OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to: During the re-licensure survey, conducted 05/19/25 through 05/27/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. 1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas: Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas: OAR 411-054-0025 Facility Administration OAR 411-054-0055 (1) Safe Medication System OAR 411-054-0025 (4) Reasonable Precautions OAR 411-054-0027(1) Resident Rights OAR 411-054-0040 (1-2) Change of Condition OAR 411-054-0070 (1) Staffing Requirements OAR 411-054-0090 (1-2) Fire and Life Safety An Immediate plan of correction was request on 05/20/25, 05/21/25, and 05/22/25. The facility provided a plan of correction on 05/20/25 at 7 pm, 05/21/25 at 6:20pm, and 05/23/25 at 5:30 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. 2. Refer to deficiencies in the report.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: During the survey, multiple sampled and non-sampled residents expressed their concerns during a group interview as well as individual interviews regarding complaints being minimized or going unaddressed. Examples given included: * Housekeepers not completing all required housekeeping tasks; * Duct tape on carpet was dangerous and caused falls; * Medications not administered timely, not administered at all, administered incorrectly, and left at bedside; * Foods served undercooked, cold, and in small portions; * Menus not provided a week in advance; * Menu frequently changed without notice because foods were not available; * Lack of diabetic snack options; * Resident inappropriately touched multiple residents; * Unknown person entered a resident’s room and went through bedding and clothing; and * Multiple residents reported filing grievances or reporting concerns verbally with no follow-up received. On 05/23/25 at 12:46 pm, Staff 1 (ED) reported the facility’s previous grievance system included handing written grievances to the front desk representative. This led to grievances not being resolved as the written forms were often misplaced or thrown out. During the survey, Staff 1 implemented a new complaint system with a lockbox to ensure grievances were maintained. The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 and Witness 1 (RN Consultant) on 05/23/25 at 12:46 pm. They acknowledged the findings.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 05/19/25 through 05/27/25, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective. Staff 1 (ED) was interviewed on 05/21/25 at 11:12 am. During the interview he confirmed the facility had failed to conduct ongoing quality improvement programs. Refer to deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record reviews it was determined the facility failed to ensure reasonable precautions were taken to protect against any condition that could threaten the health, safety, or welfare of residents for 4 of 4 sampled residents (#s 1, 2, 4 and 6) and 3 unsampled residents. Resident 6 was lost in the community on at least two occasions and unable to find his/her way home. Additionally, Resident 6 repeatedly fondled, kissed and/or touched multiple sampled and non-sampled residents without their consent. Resident 6 was reported to block resident wheelchairs, paths, doorways and/or hold onto wheelchair handles to prevent other residents from moving freely. Findings include, but are not limited to: Resident 6 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 03/06/25 and progress notes dated 01/01/25 through 05/21/25 were completed. The resident's service plan dated 03/06/25 indicated the resident had a diagnosis of dementia. The service plan noted the "resident has occasional difficulty remembering and using information; requires some directions and reminding from others; may have difficulty following written instructions.” The resident was noted to have mild long term and short- term memory impairment. The resident had “frequent disorientation to person, place, time or situation even in familiar surroundings and requires supervision and oversight for safety.” The resident frequently wandered outside and left the community and required supervision. The resident was also noted to have occasional “disruptive”, “aggressive” or “socially inappropriate” behaviors listed as either “verbally” or “physically” improper. The resident required minimal assistance with ADLs and cues to make it to meals. a. Review of the resident's 01/01/25 to 05/21/25 progress notes showed the following: * A progress note dated 01/10/25 at 6:08 pm, indicated the resident kissed another resident while in the dining room. The resident was placed on alert charting for monitoring. There were no other specifics on the incident itself. * A progress note dated 01/13/25 at 6:13 pm, indicated the resident was placed on alert for behaviors of invading personal space. There were no other specifics on the incident or behaviors noted. * A progress note dated 01/29/25 at 6:00 am, indicated the resident was found in another resident’s room with his/her arm around the resident. Staff removed Resident 6 and assisted him/her back to his/her room. There was no further documentation. * A progress note dated 02/12/25 at 4:57 am, indicated the resident continued on alert for increase supervision and safety checks. The resident was found in another resident’s apartment with arm around the resident and seated on the sofa. * A progress note dated 02/12/25 at 9:11 am, indicated the resident was found in another room with a resident of the opposite gender. Resident 6 had his/her shirt off. The resident was redirected back to his/her room. * A progress note dated 03/05/25 at 6:22 pm, indicated the resident was placed on alert charting for inappropriate touching towards other residents. There was not specific information on the incident mentioned. * A progress note dated 04/28/25 at 9:09 am, indicated the resident had an altercation with staff. The note further indicated the resident often displayed aggressive behavior towards other residents where Resident 6 “grabs arms and necks areas.” An RN assessment completed at the request of the survey team, dated 05/21/25, indicated the resident had documented incidents of touching, kissing or making unwanted sexual comments to residents of the opposite gender on 09/27/24, 11/24/24, 12/24/24 in addition to the previously listed incidents. The resident had engaged in unwanted touching of other residents in common areas, in the elevator and in other residents’ rooms. The interventions noted for the resident’s sexual behaviors and unwanted touching included increased supervision, two hour safety checks, redirect the resident, remind the resident not to touch others, keep an eye on the resident in the dining room as s/he was making other residents feel unsafe, remind the resident of boundaries and to call the resident’s son anytime the resident touched another resident. Interviews completed between 05/19/25 and 05/23/25 with sampled and non-sampled residents showed: * Resident 1 indicated s/he was cornered by Resident 6 and his/her chest was grabbed. Resident 1 avoided Resident 6 as much as possible, s/he made Resident 1 very uncomfortable. Resident 1 reported the incident to facility administration. * Resident 4 indicated s/he had been blocked in by Resident 6 while near the elevators. Resident 4’s chest had been grabbed, and s/he was touched without his/her consent. Resident 4 stated s/he was afraid of Resident 6 and what s/he might do. Resident 4’s arm/shoulder were grabbed on a separate occasion. Resident 4 indicated Resident 6 lingered in areas that residents could get cornered alone like the elevator. Resident 4 stated s/he had reported the incidents and his/her other concerns to facility administration. * Resident 2 indicated s/he could not see well and was worried s/he might not notice when Resident 6 got too close to him/her. Resident 2 indicated his/her pants were pulled down by Resident 6 while in the dining room. Three unsampled residents reported they had been grabbed by Resident 6 on separate occasions. * One unsampled resident reported to the surveyor s/he was blocked inside the facility store, so s/he was unable to leave. S/he indicated Resident 6 had put hands on him/her twice including rubbing of the arm/upper chest and grabbing the resident’s chest without consent. The resident had yelled at the resident in English and Spanish and Resident 6 backed out of the doorway of the store and headed towards Resident 2. Residents continued to yell at Resident 6, and s/he left the area. The incidents were also reported to the facility. * A second unsampled resident reported to the surveyor one occasion that Resident 6 grabbed at his/her chest. Additional attempts were made but were unsuccessful. The incidents were also reported to the facility staff. * A third unsampled resident reported to the surveyor that Resident 6 grabbed his/her chest, blocked his/her path and had held his/her wheelchair to prevent the resident from moving. The incidents did not happen all at the same time, but they were reported to staff by the non-sampled resident. Staff 9, Staff 10 and Staff 18 (CGs) were aware of multiple instances of Resident 6 touching other residents in a sexual way. Staff 9 and 10 both had also found Resident 6 in other residents’ rooms and repeatedly had removed him/her. The staff observed incidents including Resident 6 kissing other residents of the opposite gender while those residents appeared to be pulling away and uncomfortable. Resident 6 was found with his/her hands in another resident’s pants while in other residents’ apartments, grabbing at other residents’ bodies and rubbing on the arms and upper chests. Staff 18 had not had to remove Resident 6 from any bedrooms but had redirected Resident 6 away from others. Observations of the resident between 05/19/25 and 05/23/25 showed the resident attended meals in the dining room and was able to go downstairs on his/her own in the elevator. The resident would intermittently reach out at other residents as they passed by in the dining room and would call out to others to try to get them to come towards his/her table. Several residents were observed to stay out of arms reach of Resident 6 and they would go out of the way to use different doorways to go around Resident 6. The resident was not observed to be in the common areas for extended periods. b. Additional resident progress notes dated 01/01/23 to 05/21/25 were reviewed and showed the following: * A progress note dated 01/18/25 at 7:20 pm, indicated the resident left the facility unsupervised at approximately 6:00 pm. The resident stated s/he was going for a walk but instead boarded a city bus. The resident rode the bus to the station and informed a bus worker s/he was lost. The bus worker contacted the facility based off the name the resident provided, and staff were sent to retrieve the resident. * A progress note dated 01/26/25 at 6:47 pm, indicated the resident left the facility at 1:00 pm and was redirected back into the community. The resident was asked to sign out if s/he left, the resident signed out and left a short time later. The resident exited the community and headed to the bus stop, when staff went to check for the resident s/he was no longer at the bus stop. The resident’s family was notified the resident left the facility and they indicated they would track him/her. There was no further documentation to indicate how or when the resident returned to the facility. * A progress note dated 01/27/25 at 4:43 am, indicated the resident had left the facility and stated s/he would return by 5:00 pm, the resident had not returned to the facility until 8:45 pm. The resident stated s/he was hungry and was given a sandwich. * A progress note dated 02/03/25 at 4:35 am, indicated the resident was on alert for supervision and safety checks. The resident went to the store around 7:30 pm and returned at approximately 8:45 pm. * A progress note dated 02/23/25 at 9:22 am, indicated the resident stated s/he experienced a fall while out of the facility on 02/22/25. The resident indicated “I went out to the store, when I was walking back a car was coming really fast and I fell back.” The resident was noted to be shaking and stuttering while speaking, the resident was given Tylenol and sent to the emergency room for evaluation. The resident returned a few hours later with diagnosis of a shoulder joint sprain, hand sprain and a bruise of the hip all on the right side of the body. * A progress note dated 03/03/25 at 4:31 pm, indicated the resident left the community at 11:31 am and had not returned as of the time of the note, 4:31 pm. Staff looked for the resident at the library and two stores, but did not find the resident. The resident’s son was unable to track the resident on the phone as the tracking application was not working. There was no further information documented on when and how the resident returned to the facility. The interventions in place related to the resident’s exiting and getting lost in the community included redirection and contacting the resident’s son. The resident was also to be reminded to charge his/her phone and to take it with him/her if left the facility. The resident’s son tracked the resident through the phone. Observations of the resident between 05/19/25 and 05/23/25 showed the resident attended meals in the dining room and was able to go downstairs on his/her own in the elevator. The resident was not observed to be in the common areas for extended periods. Resident 6 did not attempt to leave the facility or exit out the front door during the observations. On 05/20/25 at 6:59 pm the survey team requested an immediate plan of correction to address Resident 6’s inappropriate and unwanted touching of other residents and the resident getting lost in the community. The survey team received and accepted the plan, which included 1:1 supervision to ensure other resident rooms were not entered, residents were not touched inappropriately, and that Resident 6 did not leave the facility without supervision. Additional updates were made to the plan on 05/21/25. