. b). Resident numbers 2,3,4, and 6 will be issued a key to their apartment with proper documentation, upon request. 2. The system will be corrected so this violation does not occur again by: a). Upon initial evaluation the resident will be evaluated on the ability of a use of a key. The resident will be issued a key upon request. 3. The area needing correction will need to be monitored evaluation upon admission and upon request. 4. The Licensed nurse or designee will be responsible for ensuring the violation is corrected/ monitored.

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 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluation addressed all required elements including the pronouns for 1 of 1 sampled resident (#3) whose evaluation was reviewed. Findings include, but are not limited to: Refer to C 252, example 1.

See POC for all plan of corrections; Refer to C252

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by:

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted on 05/13/25 through 05/15/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in report.

See POC for all Citations

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. 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 C231, C242, C420, C422, C513, C545, and C555.

See POC for all Citations

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 C252, C260, C262, C270, C280, C302, C305, C330, C340, C362, and C363.

See POC for all Citations

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed, and included in the service plan for 4 of 5 sampled memory care residents (#s 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: The current service plans and interim service plans for Residents 2, 3, 4 and 5 were reviewed, and lacked individualized nutrition and hydration plans, based on the residents’ needs. On 05/15/25, the need for individualized nutrition and hydration plans, including interventions based on resident needs, was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. The action will be taken to correct the rule violation include: a). Resident numbers 2,3,4, and 5's service plan will be updated to include, but not limited to: individualized nutrition and hydration plans including interventions based on resident needs. 2. The system will be corrected so this violation does not occur again by: a) The residents service plans will be reviewed and updated to ensure they have an individualized nutrition and hydration plan specific to meet their needs and preferences. b) All newly admitted residents will be evaluated by the Licensed Nurse or designee prior to admission to ensure an individualized hydration and nutrition plan is developed. This plan will be evaluated within 30 days of move-in, quaterly, or with changes of condition to reflect the active preferences and adaptations for the resident as well as ensure there are proper staff instructions for residents daily meal program. 3. The areas needing correction will need to be monitored by the service planning team after the initial, 30 day, quarterly, and upon change of condition service plan. 4. The Administrator or designee will be responsible for ensuring the violation is corrected/monitored.

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

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5)) whose service plans were reviewed. Findings include, but are not limited to: Though Resident 1, 2, 3, 4 and 5's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities. On 05/15/25, the need to ensure the facility developed an individualized activities plan for each resident, based on a thorough evaluation was discussed with Staff 1 (Memory Care Director). She acknowledged the findings

1. The action will be taken to correct the rule violation include: a). Resident numbers 1, 2, 3, 4, and 5's service plan will be updated to include, but not limited to the following: Past and current interests; Current abilities and skills; Emotional and social needs and patterns; Physical abilities and limitations; Adaptations necessary for the resident to participate; and Activities that could be used as behavioral interventions, if necessary. b). Resident numbers 1,2,3,4, and 5 will have an activites plan created to address the residents capabilities, needs, and interests. 2. The system will be corrected so that this violation does not occur again by: a) The Assistant Lifestyle Resident Director will ensure that all residents are evaluated and have a documented person-centered activities plan to engage them in meaningful activities. The evaluation and plan development will involve the service plan team. The plan will be updated upon move in, quarterly, and with changes of condition to reflect the residents current needs, preferences, and abilities. 3.The areas needing correction will need to be monitored by the Administrator or designee will review activite plans during 1:1 meeting with the Resident Lifestyle Director. 4. The Assistant Resident Lifestyle Director and the Administrator will be responsible for ensuring corrections are completed/monitored.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: