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 facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the relicensure survey conducted 10/15/25 through 10/17/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in the report.

C0150- Facility Administration; Operation; 1- The survey citiations have been reviewed and corrective actions have been completed for each of the citiations. 2- Operation of the community; the systems identified in the survey have been corrected, so this violation will not happen again. 3- The systems will be re-evaluated monthly in the Quality Assurance program meetings. 4- The Administrator will be responsible for overall compliance.

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 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to: On 10/15/25 at 11:00 am, a tour of the facility was conducted. The following required postings were not observed to be posted: * Facility license; * Current facility staffing plan; * LGBTQIA2S+ rights and protections; and * LGBTQIA2S+ nondiscrimination notice. The need to ensure all required postings were displayed was discussed with Staff 1 (Administrator/Owner) on 10/17/25 at 12:53 pm. He acknowledged the findings.

0152- Facility Administration: Required Postings *** Refer to C 152 ***

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

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness and accuracy of resident records were maintained for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents. Findings include, but are not limited to: a. During the relicensure survey, dated 10/15/25 through 10/17/25, Resident 1 and Resident 2 presented with short-term changes of condition related to a skin rash and medication changes, respectively. On 10/15/25 at 11:45 am, Staff 1 (Administrator/Owner) was asked how the facility documented changes of condition and monitoring. He acknowledged the facility previously used progress notes to document resident changes of condition but had not been doing so recently. On 10/16/25 at 10:42 am, survey requested documentation of monitoring for Resident 1 and 2's changes of condition. On 10/16/25 at 3:05 pm, Staff 1 confirmed there was no documented evidence of monitoring the resident’s changes of condition. He also acknowledged the facility did not currently have progress notes on any residents. Due to the lack of documented monitoring of changes of condition, the facility failed to ensure the completeness of resident records. b. Review of MARs for Residents 1 and 2 revealed exceptions were not consistently documented for items that were circled on the MAR. The survey team was unable to share the findings regarding the need to ensure the preparation, completeness and accuracy of resident records were maintained.

C0155- Facility Administration; Records 1- The residents (Resident #1 and resident #2) identified in the survey have had their records reviewed and current progress notes and related documentation is now in place to reflect their current conditions. 2- The community has changed the process for documentation to an Electronic platform (Care Right Solutions) porgress notes, Alert charting and other related resident information will be charted on in this platform. 3- The community will run the Clinical Dashboard daily, to review the progress notes, Alert chart notes and other related information to ensure completion. 4- The Administrator and the Wellness Director will be responsible for compliance.

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: 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 interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings include, but are not limited to: During the re-licensure survey, conducted 10/15/25 through 10/17/25, quality improvement oversight to ensure adequate resident care, service and satisfaction was found to be ineffective. In an interview on 10/16/25 at 2:30 pm, Staff 1 (Administrator/Owner) stated the facility utilized a company that sent out questionnaires once a year to residents, and then he would review the results. Staff 1 was unable to provide documented evidence of the questionnaire results. The facility lacked documented evidence of a quality improvement program. The survey team was unable to share the findings regarding the need to ensure the facility conducted ongoing quality improvement programs that evaluated services, staff performance, resident outcomes, and resident satisfaction.

C0156-Facility Administration: Quality Improvement 1- The community has impleneted a policy and procedure for a Quality Improvement program. 2- The community will meet with the QA team and follow the process for areas that have been identified in the survey. 3- The QA team will meet on a weekly basis to review the systems for improvements. 4- The Administrator will be responsible for overall compliance.

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 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the re-licensure survey, 10/15/25 through 10/17/25, there was a lack of daily activities based upon individual and group interests. Upon entrance to the building on 10/15/25, the facility had a September activity calendar posted in the corridor leading to the facility’s kitchen. This calendar was printed on half a standard piece of paper with small font which made it challenging to read. There was one activity posted daily without a corresponding time. The October activity calendar was requested upon survey’s entrance to the building on 10/15/25 at 9:50 am, and again on 10/16/25 at 10:42 am. Once received, the facility activity calendar for October was reviewed and included the following unscheduled daily activities: * 10/15/25 – “Crafts, Chess, checkers”; * 10/16/25 – “Bingo” and “Singer”; and * 10/17/25 – “Trivia night”. The only activity observed during the survey was the “singer” on 10/16/25 at 2:00 pm. Additionally, the October activity calendar had all weekend activities crossed out with the handwritten addition of “Window Paint by Paris” scheduled on 10/11/25. On 10/15/25 at 11:45 am, the surveyor overheard Staff 1 (Administrator/Owner) cancel Bingo for the day. On 10/16/25 at 10:50 am, Staff 1 confirmed Bingo had been cancelled the previous day with no alternate activity scheduled for the residents. On 10/17/25 at 1:13 pm, Staff 4 (CG/MT) stated the care staff lead bingo two or three times weekly, and a guitarist will come twice a month; otherwise, “nothing else happens.” The survey team was unable to share the findings regarding the need to ensure a daily activity program was provided for residents.

C0242- Resident Services: Activities 1- The community has completed resident interviews to establish their personal likes and interests as it relates to their activity involvement. 2- A new Activity Programming Calendar has been developed to reflect both individual and group needs for the residents. 3- Activity Programming will be monitored daily to ensure that the residents’ engagement and preferences are met. 4- The Wellness Director will be responsible for initiation and oversight. The Administrator will be responsible for overall compliance.

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

OAR 411-054-0036 (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 interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction regarding the delivery of services for 1 of 2 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 moved into the community in 04/2024 with diagnoses including paranoid schizophrenia. The resident’s record was reviewed, including the current service plan, dated 08/10/25 and interviews with staff were conducted. The service plan was not reflective of the resident's current care needs and did not provide clear direction in the following areas: * Interview with staff 2(MT/CG) on 10/17/25 at 1:15 pm revealed Resident 2 had behaviors of undressing, sexually self-stimulating and positioning self in a sexual manner that were offensive to other residents. Resident 2’s service plan lacked documentation of the behavior and/or clear direction to staff on how to support resident. * Invega injection quarterly; * Pain management, related to current pharmacological interventions; and * Denture status including need for denture adhesive. The survey team was unable to share the findings regarding the need to ensure resident service plans were reflective of residents’ current care needs and provided clear direction to staff.

C0260- Service Plan: General 1- Resident # 2 