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the resident's unwanted sexual behaviors, blocking other residents from leaving the dining room or elevator and exiting the facility without supervision were investigated and interventions implemented to protect all involved residents was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Director of Health and Wellness/LPN) and Witness 1 (RN Consultant) on 05/21/25 at 8:15 am and 9:54 am. The staff acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect and to have a safe and homelike environment for 4 of 4 sampled residents (#s 1, 2, 4 and 6) and 3 unsampled Residents related to inappropriate sexual behaviors and staff treatment of residents. Residents 1, 2 and 4 were repeatedly touched by Resident 6, in an intimate manner without consent. Resident 4 additionally expressed distress over treatment by staff of the facility. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 03/06/25 and progress notes dated 01/01/25 through 05/21/25 were completed. The resident's service plan dated 03/06/25 indicated the resident had a diagnosis of dementia. The service plan noted the "resident has occasional difficulty remembering and using information; requires some directions and reminding from others; may have difficulty following written instructions.” The resident was noted to have mild long term and short-term memory impairment.” The resident was also noted to have occasional disruptive, aggressive or socially inappropriate behaviors listed as either verbally or physically improper. The resident required minimal assistance with ADLs and cues to make it to meals. Progress notes dated 01/01/25 through 05/21/25, resident interviews, staff interviews and an RN assessment dated 05/21/25 showed numerous instances when Resident 6 was observed to rub other residents' shoulders, attempted to kiss other residents, grabbed/groped/fondled others breasts, placed his/her hand inside another resident's pants and/or was to be threatening towards other residents and restricted their movements. Sampled Residents 1, 2 and 4 and three unsampled residents were involved in these incidents. There was inconsistent documentation to show all incidents were thoroughly investigated to determine effectiveness of current interventions and determine if new interventions were needed to prevent reoccurrence and protect residents from unwanted intimate touch and restraint of movement. Sampled and unsampled Residents all stated they did not consent to the touching or interactions with Resident 6. The residents did not want any involvement with Resident 6 and felt like they were at risk anywhere they could run into Resident 6. The residents did not feel they were taken seriously regarding Resident 6 and the fear s/he might grab them or trap them again. Multiple observations of Resident 6 between 05/19/25 and 05/23/25 showed the resident interacting with those who would engage while in the dining room. The resident was not observed in activities and spent a lot of time in his/her apartment. The other residents with previous incidents around Resident 6 avoided the resident and did not engage in any verbal interactions or get within arm’s reach. a. Resident 1 was readmitted to the facility in 03/2025 with diagnoses including fracture. Resident 1 experienced one incident of intimate touch that startled and frightened him/her. Resident 1 stated s/he was confused by the incident and left the area immediately. Resident 1 avoids getting near Resident 6 and will not get into the elevator with the resident. b. Resident 2 was admitted to the facility in 03/2025 with diagnoses including stroke. Resident 2 stated his/her pants were pulled down by Resident 6 while they were both in the dining room. Resident 2 indicated Resident 6 had tried to grab/touch her on another occasion but was not successful. Resident 2 had a vision impairment and stated s/he was afraid of Resident 6 and what s/he might due or try before the resident would know s/he was nearby. c. Resident 4 was admitted to the facility in 10/2024 with diagnoses including depression and anxiety. Resident 4 stated s/he had been touched without his/her consent by Resident 6. Resident 6 had cornered Resident 4 near the elevator and blocked the resident from moving forward and rubbed Resident 4’s arm and grabbed his/her chest. Attempts were made by Resident 6 on other occasions to try and corner Resident 4 and others in the elevator or other areas where it was difficult to get out of, especially in a wheelchair. Resident 4 further stated s/he reported the incidents to the administration and “was not taken seriously.” d. One unsampled Resident stated s/he was trapped by Resident 6 in the small facility store as well as near the elevator on a different occasion. Resident 6 rubbed the resident’s arm and then moved to his/her chest. When Resident 6 blocked the doorway to the store, the unsampled Resident was frightened and angry. S/he started yelling at Resident 6 and waved arms at him/her. Resident 6 then left the room and headed towards Resident 2, the other residents continued to yell, and Resident 6 left the area. The unsampled Resident reported the incidents to administration but did not feel like it was taken seriously. Resident 6 continued to “target” others and try to “trap” others inside or near the elevator. e. A second unsampled Resident stated s/he was groped on one occasion by Resident 6. The resident did not offer any additional information about the resident but did indicate it was reported to administration. f. A third unsampled Resident indicated s/he had a few “bad” experiences with Resident 6. The resident stated his/her chest was grabbed against his/her will and s/he “yelled no.” Resident 6 also has stood in front of the unsampled Resident’s wheelchair, grabbed at the handles and would not let him/her move. Staff came and assisted unsampled Resident to move away and enter the elevator alone. The resident further indicated s/he reported the incidents to staff. Staff 9, Staff 10 and Staff 18 (CGs), Staff 8 (MT) and Staff 13 (Dietary) were all aware of multiple instances of Resident 6 touching other residents in an intimate way. Staff 9 and 10 both have also found Resident 6 in other residents’ rooms and repeatedly had removed him/her. The staff had observed incidents including Resident 6 kissing other residents of the opposite gender, while those residents appeared to be pulling away and uncomfortable. Resident 6 was found with his/her hands in another resident’s pants while in other residents’ apartments, grabbing at other residents’ bodies and rubbing on the arms and upper chests. Staff 18 had not had to remove Resident 6 from any bedrooms but had redirected Resident 6 away from others. Staff 13 assisted an unsampled to move away from Resident 6, when Resident 6 was upsetting him/her and blocking the path. The facility failed to ensure residents were treated with dignity, respect and had a safe environment due to reoccurring sexually inappropriate and/or aggressive behaviors by Resident 6. Interventions put into place were insufficient to ensure Resident 6 did not continue to touch others without their consent, invaded personal space and/or created a fearful environment for other residents. On 05/20/25 at 6:59 pm the survey team requested an immediate plan of correction to address Resident 6’s inappropriate and unwanted touching of other residents. The survey team received and accepted the plan, which included 1:1 supervision to ensure other resident rooms were not entered, residents were not touched inappropriately. Additional updates were made to the plan on 05/21/25. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure residents were treated with dignity and respect and had a safe and homelike environment was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Director of Health and Wellness/LPN) and Witness 1 (RN Consultant) on 05/21/25 at 8:15 am and 9:54 am. The staff acknowledged the findings. 2. Resident 4 was admitted to the facility in 10/2024 with diagnoses including depression and anxiety. The resident was noted to be an above knee amputee on the right side, utilized a wheelchair for mobility and required staff assistance with some of his/her ADLs. The resident was alert and oriented and could direct his/her own care. The resident stated s/he required transfer assistance, especially in the bathroom, to help keep his/her balance and assistance with lower extremity dressing. The resident indicated s/he had a hard time balancing on one leg and would sometimes get the shakes in his/her limbs. The resident’s May 2025, Service Checkoff List for staff, indicated staff were to assist the resident with toileting, perineal care/incontinent care and assist with the resident’s pants. In interviews between 05/19/25 and 05/21/25, the resident stated s/he rarely called for staff assistance anymore. The resident indicated s/he did not trust most of the staff on duty and had experienced long wait times as well as poor treatment. The resident stated s/he had friends who also lived in the facility that would come and help him/her with clothing and transfers. The resident indicated the longest s/he had been left on the toilet when s/he had requested assistance was 30-45 minutes. Staff either would not answer or check in, turn off the call light and leave. The resident further stated the agency staff treated him/her the worst but some of the regular facility staff were also short and disrespectful. Resident 4 made the following statements regarding his/her care and interactions at the facility: * “I’m scared to fall, but I don’t want to wet myself;” * “I have had several falls in the bathroom after losing balance;” * The resident had sustained multiple concussions, as well as several knee dislocations; * The resident indicated his/her bathroom was not safe for him/her to transfer without assistance, but his/her requests for a transfer pole had not been addressed; * The resident stated s/he had more than one accident while trying to get himself/herself to the bathroom when s/he could not wait any longer. Falls have occurred around slipping in the urine on the floor; * Agency staff had walked into the room, seen the resident was an amputee, told him/her they couldn’t help them and left; * “The staff just ignore me and everybody else,” “The flat out ignoring what I am saying is frustrating,” have been told to “quit whining;” * The resident “feels less than Human;” and * An agency staff tried more than once to force medication on the resident that was not his/hers. The resident had to argue with the staff that they were incorrect, and the staff member was dismissive and rude. The need to ensure residents were treated with dignity and respect and had a safe and homelike environment was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Director of Health and Wellness/LPN) and Witness 1 (RN Consultant) on 05/21/25 at 8:15 am and 9:54 am. The staff acknowledged the findings.

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

OAR 411-054-0028 (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: HEADER & EX SM Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause and allegations of abuse were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office when required, for 4 of 4 sampled residents (#s 1, 2, 4 and 6) and 3 unsampled residents. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 03/06/25 and progress notes dated 01/01/25 through 05/21/25 were completed. a. Review of incident investigations and progress notes from 01/01/25 to 05/21/25 showed the following: * A progress note dated 01/10/25 at 6:08 pm, indicated the resident kissed another resident while in the dining room. The resident was placed on alert charting for monitoring; * A progress note dated 01/13/25 at 6:13 pm, indicated the resident was placed on alert for behaviors of invading personal space; * A progress note dated 01/29/25 at 6:00 am, indicated the resident was found in another resident’s room with his/her arm around the resident. Staff removed Resident 6 and assisted him/her back to his/her room; * A progress note dated 02/12/25 at 4:57 am, indicated the resident was found in another resident’s apartment with arm around the resident and seated on the sofa; * A progress note dated 02/12/25 at 9:11 am, indicated the resident was found in another room with a resident of the opposite gender. Resident 6 had his/her shirt off; * A progress note dated 03/05/25 at 6:22 pm, indicated the resident was placed on alert charting for inappropriate touching towards other residents. There was not specific information on the incident mentioned. * A progress note dated 01/18/25 at 7:20 pm, indicated the resident left the facility unsupervised at approximately 6pm. The resident stated s/he was going for a walk but instead boarded a city bus. The resident rode the bus to the station and informed a bus worker s/he was lost. The bus worker contacted the facility based off the name the resident provided to the bus worker and staff were sent to retrieve the resident; * A progress note dated 01/26/25 at 6:47 pm, indicated the resident left the facility at 1:00 pm, and was redirected back into the community. The resident was asked to sign out if s/he left, the resident signed out and left a short time later. The resident exited the community and headed to the bus stop, when staff went to check for the resident s/he was no longer at the bus stop. There was no indication when or how the resident returned to the facility; * A progress note dated 02/23/25 at 9:22 am, indicated the resident stated s/he experienced a fall while out of the facility on 02/22/25. The resident indicated “I went out to the store, when I was walking back a car was coming really fast and I fell back.” The resident was sent to the emergency room for evaluation of injuries and pain; and * A progress note dated 03/03/25 at 4:31 pm, indicated the resident left the community at 11:31 am and had not returned as of the time of the note, 4:31 pm. Staff looked for the resident at the library and two stores, but did not find the resident. The resident’s son was unable to track the resident on the phone as the tracking application was not working. There was no further information documented on when and how the resident returned to the facility. No investigations were completed for the above mentioned incidents. The facility did not report any of the above incidents to the local SPD office. The surveyor reported the incidents to the local SPD office on 05/21/25, confirmation of the reports was received via email. b. Interviews completed between 05/19/25 and 05/23/25 with sampled and unsampled residents showed: * Resident 1 indicated s/he was cornered by Resident 6 and his/her chest was grabbed. Resident 1 avoided Resident 6 as much as possible, s/he made Resident 1 very uncomfortable. Resident 1 reported the incident to the facility administration. * Resident 4 indicated s/he had been blocked in by Resident 6 while near the elevators. Resident 4’s chest had been grabbed, and s/he was touched without his/her consent. Resident 4’s arm/shoulder were grabbed on a separate occasion. Resident 4 stated s/he had reported the incidents and his/her other concerns to facility administration. * Resident 2 indicated s/he could not see well and was worried s/he might not notice when Resident 6 got to close to him/her. Resident 2 indicated his/her pants were pulled down by Resident 6 while in the dining room. Resident 2 reported the incident to facility staff. * One unsampled resident reported to the surveyor s/he was blocked inside the facility store, so s/he was unable to leave. S/he indicated Resident 6 had put hands on him/her twice including rubbing of the arm/upper chest and grabbing the resident’s chest without consent. The incidents were reported to the facility. * A second unsampled resident reported to the surveyor one occasion that Resident 6 grabbed at his/her chest. Additional attempts were made but were unsuccessful. The incidents were reported to the facility staff. * A third unsampled resident reported to the surveyor that Resident 6 grabbed his/her chest, blocked his/her path and had held his/her wheelchair to prevent the resident from moving. The incidents did not happen all at the same time, but they were reported to staff by the unsampled Resident. No investigations were completed for the above mentioned incidents. The facility did not report any of the above incidents to the local SPD office. The surveyor reported the incidents to the local SPD office on 05/21/25, confirmation of the reports was received via email. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reported when required to the local SPD office was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Director of Health and Wellness/LPN) and Witness 1 (RN Consultant) on 05/21/25 at 8:15 am and 9:54 am and with Staff 1 and Witness 1 on 05/23/25 at 1:05 pm. The staff acknowledged the findings.

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 report injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office, unless an immediate facility investigation reasonably concluded and documented abuse had been ruled out for 1 of 1 sampled resident (# 10) with an injury of unknown cause. This is a repeat citation. Findings include, but are not limited to: Resident 10 moved into the assisted living facility in 08/2019 with diagnosis including mild cognitive impairment. Resident 10’s progress notes from 07/26/25 to 09/02/25, service plans, and incident reports were reviewed, the following was identified: An 08/22/25 incident report documented that at 10:30 am Resident 10 “was being assisted by care staff when she noticed blood on his/her ear, resident could not say what happened”. Resident 10 was discovered to have a laceration of the left ear, laceration of the left ankle, an abrasion on their back, and a skin tear on their left forearm. They were sent to the emergency room for wound care and received stitches to close the laceration of the ear. The incident report dated 08/22/25 noted “not able to identify if he/she indeed fell or where the wound originated, this is a self report to APS.” Interviews on 09/04/25 with Staff 2 (Interim ED), Staff 19 (Regional Director of Operations) and Staff 27 (Director of Health and Wellness, LPN) revealed the self report was not sent to APS until 09/02/25. On 09/04/25 at 2:30 pm, the need to investigate injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 2, Staff 19, and Staff 27. They acknowledged the findings.

1. Inservice will be conducted on incident report releated to investigation and appropriate/timely reporting to SPD. Resident #10 was reported on 09/02/2025 2. Incident reports and progress notes will be reviewed during clinical meetings daily to determine need of reporting to SPD. If abuse can be ruled out upon immediate facility investigation- Executive Director and/or Director of Health and Wellness to ensure documentation that abuse has been ruled out within investigation. Direct care staff will be in-service on immediate notification to Executive director and/or designee when resident incident occurs. Executive Director and/or designee will screen for the following after hours and on weekends: abuse, neglect, suspected abuse, suspected neglect, injuries of unknown cause/origin, and severe injuries such as fractures or those that result in hospitalization. Executive Director and/or designee will notify SPD, if indicated. 3. Daily during clinical meeting 4. Executive Director, Director of Health and Wellness, and/or designee

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 411-054-0034 (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 move-in evaluations addressed all required elements and were updated and modified as needed during the 30-days following move-in for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed; and the facility failed to ensure quarterly evaluations were completed for 1 of 5 sampled residents (#8) whose quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 03/2025 with diagnoses including cerebrovascular accident (stroke). a. The resident's new move-in evaluations, dated 03/24/25 and 04/02/25, were reviewed and the following required elements were not addressed: * Pharmaceutical and non-pharmaceutical interventions for pain; * Personality including how the person copes with change or challenging situations; * Pronouns; and * Ability to safely smoke. b. The resident's initial evaluation was not updated or modified as appropriate within the first 30 days after move-in. The need to ensure move-in evaluations included all required elements and were updated and modified as appropriate within the first 30-days of move-in was discussed with Staff 1 (ED), Witness 1 (RN Consultant), Staff 19 (Regional Director of Operations), Staff 20 (CEO), and Staff 21 (Regional Director of Health and Wellness) on 05/27/25 at 11:29 am. They acknowledged the findings, and no additional documentation was provided. 2. Resident 8 was admitted to the facility 04/2023 with diagnoses of hypothyroidism and depressive disorder. Resident 8’s most recent service plan was dated 11/26/24. There was no further documented evidence Resident 8’s evaluation had a been performed at least quarterly, to correspond with the quarterly service plan updates since his/her service plan dated 11/26/24. The need to ensure resident evaluations were performed at least quarterly, to correspond with the quarterly service plan updates with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25 at 11:30 am. They acknowledged the findings.

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’ needs; were completed before a resident moved-in with updates and changes made as appropriate within the first 30-days; provided clear direction regarding the delivery of services; and were implemented for 5 of 6 sampled residents (#s 1, 2, 4, 6, and 8) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility on 03/31/25 with diagnoses including cerebrovascular accident (stroke) and Crohn’s disease (inflammatory bowel disease). The resident's service plan, dated 04/10/25, was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 05/21/25 and 05/27/25. a. Resident 2's service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Dietary preferences and needs related to Crohn’s disease; * Non-pharmaceutical pain interventions regarding preferred positioning; and * Preferences regarding liquid temperatures due to dental status. b. Resident 2’s move-in service plan and 30-day service plan were requested. On 05/23/25 at 10:46 am, Witness 1 (RN Consultant) confirmed the facility did not have a service plan dated prior to the resident’s move-in date of 03/31/25 nor did the facility have a 30-day service plan update. The need to ensure service plans were reflective of the identified needs of the resident, were completed prior to the resident moving into the facility, were updated within 30-days of move-in, and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Witness 1, Staff 19 (Regional Director of Operations), Staff 20 (CEO), and Staff 21 (Regional Director of Health and Wellness) on 05/27/25 at 11:29 am. They acknowledged the findings, and no additional documentation was provided. 2. Resident 1 was readmitted to the facility in 03/2025 with diagnoses including fracture. Observations of the resident, interviews with staff and review of the service plan, dated 05/06/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Evacuation assistance since fracture; * Depression, how it manifests and interventions needed; * Toileting, incontinent care and brief changes; * Showers since fracture; * Dressing assistance related to lower body and walking boot; * Carpet allergy; * Falls and safety interventions; and * Unwanted attention/touch from another resident and ongoing concerns. The need to ensure resident service plans were reflective of current care needs, was consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25 at 1:05 pm. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 10/2024 with diagnoses including above the knee amputee. Observations of the resident, interviews with staff and review of the only service plan located in the staff binder, dated 12/04/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Evacuation assistance; * Fall risk, safety interventions and lift needs; * Bathing assistance; * Side rail use; * Toileting, incontinent care and brief changes; * One vs two person staff assistance for transfers/toileting; * Dressing assistance related to lower body; * Ongoing allegations towards residents and staff; * Depression, anxiety and suicidal thoughts and/or statements; * Chronic knee dislocation and pain; and * Unwanted attention/touch from another resident and ongoing fears. The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25 at 1:05 pm. They acknowledged the findings. 4. Resident 6 was admitted to the facility in 09/2024 with diagnoses including dementia. a. Observations of the resident, interviews with staff and review of the provided service plan dated 03/06/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Chronic anxiety, mood and depression; * Fall risk and safety interventions; * Occasional disruptive, aggressive or socially inappropriate behaviors; * Suicidal ideations; * Language needs and bilingual abilities; * Activities for leisure and behaviors; * Changing clothes, removing soiled items and attending meals; * Wandering, exiting the facility and unable to return on own; and * Sexual behaviors and touch towards females. b. There was no service plan located in the binder for staff. A service plan was requested on 05/20/25 and was printed by Staff 2 (Associate ED). The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25 at 1:05 pm. They acknowledged the findings. 5. Resident 8 was admitted to the facility in 04/2023 with diagnoses including bilateral edema of the lower extremity. At 11:50 am, in an interview on 05/23/25, Staff 12 (CG) stated caregivers assisted Resident 8 with putting on his/her compression stockings. Resident 8’s service plan, dated 11/26/24, failed to indicate s/he required assistance with his/her compression stockings. The need to ensure resident service plans were reflective of current care needs, was consistently implemented, provided clear direction to staff, and was updated quarterly as required, was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 2 sampled residents (#s 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 10 moved into the assisted living facility in 08/2019 with diagnosis including mild cognitive impairment. Observations were made of the resident's care from 09/02/25 through 09/04/25. Interviews with the resident, facility staff and the resident’s outside provider were conducted. The current service plan dated 07/17/25 was reviewed. Resident 10's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Hearing and assistive device used for communication; * Safety checks each shift; and * Ambulation and which assistive device used. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 2 (Interim ED), Staff 19 (Regional Director of Operations) and Staff 27 (Director of Health and Wellness, LPN). They acknowledged the findings. 2. Resident 9 moved into the assisted living facility in 10/2024 with diagnoses including chronic kidney disease stage 3. The resident’s service plan dated 08/21/25 with updates dated 08/28/25 was reviewed, and interviews with staff and the resident were conducted. The resident’s service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Transportation regarding driving status; * Current mood and depression related to loss of spouse; * Bathing; * Oxygen use; and * Pain related to where pain was located and how pain was expressed. On 09/04/25 at 1:45 pm the need to ensure service plans were reflective of the residents’ current status and provided clear direction to staff was discussed with Staff 2 (Interim ED), Staff 19 (Regional Director of Operations) and Staff 27 (Director of Health and Wellness, LPN). They acknowledged the findings.

1. Residents #9 and 10 service plans will be reviewed and updated to reflect their current needs and provide clear director for delivery of services 2. Oregon specific checklist for specifc evaluation and service plan requirements has been provided and will be referenced going forward. Inservice will be conducted for clinical team related to responsibilities of updating evaluation or service plans. Residents service plans will be reviewed for requirement elements and updated accordingly. 3. Weekly for 3 weeks 4. Administrator, Director of Health and Wellness, Registered Nurse, and Resident Care Director, and/or designee

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

OAR 411-054-0036 (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 resident’s choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services for 5 of 6 sampled residents (#s 1, 3, 4, 5, and 8) whose service planning team was reviewed. Findings include but are not limited to: Resident 1, 3, 4, 5, and 8’s most recent service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. Additionally, four unsampled residents in a group interview reported not being included in a service planning team. On 05/26/25, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Witness 1 (RN Consultant). They acknowledged the findings.

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 short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, interventions were communicated to staff, the condition was monitored at least weekly to resolution and interventions were re-evaluated to determine effectiveness for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 6) who experienced changes of condition. Resident 6 repeatedly touched other residents in an intimate manner without consent. Resident 6 also had left the community on at least two occasions and was unable to return on his/her own. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 03/06/25 and progress notes dated 01/01/25 through 05/21/25 were completed. The resident's service plan dated 03/06/25 indicated the resident had a diagnosis of dementia. The service plan noted the resident had long term and short-term memory impairment. The resident had “frequent disorientation to person, place, time or situation even in familiar surroundings and requires supervision and oversight for safety.” The resident frequently wandered outside and left the community and required supervision. The resident was also noted to have occasional “disruptive,” “aggressive” or “socially inappropriate” behaviors listed as either “verbally” or “physically” improper. Observations of the resident between 05/19/25 and 05/23/25 showed the resident attended meals in the dining room and was able to go downstairs on his/her own in the elevator. The resident would intermittently reach out at other residents as they passed by in the dining room and would call out to others to try to get them to come towards his/her table. Several residents were observed to stay out of arms reach of Resident 6 and they would go out of the way to use different doorways to go around Resident 6. The resident was not observed to be in the common areas for extended periods. The resident did not leave the facility during any of the observations. a. Interviews with sampled and unsampled residents, interviews with staff and review of progress notes dated 01/01/25 through 05/21/25 showed numerous instances when the resident was observed with his/her arms around other residents, rubbing other residents' arms and/or shoulders, attempting to kiss other residents, entering others' rooms, putting his/her hands in other residents' pants, intimidating others, invading personal space and/or grabbing/groping other residents' chests. Interim Service Plans dated 09/26/24 through 04/28/25 showed the following interventions were implemented related to the resident’s unwanted touching of other residents: * On 09/26/24, behavior of inappropriate touching of other residents was noted. Interventions of redirect resident not to touch residents of the opposite gender; * On 12/13/24, behavior of resident touching residents of the opposite gender, and they don’t want to be touched. Interventions of call the resident’s “son anytime touches others,” “have eyes on the resident during meals,” s/he “is making other residents feel unsafe,” and behavioral specialist evaluation requested from physician; * On 01/10/25, behavior of “maintaining boundaries.” Interventions of staff to educate resident on importance of boundaries, will be referred to a behavioral specialist, staff to encourage the resident to sit at a table away from opposite gender residents; * On 03/05/25, behavior of inappropriate touching towards other residents. Interventions of resident on two-hour checks, “please write down any incidents,” ensure the resident is redirected and please ensure safe environment when redirecting due to dementia; and * On 04/28/25, behavior of aggressive physical touch. Interventions of redirecting as needed, continue two-hour checks, report to medication technician, remind/encourage to keep hands to himself/herself and direct safely with verbal and hand gestures due to dementia. Review of the resident's 01/01/25 to 05/21/25 progress notes showed the following: * On 01/10/25 at 6:08 pm, indicated the resident kissed another resident while in the dining room; * On 01/13/25 at 6:13 pm, indicated the resident was placed on alert for behaviors of invading personal space; * On 01/29/25 at 6:00 am, indicated the resident was found in another resident’s room with his/her arm around the resident; * On 02/12/25 at 4:57 am, indicated the resident was found in another resident’s apartment with arm around the resident and seated on the sofa; * On 02/12/25 at 9:11 am, indicated the resident was found in another room with a resident of the opposite gender. Resident 6 had his/her shirt off: * On 03/05/25 at 6:22 pm, indicated placed on alert charting for inappropriate touching towards other residents; and * On 04/28/25 at 9:09 am, indicated the resident displayed aggressive behavior towards other residents where Resident 6 “grabs arms and necks areas.” An RN assessment completed at the request of the survey team, dated 05/21/25, indicated the resident had additional documented incidents of touching, kissing or making unwanted sexual comments to residents of the opposite gender on 09/27/24, 11/24/24, 12/24/24 in addition to the previously listed incidents. The resident had engaged in unwanted touching of other residents in common areas, in the elevator and in other residents’ rooms. Interviews completed between 05/19/25 and 05/23/25 with sampled and non-sampled residents showed: * Resident 1 indicated s/he was cornered by Resident 6 and his/her chest was grabbed. * Resident 4 indicated s/he had been blocked in by Resident 6 while near the elevators. Resident 4’s chest had been grabbed, and s/he was touched without his/her consent. Resident 4 stated s/he was afraid of Resident 6 and what s/he might do. Resident 4’s arm/shoulder were grabbed on a separate occasion. * Resident 2 indicated his/her pants were pulled down by Resident 6 while in the dining room. * One unsampled resident reported to the surveyor s/he was blocked inside the facility store, so s/he was unable to leave. S/he indicated Resident 6 had put hands on him/her twice including rubbing of the arm/upper chest and grabbing the resident’s chest without consent. * A second unsampled resident reported to the surveyor one occasion that Resident 6 grabbed at his/her chest. Additional attempts were made but were unsuccessful. * A third unsampled resident reported to the surveyor that Resident 6 grabbed his/her chest, blocked his/her path and had held his/her wheelchair to prevent the resident from moving on separate occasions. Staff 9, Staff 10 and Staff 18 (CGs) were all aware of multiple instances of Resident 6 touching other residents in a sexual way. Staff 9 and 10 both had also found Resident 6 in other residents’ rooms and repeatedly had removed him/her. The staff observed incidents including Resident 6 kissing other residents of the opposite gender while those residents appeared to be pulling away and uncomfortable. Resident 6 was found with his/her hands in another resident’s pants while in other residents’ apartments, grabbing at other residents’ bodies and rubbing on the arms and upper chests. Staff 18 had not had to remove Resident 6 from any bedrooms but had redirected Resident 6 away from others. There was inconsistent documentation to show all incidents had a complete investigation, were evaluated to determine resident specific interventions, determine effectiveness of current interventions, and to report interventions to staff to prevent reoccurrence and protect residents from unwanted intimate touch. On 05/20/25 at 6:59 pm the survey team requested an immediate plan of correction to address Resident 6’s inappropriate and unwanted touching of other residents and the resident getting lost in the community. The survey team received and accepted the plan, which included 1:1 supervision to ensure other resident rooms were not entered, residents were not touched inappropriately, and that Resident 6 did not leave the facility without supervision. Additional updates were made to the plan on 05/21/25. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. b. Interim Service Plans dated 09/26/24 through 04/28/25 showed the following interventions were implemented related to the resident leaving the facility without supervision and getting lost in the community: * On 01/28/25, behavior of the resident leaving the facility on long trips. Interventions of discussion related to memory care placement, staff to monitor any possible exit seeking and chart any changes in behavior and “At Risk Agreement,” due to resident going long distances away and occasionally needing assistance back; and * On 03/03/25, behavior listed as “charge phone.” Intervention of please charge phone, this helps resident’s son to locate the resident. Additional resident progress notes dated 01/01/25 to 05/21/25 were reviewed and showed the following: * On 01/18/25 at 7:20 pm, indicated the resident left the facility unsupervised at approximately 6:00 pm. The resident stated s/he was going for a walk but instead boarded a city bus. The resident rode the bus to the station and informed a bus worker s/he was lost. The bus worker contacted the facility based off the name the resident provided, and staff were sent to retrieve the resident. * On 01/26/25 at 6:47 pm, indicated the resident left the facility at approximately 1:00 pm and headed to the bus stop, when staff went to check for the resident s/he was no longer at the bus stop. The resident’s family was notified s/he had left the facility. The family indicated they would track the resident’s location through the phone. * On 01/27/25 at 4:43 am, indicated the resident had left the facility and stated s/he would return by 5:00 pm, the resident had not returned to the facility until 8:45 pm. * On 02/03/25 at 4:35 am, indicated the resident was on alert for supervision and safety checks. The resident went to the store around 7:30 pm and returned at approximately 8:45 pm. * On 02/23/25 at 9:22 am, indicated the resident stated s/he experienced a fall while out of the facility on 02/22/25. The resident indicated “I went out to the store, when I was walking back a car was coming really fast and I fell back.” The resident was noted to be shaking, stuttering while speaking and showed signs of pain. The resident was sent to the emergency room for evaluation of injuries. * On 03/03/25 at 4:31 pm, indicated the resident left the community at 11:31 am and had not returned as of the time of the note, 4:31 pm. Staff looked for the resident at the library and two stores, but did not find the resident. The resident’s son was unable to track the resident on the phone. There was no indication when or how the resident returned to the facility. There was inconsistent documentation to show all incidents had a complete investigation, were evaluated to determine resident specific interventions, determine effectiveness of current interventions, and to communicate interventions to staff to prevent reoccurrence, protect Resident 6 from being lost in the outside community and from potential injuries. On 05/20/25 at 6:59 pm the survey team requested an immediate plan of correction to address Resident 6’s inappropriate and unwanted touching of other residents and the resident getting lost in the community. The survey team received and accepted the plan, which included 1:1 supervision to ensure other resident rooms were not entered, residents were not touched inappropriately, and that Resident 6 did not leave the facility without supervision. Additional updates were made to the plan on 05/21/25. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. c. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Medication changes; * Emergency Department return; and * Fall with injuries. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25 at 1:05 pm. The staff acknowledged the findings. 2. Resident 1 was readmitted to the facility in 03/2025 with diagnoses including fracture. The resident's 05/06/25 service plan, 02/19/25 through 05/15/25 progress notes, incident investigation notes and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Leg swelling; * Medication changes; * Emergency Department return; and * Stomach upset. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25 at 1:05 pm. The staff acknowledged the findings. 3. Resident 4 was admitted to the facility in 10/2024 with diagnoses including depression and anxiety. The resident's 12/04/24 service plan, 01/01/25 through 05/21/25 progress notes, incident investigation notes and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Fear and anxiety; * Falls; * Dislocated knee; * Brace “cast” use; * Medication changes; * Unwanted attention/touch from Resident 6; * Emergency Department return; and * Stomach upset. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25 at 1:05 pm. The staff acknowledged the findings. 4. Resident 2 moved into the community in 03/2025 with diagnoses including cerebrovascular accident (stroke) and Crohn’s disease (inflammatory bowel disease). The current service plan, dated 04/10/25, and progress notes, dated 03/31/25 through 05/22/25, were reviewed. Interviews with staff were completed between 05/21/25 and 05/27/25. The facility failed to determine actions or interventions needed for the resident, communicate the actions or interventions to staff on each shift, and/or document weekly progress until the condition resolved for the following short-term changes of condition: * 03/31/25 – New move-in; * 04/15/25 – Behaviors toward staff; * 04/20/25 – Inappropriate smoking; * 05/06/25 – Fall; * 05/06/25 – Bruise and skin tear; * 05/05/25 – Eliquis (blood thinner) refusals; and * 05/18/25 – Medication changes. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, communicated the actions or interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Witness 1 (RN Consultant), Staff 19 (Regional Director of Operations), Staff 20 (CEO), and Staff 21 (Regional Director of Health and Wellness) on 05/27/25 at 11:29 am. They acknowledged the findings, and no additional documentation was provided. 5. Resident 3 was admitted to the facility in 02/2025 with diagnoses including hypertension. Resident 3's clinical record was reviewed for changes of condition and revealed the following: *Progress notes dated 03/10/25 indicated Resident 3 experienced an unwitnessed fall with injury. The fall resulted in Resident 3 being sent out to the emergency room with an injury to the head. There was no documented evidence the facility evaluated Resident 3 to determine what actions or interventions were needed to minimize the further occurrence of falls. On 05/26/25, the need to ensure residents who experienced changes of condition had resident-specific interventions determined, documented, and communicated to staff was discussed with Staff 1 (ED) and Witness 1 (RN Consultant). They acknowledged the findings.

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 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for residents. The number of citations and the severity of concerns; resulted in the potential for harm for any residents administered medications by the facility. Findings include, but are not limited to: 1. During the re-licensure survey, conducted 05/19/25 through 05/23/25, the facility failed to ensure a safe medication system, and administrative oversight was found to be ineffective based on deficiencies and the level of severity in the following areas: C 301: Systems: Medication Administration; C 302: Systems: Tracking Controlled Substances; C 303: Systems: Medication and Treatment Orders; C 305: Systems: Resident Right to Refuse Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Director of Health and Wellness/LPN) and Witness 1 (RN Consultant) on 05/20/25 and 05/21/25. The staff acknowledged the findings. 2. Resident 4 was admitted to the facility in 10/2024 with diagnoses including nerve pain. Review of the resident’s physician orders, physician communications, 12/21/24 service plan, 04/01/25 through 05/20/25 MAR/TAR, interviews with Resident 4, interviews with staff and 01/01/25 through 05/12/25 progress notes were completed. The resident stated an agency staff attempted to force insulin administration on the resident. The resident did not have an order for any injections or insulin and did not have a diagnosis of diabetes. The resident further stated s/he had to fight with the staff member not to give Resident 4 the injection. The resident indicated s/he told the staff member repeatedly s/he did not take insulin and was not diabetic, the staff responded with insults and was disrespectful. Resident 4 stated the staff member told him/her “just take it,” “I don’t have time for this,” and “quit whining,” which s/he has heard from others before. The resident stated s/he had not actually been injected with any insulin but should not have to fight a staff to convince them s/he knows what medications s/he should and should not be given. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Director of Health and Wellness/LPN) and Witness 1 (RN Consultant) on 05/22/25 at 2:15 pm. The staff acknowledged the findings. Refer to C301, C 302, C303, and C305.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the staff person who administered the medication visually observed the resident take the medication for 2 of 2 sampled residents (#s 2 and 7) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 03/2025 with diagnoses including cerebrovascular accident (stroke) and hypertension (high blood pressure). Resident 2's current physician's orders, MAR/TAR, dated 05/01/25 through 05/22/25, and service plan, dated 04/10/25, were reviewed. Observations of the resident and interviews with staff and the resident were completed between 05/21/25 and 05/27/25. The following was identified: * On admission the resident’s house physician orders, dated 03/31/25, indicated the resident was not able to administer his/her own prescription medications; * The resident's service plan gave direction for the "Med Tech to administer [Resident 2 his/her] medications"; and * Resident 2 was interviewed in his/her room on 05/22/25 at 3:00 pm. An oblong white pill was observed on the resident's bedside table. The resident stated the pill was left last night, and s/he wanted to identify the medication before taking it. The pill was identified as atorvastatin 40mg and was prescribed to be taken in the evening for hyperlipidemia (high cholesterol). The resident's MAR was initialed by multiple MTs indicating the atorvastatin was administered or refused on all occasions between 05/13/25 and 05/21/25. On 05/27/25 at 11:30 am, the need to ensure the staff person who administered the medication visually observed the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication stated otherwise was discussed with Staff 1 (ED), Staff 19 (Regional Director of Operations), Staff 20 (CEO), Staff 21 (Regional Director of Health and Wellness) and Witness 1 (RN Consultant). They acknowledged the findings. 2. Resident 7 was admitted to the facility in 10/2019 with diagnoses including Type 2 diabetes, atrial fibrillation, hypertension, and heart disease. MARs dated 04/01/25 to 04/30/25 and 05/01/25 to 05/21/25 were reviewed. In an interview with Resident 7 on 05/22/25 at 10:00 am, s/he reported that the regular third floor med tech did not stay to watch him/her take their medications but rather set them on the nightstand beside the bed. This surveyor observed 10 different medications in and around the pill cup on Resident 7’s bedside table during the interview. Resident 7 confirmed that these medications had been passed 7:30 am that morning. The need to ensure staff who administered medications observed the resident take medications was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25. They acknowledged the findings.

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. 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 3 sampled residents (#4) whose MARs and Controlled Substance Disposition logs were reviewed. Resident 4’s narcotic pain medication was not tracked effectively to ensure the medication was administered as ordered and that the resident had sufficient medication to make it until a refill could be authorized. Findings include, but are not limited to: Resident 4 was admitted to the facility in 10/2024 with diagnoses including knee pain. The resident's 01/01/25 through 05/21/25 progress notes, 12/31/24 signed physician orders and the 04/01/25 through 05/23/25 MAR/TAR were reviewed. The resident had an order for oxycodone 5mg tablet, take one tablet every four hours PRN for pain. Order changes made by the physician were reflected on the MAR. The resident's Controlled Substance Disposition logs and MARS dated 04/01/25 through 05/21/25, and observation of the medication cards on 05/22/25, showed the following: The following doses were reflected on the disposition log, but were not signed as administered on the MAR. * On 04/27/25 doses noted at 10:47 pm and 4:47 am; * On 05/01/25 doses noted at 2:30 (no am or pm noted); * On 05/02/25 doses noted at 11:32 am and 5:00 pm; * On 05/04/25 a dose noted at 12:53 am; * On 05/05/25 doses noted at 8:02 am and 3:40 pm; * On 05/06/25 a dose noted at 1:09 pm; * On 05/07/25 a dose noted at 6:12 am; * On 05/08/25 doses noted at 6:29 am and 1:00 pm; * On 05/09/25 doses noted at 7:02 am, 1:15 pm and 9:43 pm; * On 05/10/25 a dose noted at 2:42 (no am or pm noted); * On 05/11/25 a dose noted at 2:00 (no am or pm noted); * On 05/14/25 doses noted at 7:42 am, 12:10 pm and 4:35 pm; * On 05/15/25 doses noted at 2:42 (no am or pm noted) and 10:19 am; * On 05/16/25 doses noted at 1:30 am, 6:29 am, 11:34 am, 4:01 pm and 8:27 pm; * On 05/17/25 doses noted at 6:29 am, 10:53 am, 2:54 am and 12:10 (no am or pm noted); * On 05/18/25 a dose noted at 7:42 am; * On 05/20/25 an am dose with an illegible time, only time on the MAR already matched a dose on the disposition log; and * 05/21/25 a dose noted as 8:36 pm. The following dose administrations were recorded on the MAR but not on the disposition log: * On 05/03/25 a dose noted at 11:04 am; and * On 05/08/25 a dose noted at 11:18 am. The following doses were marked as errors, but the medication count decreased. There was no documentation that any medications were destroyed. * On 04/28/25 a dose at 2:30 pm, was crossed out and marked as an error, the medication count decreased by one. * On 05/08/25 a dose at 12:43 pm, was crossed out and marked as an error, the medication count decreased by one. In an interview on 05/22/25, Staff 11 (MT) indicated the resident had one active card that was in use. The resident was able to ask for the medications when s/he needed them. Staff 11 stated a new card order should be coming in that night as s/he was low on medication. The pill card showed four pills were remaining in the card for administration. The disposition log reflected a count of four pills as well. The card was delivered/filled on 05/13/25 with 30 pills to last 28 days. Staff 11 was unsure why the pills already needed a refill. Staff 11 stated the resident did take the medication but was not typically taking the maximum s/he could. The resident’s other pain medication, tramadol was discontinued, and the remaining pills were destroyed. The resident did not have an oxycodone order until middle to late April 2025. In interviews between 05/21/25 and 05/22/25, Resident 4 expressed concerns about his/her narcotic medications. The resident indicated s/he received a call from the doctor’s office that indicated a refill was requested by the facility. The doctor’s office was confused why medications would be needed so soon, when they were just filled on 05/13/25 for 30 pills. The resident indicated s/he did frequently take the pain medication but did not take more than one or two in a day typically and not every day. Resident 4 further stated s/he was aware there was a limit to the medication and how much s/he could have and did not want to risk running out and not having the medication when his/her knee pain was severe. The resident was adamant s/he did not take 26 pills in less than two weeks. In a follow up interview on 05/22/25, Staff 11 indicated the facility received a notice the oxycodone could not be refilled as it was too soon. The medication would not be refilled for another three days. In an interview on 05/22/25 at 2:15 pm, Staff 1 (ED), Staff 2 (Associate ED) and Staff 3 (Director of Health and Wellness/LPN) were unable to offer any information on how the facility was monitoring the controlled substance system. The facility failed to ensure narcotic administration was accurately documented to ensure the resident’s medication was properly accounted for and administered only to the resident. The resident’s medication had only four pills remaining when a refill could not be authorized for an additional three days. The facility began an investigation of the inaccuracies at the time survey discovered and reported the issues on 05/22/25. The inaccuracies in the disposition log and MARs were reported to the local SPD office by the surveyor. A confirmation of the report was received via email prior to survey exit. The need to ensure narcotic disposition logs, MARs and medication cards accurately reflected medication administered was discussed with Staff 1, Staff 2, Staff 3 and Witness 1 (RN Consultant) on 05/22/25 at 2:15 pm. The staff acknowledged the findings.

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 2 of 2 sampled residents (#s 9 and 11) whose MARs and Controlled Substance Disposition logs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 moved into the assisted living facility in 10/2024 with diagnoses including chronic kidney disease stage 3. Resident 9 had a physician order for oxycodone 5 mg, take one tablet by mouth every four hours as needed for pain, and morphine sulfate 0.25 mg orally every hour as needed for pain. Resident 9's 08/01/25 through 08/31/25 MAR and Controlled Substance Disposition Logs were reviewed, and the following was identified: a. Between 08/01/25 and 08/31/2025, there were three occasions staff signed the drug disposition log that the PRN Oxycodone was removed from the drug card; however, staff failed to initial and document on the MAR that the resident received the PRN medication. b. Between 08/01/25 and 08/31/25, there were three occasions staff signed the drug disposition log that the PRN morphine sulfate was removed from the bottle; however, staff failed to initial and document on the MAR that the resident received the PRN medication. Discrepancies between the drug disposition log and the MAR were reviewed with Staff 27 (Director of Health and Wellness, LPN) and Witness 8 (RN Consultant). They acknowledged the findings. The need to ensure the facility had a system for accurately tracking controlled substances administered by the facility was discussed with Staff 2 (Interim ED), Staff 19 (Regional Director of Operations), and Staff 27 on 09/04/25 at 1:45 pm. They acknowledged the findings. 2. Resident 11 moved into the assisted living community in 08/2024 with diagnoses including chronic pain. Resident 11 had a physician order for oxycodone 5 mg, take .5 mg (2.5 mg) tablet by mouth every six hours as needed for pain. Resident 11's 08/01/25 through 08/31/25 MAR and Controlled Substance Disposition Logs were reviewed and identified the following: Between 08/01/25 through 08/31/2025 there were 14 occasions staff signed the drug disposition log that the PRN Oxycodone was removed from the drug card however, staff failed to initial and document on the MAR that the resident received the PRN medication. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 2 (Interim ED) and Staff 19 (Regional Director of Operations) on 09/04/25 at 12:28 pm. They acknowledged the findings.

1. Resident #9 and 11 MARs and drug disposition log will be reviewed. Interview staff responsible for documentation discrepancies. Root cause analysis will be conducted based on information gained. 2. MAR and drug disposition log will be reviewed for discrepancies daily by clinical team. Community staff involved in medication administration will be required to attend training related to medication administration and managing controlled substances. 3. Daily for 3 weeks then spontaneous monthly checks thereafter 4. Director of Health and Wellness, Registered Nurse, Resident Care Director, and/or designee.

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)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 5 of 7 sampled residents (#s 2, 3, 4, 5, and 8) whose orders were reviewed. Findings include, but are not limited to: 1. Review of Resident 5's most recent physician orders, dated 04/18/25 and the 05/01/25 – 05/19/25 MAR, revealed the facility was not following the orders as written. Resident 5 had orders to receive one senna 8.6 mg tab by mouth twice a day scheduled for bowel regimen. The order documented on the resident's 05/2025 MAR was written as one senna 8.6 tab by mouth as needed for prevention of constipation. In an interview with Staff 2 (Director of Health & Wellness, LPN) at 12:26 pm on 05/26/25, she verified the current orders were not followed as prescribed. The need to ensure facility staff carried out all orders as prescribed was discussed with Staff 1 (Executive Director) and Witness 1 (RN Consultant) on 02/23/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 03/2025 with diagnoses including cerebrovascular accident (stroke), hypertension (high blood pressure), and Crohn’s disease (inflammatory bowel disease). Resident 2's current physician's orders, MAR/TAR dated 05/01/25 through 05/21/25, and progress notes dated 03/31/25 through 05/22/25 were reviewed. The following was identified: * On 05/01/25, Resident 2 was prescribed Eliquis 5mg twice a day for deep vein thrombosis of the upper arm (blood clot). The first dose was administered to the resident on 05/05/25 at 8:00 am. Therefore, the resident did not receive his/her medication as prescribed on seven occasions; and * Resident 2 had an order to apply a lidocaine 5% patch topically, leave on for 12 hours then remove for 12 hours as needed for back pain. The resident received the PRN order on 14 occasions; however, there was no indication the patch was removed per prescriber's orders. Additionally, on 05/07/25, the resident received two lidocaine patches within 13 hours. On 05/23/25 at 1:38 pm, Staff 8 (MT) and this surveyor confirmed the electronic MAR did not provide evidence the patch was removed 12 hours following administration. On 05/27/25 at 11:30 am the need to ensure all medication and treatments were carried out as prescribed was discussed with Staff 1 (ED), Staff 19 (Regional Director of Operations), Staff 20 (CEO), Staff 21 (Regional Director of Health and Wellness) and Witness 1 (RN Consultant). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 10/2024 with diagnoses including knee pain. The resident's 01/01/25 through 05/21/25 progress notes, 12/31/24 signed physician orders and the 04/01/25 through 05/21/25 MAR/TAR were reviewed. In interviews between 05/19/25 and 05/23/25, multiple sampled and unsampled residents expressed medication administration concerns. Resident 4 indicated his/her medications for the evening were frequently given after 10:00 pm, midnight or even later. The resident additionally expressed concerns that his/her antidepressant medication was not being given at a consistent time in the morning and it was affecting his/her moods and mental health. a. The 01/01/25 through 05/23/25 physician communications, the 12/31/24 signed physician orders and the 04/01/25 through 05/21/25 showed multiple physician orders for medications to be administered at HS (hour of sleep). The facility’s HS administration time was between 7pm and 9pm. The following medications were not given timely between 04/01/25 and 05/21/25: * Hydroxyzine (for anxiety) was given on 18 occasions between 9:44 pm and 12:27 am; * Gabapentin (for nerve pain) was given on 18 occasions between 9:44 pm and 12:27 am; * Tylenol (for pain) was given on 18 occasions between 9:44 pm and 12:27 am; * Metoclopramide (for reflux) was given on 18 occasions between 9:44 pm and 12:27 am; and * Tizanidine (muscle relaxer) was given on 18 occasions between 9:44 pm and 12:27 am. b. An order for Fluoxetine (antidepressant) in the AM. The facility’s AM medication pass was between 7:00 am and 9:00 am. Resident 4’s antidepressant was given daily. On nine occasions the dose was given between 45 minutes and two hours later than the previous days dose. The need to ensure the facility administered all medications timely and as ordered by the physician was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/27/25 at 1:05 pm. The staff acknowledged the findings. 4. Review of Resident 3’s 04/01/25 through 05/19/25 MAR revealed multiple medications with blanks, indicating the medication was not administered. During an interview on 05/22/25, Staff 7 (MT) reported blanks on a resident MAR indicated the resident had not received the medication. Staff 7 was unable to locate documented evidence of why Resident 3’s medications were not administered as prescribed. On 05/26/25, the need to ensure resident medications are administered as prescribed was discussed with Staff 1 (ED) and Witness 1 (RN Consultant). They acknowledged the findings. 5. Review of Resident 8’s 05/01/25 through 05/22/25 MAR revealed the following: Resident 8’s physician orders, dated 03/26/25, indicated s/he was to receive levothyroxine 75mcg (thyroid medication) 30 minutes prior to receiving breakfast. In an interview on 05/21/25 at 9:37 am, Resident 8 stated s/he had a thyroid medication s/he needed to take 30 minutes prior to eating breakfast and stated s/he had not been receiving his/her medication on time, leading to late or missed meals. Resident 8 takes breakfast in his/her room at 5:00 am. Resident 8’s MAR, 05/01/25 through 05/22/25, indicated levothyroxine was given daily. On eight occasions the dose was given between two and five hours later than 5:00 am. The need to ensure the facility administered all medications timely and as ordered by the physician was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25. The staff acknowledged the findings. Refer to H1522.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. 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 1 of 1 sampled resident (# 2) who had documented medication refusals. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2025 with diagnoses including cerebrovascular accident (stroke), hypertension (high blood pressure), and Crohn’s disease (inflammatory bowel disease). Resident 2's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication refusals from 05/01/25 through 05/15/2025. The medications refused included: * Eliquis 5mg for deep vein thrombosis of upper arm (blood clot) refused on 14 occasions; and * Atorvastatin 40mg for hyperlipidemia (stroke prevention) refused on two occasions. On 05/27/25 at 11:30 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 (ED), Staff 19 (Regional Director of Operations), Staff 20 (CEO), Staff 21 (Regional Director of Health and Wellness) and Witness 1 (RN Consultant). They acknowledged the findings. No further documentation was provided.

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide sufficient direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident, and adequate direct care staff present at all times to meet the fire safety evacuation standards. This posed an immediate jeopardy situation that put the health and safety of residents at risk. Findings include, but are not limited to: 1. The facility failed to provide adequate direct care staff present at all times to meet the fire safety evacuation standards. Refer to deficiencies in the report. 2. On 05/20/25, Resident 8 stated caregivers had left him/her unattended in the shower while answering other resident’s call lights. On 5/20/25, Witness 4 (Family) stated s/he had to provide showers for Resident 8 as staff were unavailable, and the facility was regularly understaffed on weekends. The facility census at the time of survey was 52, with all resident rooms being located on the second and third floors. Review of the facility night shift staffing indicated the facility was staffing one MT and one CG. During an interview on 05/21/25 at approximately 1:15 pm, Staff 10 (CG) reported 13 of the 52 residents on the second and third floors required an electric or manual wheelchair to ambulate outside of their apartment. Staff 10 reported during the event of a fire, staff had been instructed to use a sheet or hospital blanket to carry these residents down stairwells, requiring multiple staff to evacuate the resident's downstairs using this method. The facility’s posted staffing plan indicated: Caregivers worked three shifts, day shift from 6:00 am to 2:00 pm, swing shift from 2:00 pm to 10:00 pm and night shift from 10:00 pm to 6:00 am; There were to be three caregivers on day and swing shift, and one caregiver on night shift; Med techs worked 12-hour shift, 6:00 am to 6:00 pm and 6:00 pm to 6:00 am; and There were to be two med techs from 6:00 am to 6:00 pm and one med tech from 6:00 pm to 6:00 am. Facility timecards, dated 05/11/25 through 05/18/25, indicated the facility did not staff according to their posted staffing plan for 8 of 24 shifts. Additionally, the facility had no caregivers clocked in for day shift on 05/17/25 nor day or swing shift on 05/18/25. Staff 2 (Associate ED) stated the facility had not used agency staff as caregivers during the week of 05/11/25 through 05/18/25. On 05/21/25 at 4:29 pm, the Survey team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 05/21/25 at approximately 6:20 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. On 05/21/25, the Department requested a staffing plan for the facility indicating which staff would be working each shift. The facility did not provide the requested staffing plan. On 05/22/25, the Department again requested a staffing plan for the facility indicating which staff would be working each shift, due by 12:00 pm on 05/23/25. The facility did not provide the requested staffing plan. On 05/22/23, the facility was observed to have two caregivers and one med tech on swing shift. This did not meet the staffing plan outlined in the plan of correction. On 05/23/25, the facility was observed to have one caregiver and one med tech from approximately 4:30 pm to 6:00 pm. This did not meet the staffing plan outlined in the plan of correction. On 05/23/25, at approximately 5:30 pm, Staff 1 (ED) stated the facility had not made a staff schedule for the following week. The need to ensure the facility provided sufficient direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident, and adequate direct care staff present at all times to meet the fire safety evacuation standards was discussed with Staff 1 and Witness 1 (RN Consultant) on 05/23/25. They acknowledged the findings.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 7 sampled residents (#s 5, 8). Findings include, but are not limited to: 1. Resident 5’s service plan, dated 04/30/25, was reviewed and indicated: S/He required “increased monitoring” due to being “at risk for falls;” Resident 5 had difficulty expressing his/her needs verbally; Staff were to assist Resident 5 with dressing; Resident 5 had occasional disruptive behaviors and needed to be redirected; and Staff were to assist Resident 5 once a week with bathing. Resident 5’s ABST profile indicated no allotted times for the above tasks. 2. Resident 8’s service plan indicated s/he was to receive assistance with dressing. Resident 8’s ABST profile failed to indicate time allotted for dressing. The need to ensure the facility to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 2 sampled residents (#s 9 and 10) whose ABST were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 moved into the assisted living facility in 10/2024 with diagnoses including chronic kidney disease stage 3. Observations of the resident, interviews with the resident and staff, the service plan dated 08/21/25 with updates dated 08/28/25, and Resident 9’s ABST data was reviewed. The following areas were not reflective of the residents current ADL assistance: * How much time is spent on ambulation, escorting to and from meals or activities; and * How much time is spent with bathing. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 2 (Interim ED), Staff 19 (Regional Director of Operations), and Staff 27 (Director of Health and Wellness, LPN) on 09/04/25 at 1:45 pm. They acknowledged the findings. 2. Resident 10 moved into the assisted living facility in 08/2019 with diagnoses including mild cognitive impairment. A review of Resident 10’s ABST record showed the resident required zero minutes on multiple care areas. However, observations, interviews, and review of clinical records for Resident 2 revealed the resident required staff assistance in multiple care areas and the ABST tool did not accurately reflect the amount of staff time needed to provide care. On at 09/04/25 at 2:20 pm, the surveyor reviewed the resident’s ABST record with Staff 2 (Interim ED) and Staff 19 (Regional Director of Operations). They acknowledged the finding that the ABST minutes had not been increased when Resident 10’s care needs increased.

1. Resident #9 ABST will be reviewed to ensure “How much time is spent on ambulation, escorting to and from meals or activities; and * How much time is spent with bathing” are reflected ADL assistance. Resident #10 ABST will be reviewed to ensure ADL assistance is reflected according to resident needs. 2. ABST will be updated immediately following completion of assessment and care plan changes. Clinical team to collaborate with direct care staff on time and frequency of the care tasks and time to ensure accuracy. 3. Weekly for 3 weeks and then quarterly thereafter 4. Administrator, DHW, RN and/or designee

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, the facility failed to complete or update and review the ABST evaluation for each resident before a resident moved in and no less than quarterly at the same time the resident's service plan was updated as required. Findings include, but are not limited to: 1. A review of the facility’s ABST on 05/20/25 indicated 3 of 51 unsampled residents were not updated quarterly as required. The need to ensure the facility completed or updated and reviewed the ABST evaluation for each resident before a resident moved in and no less than quarterly at the same time the resident's service plan was updated was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25. 2. Resident 2 was admitted to the facility on 03/31/25 with diagnoses including cerebrovascular accident (stroke), hypertension (high blood pressure), and Crohn’s disease (inflammatory bowel disease). The facility’s ABST data was reviewed during the survey 05/19/25 through 05/27/25. Resident 2's ABST evaluation was entered on 04/02/25; therefore, the resident's ABST evaluation was not completed prior to moving into the facility. The need to ensure residents’ ABST evaluations were completed prior to move-in was discussed with Staff 1 (ED), Staff 19 (Regional Director of Operations), Staff 20 (CEO), Staff 21 (Regional Director of Health and Wellness) and Witness 1 (RN Consultant) on 05/27/25 at 11:30am. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated with a significant change of condition for one sampled resident (# 9) and multiple unsampled residents at least quarterly at the same time as the resident’s service plan. This is a repeat citation. Findings include; but are not limited to: The facility’s ABST data was reviewed at 10:15 am on 09/03/25 and revealed the following: a. Three unsampled residents had not been updated since 2024. b. 42 unsampled residents had not been updated quarterly. c. Resident 9 experienced a significant change of condition on 08/26/25, and the ABST data had not been updated. The ABST data was reviewed with Staff 2 (Interim ED) and Staff 19 (Regional Director of Operations) on 09/03/25 at 11:15 am. They had no additional information to provide. The need to ensure residents’ ABST was updated with significant change of condition and no less than quarterly was discussed with Staff 1, Staff 2, and Staff 27 (Director of Health and Wellness, LPN) on 09/04/25 at 1:45 pm. They acknowledged the findings.

1. Resident #9 ABST will be reviewed and updated based on significant change of condition. Resident Service plans will be reviewed against ABST to reflect the current assessments and care plans. Review of ABST will be conducted to ensure resident updated within the last 90 days. 2. ABST will be reviewed during clinical meeting and updated accordingly. Clinical staff will be re-educated on change of condition to ensure assessments, care plan and ABST reflect changes. 3. Weekly for 3 weeks and then quarterly thereafter and as needed with change of conditions. 4. Administrator, AED, DHW, RN, RCD and/or designee

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 22, 23 and 24) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 05/21/25 at 3:00 pm revealed the following: a. There was no documented evidence Staff 22 (CG), hired 04/03/25, had demonstrated competency in all required areas and within 30 days of hire including: * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. b. There was no documented evidence Staff 23 (CG), hired 04/01/25, and Staff 24 (CG), hired 04/10/25, had demonstrated competency in the following required areas within 30 days of hire: * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. c. There was no documented evidence Staff 23 and Staff 24 had completed training in the administration of medications and treatments within 30 days of hire. d. There was no documented evidence Staff 23 and Staff 24 had completed First Aid/Abdominal thrust within 30-days of hire. The need to document demonstrated competency of job duties and complete First Aid certification and abdominal training within 30 days of hire was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 6 of 6 newly hired staff (#s 31, 32, 33, 34, 35 and 36) had documented demonstration of competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Review of the facility's training records on 09/03/25 through 09/04/25 identified the following: a. There was no documented evidence Staff 31 (CG), hired 07/24/25, demonstrated competency in the following required areas within 30 days of hire: * Changes associated with normal aging; and * Conditions that require assessment, treatment, observation and reporting. b. There was no documented evidence Staff 32 (CG), hired 08/01/25, demonstrated competency in the following required areas within 30 days of hire: * Role of the service plan in providing individualized care; * Changes associated with normal aging; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid/abdominal thrust. c. There was no documented evidence Staff 33 (MA), re-hired 07/02/25, demonstrated competency in the following required areas within 30 days of hire: * Providing assistance with ADL care; and * Conditions that require assessment, treatment, observation and reporting. d. There was no documented evidence Staff 34 (CG), hired 07/30/25, demonstrated competency in the following required areas within 30 days of hire: * Conditions that require assessment, treatment, observation and reporting. e. There was no documented evidence Staff 35 (CG), hired 07/23/25, had demonstrated competency in all required areas and within 30 days of hire including: * Role of service plan in providing individualized care; * Assistance with ADL’s was not completed within required timeframe; and * Conditions that require assessment, treatment, observation and reporting. f. There was no documented evidence Staff 36 (MA), hired 07/28/25, demonstrated competency in the following required areas within 30 days of hire: * Role of the service plan in providing individualized care; * Identification, documentation and reporting on changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure new direct care staff had documented demonstration of competency training within 30 days of hire was discussed with Staff 2 (Interim ED) and Staff 19 (Regional Director of Operations) on 09/04/25 at 12:12 pm. They acknowledged the findings.

1. Newly hired staff #31, 32, 33, 34, 35, and 36 have been assigned missing competencies listed in SOD. Supervisors will monitor the completion of required trainings. 2. Staff that have not completed required training by compliance date will be removed from the schedule until completed is achieved. Milestone training tracker will continue to be monitored and adjusted based on training completions. Milestone received a state approved training list that has been added to each employee Relais training plan. Completed courses will be marked completed based on date of the Oregon Care Partners certificate of completion. AED and BOM will monitor routinely with support of HR team. 3. At minimum weekly 4. Executive Director, Business Office Manager, AED, Corporate HR Team

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

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term direct care staff (#s 9 and 25) completed 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including 6 hours on dementia care and annual home and community based care (HCBS) training. Findings include, but are not limited to: Staff training records were reviewed on 05/21/25. Staff 9 (CG), hired 04/18/2018, and Staff 25 (MT), hired 12/20/2016, lacked documentation of completing 6 hours of annual in-service training on dementia care and the required HCBS training based on their anniversary dates of hire. In an interview with Staff 4 (Business Office Manager) on 05/23/25, she stated all staff members had been assigned the HCBS training to complete via Relias online but not everyone had done this at the time survey was in the building. The need to ensure all direct care staff completed 12 hours of annual required training including 6 hours on dementia care was discussed with Staff 1 (ED) and Witness 1 (RN Consultant) on 05/23/25. They acknowledged the findings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. 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 in accordance with the Oregon Fire Code, fire and life safety instruction was provided to staff on alternate months and that resident evacuation needs were met. The second and third floors had multiple residents who were unable to walk down the stairs in case of a fire with insufficient staff to evacuate. This placed the resident at risk and constituted an immediate threat to the resident's health and safety. Findings include, but are not limited to: a. The facility census at the time of survey was 52, with all resident rooms being located on the second and third floors. Review of the facility night shift staffing indicated the facility was staffing one MT and one CG. During an interview on 05/21/25 at approximately 1:15 pm, Staff 10 (CG) reported 13 of the 52 residents on the second and third floors required an electric or manual wheelchair to ambulate outside of their apartment. Staff 10 reported during the event of a fire, staff had been instructed to use a sheet or hospital blanket to carry these residents down stairwells, requiring multiple staff to evacuate the resident's downstairs using this method. Fire and life safety records, reviewed between 10/2024 and 04/2025, indicated the facility was not consistently conducting fire drills and fire life safety instruction to staff on alternating months. The facility failed to document escape routes used and evacuation time needed for the fire drills which were conducted. On 05/21/25 at approximately 2:15 pm, fire and life safety records were reviewed with Staff 1 (ED), Staff 5 (Maintenance Director), and Staff 6 (Maintenance Assistant). Staff 5 reported the facility was not consistently relocating residents during fire drills. The facility had no documented evidence of conducting a full evacuation fire drill to establish how long it would take to fully evacuate the facility in the event of a fire. This constituted a significant risk to resident health and safety and required an immediate plan of correction to ensure residents on upper floors could be safely and effectively evacuated to the first floor if needed in case of a fire. On 05/21/25 at 6:20 pm, the facility provided a plan of correction to the survey team. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. On 05/21/25, the need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training and the facility was relocating residents during drills, was discussed with Staff 1, Staff 5, and Staff 6. They acknowledged the findings.

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 provide fire and life safety procedures for residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: On 05/21/25, fire and life safety records were reviewed with Staff 1 (ED), Staff 5 (Maintenance Director), and Staff 6 (Maintenance Assistant). There was no documented evidence a written record of Fire and life safety training and procedures to residents upon admission and at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills. On 05/21/25, the need to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and least annually was discussed with Staff 1, Staff 5, and Staff 6. They acknowledged the findings.

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C231, C260, C302, C362, C363, C372, and C613.

Plan of correction to be submitted by 09/23 Refer to C231, C260, C302, C362, C372 and C613 Plan of correction review and approved by Milestone Management and Elderwise RN Consultant prior to submission to department. POC final submission will be copied to Milestone Management and Elderwise RN consultant. Responsible persons: RDO

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

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility from 05/20/25 through 05/26/25 identified the following areas in need of cleaning and repair: a. Interior: * Multiple areas of the carpet in the dining room, corridors, and stairwells throughout the facility had stains and/or black spots; * Multiple areas of the carpet were observed with duct tape, torn, and/or bubbling up resulting in an uneven surface and tripping hazard; * Multiple apartment doors, door frames, and walls had significant dings and paint scrapes; and * Multiple wood dining room chairs were worn down to bare wood. b. Exterior: * Exterior carpeting near the front entrance and outside the dining room was observed with stains and black matter. On 05/20/25 at approximately 1:00 pm, the areas in need of cleaning and repair were reviewed Staff 1 (ED) and Witness 1(RN Consultant). They acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility from 09/03/25 through 09/04/25 identified the following areas were in need of cleaning and repair: a. Interior: * Multiple areas of the carpet in the dining room, corridors, and stairwells throughout the facility had stains and/or black spots; * Multiple areas of the carpet were observed with duct tape, torn, and/or bubbling up resulting in an uneven surface and tripping hazard; * Multiple apartment doors, door frames, and walls had significant dings and paint scrapes; and * Multiple wood dining room chairs were worn down to bare wood. b. Exterior: * Exterior carpeting near the front entrance and outside the dining room was observed with stains and black matter. During an interview on 09/03/25 at 10:41 am, Staff 5 (Maintenance Director) reported the facility is currently undergoing a major remodel. Staff 5 was unable to provide a date of completion in which the above areas of concern would be repaired. During an interview on 09/03/25 at 12:30, Staff 2 (Interim ED) and Staff 19 (Regional Director of Operations) acknowledged the above areas of concern were not repaired.

Approval of extension while construction continues at community has been submitted and approved through November 28, 2025. If additional time is needed, this will be requested at this time.

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

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF 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 at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. 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.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF 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 provide security and to alert staff when residents exited the building. Findings include, but are not limited to: During the survey, the exit doors from the ALF dining area and stairwells failed to have a working alarm or other acceptable system to alert staff when residents exited the building. In an interview, on 05/21/25, Staff 10 (CG) reported stair wells and dining room exit doors didn’t notify staff when residents exited the building. On 05/21/25, the lack of alarms on exit doors or other acceptable system to alert staff was discussed with Staff 1 (ED) and Witness 1 (RN Consultant). They acknowledged the findings.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF 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 at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. 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.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF 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(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents’ rights of privacy and dignity. Findings include, but are not limited to: Sampled Residents 1, 2 and 4 and three non-sampled residents were subjected to repeated undignified and disrespectful verbal treatment by staff. Residents were additionally subjected to unwanted intimate touching from Resident 6. Refer to C200

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

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure sampled and unsampled residents were supported in their right to control his/her own activities and schedule. 1. Resident 4 was admitted to the facility in 10/2024 with diagnoses including depression and anxiety. Review of the resident’s progress notes dated 01/01/25 through 05/21/25, service plan dated 12/04/24 and interviews with the resident were completed. In interviews between 05/19/25 through 05/23/25, the resident indicated s/he did not feel they had control of their own daily schedule or their ADL needs. The resident had a difficult time getting assistance from staff and relied on other friends who were also residents “more than anything.” The resident stated s/he was frequently treated poorly, especially by agency, was left for extended periods when requested help or could not get any staff to assist. The resident indicated concerns were not taken seriously and s/he has been made to “feel less than human” when trying to get help. The resident felt at the mercy of when people wanted to show up, not when s/he needed or requested the help. Refer to C200 and C260 2. During a group interview on 05/21/25 with sampled and unsampled residents, surveyors were informed residents were not able to control or determine their own shower schedule if they required assistance. An unsampled resident stated s/he preferred showers twice a week in the morning. Currently the resident received a shower once a week in the evening due to staff availability. The need to ensure residents had the freedom and support to control their own schedule was discussed with Staff 1(ED) and Witness 1 (RN Consultant) on 05/23/25 at 11:49 am. They acknowledged the findings.

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. 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 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 (#2) whose evaluation was reviewed. Findings include, but are not limited to: Refer to C 252

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: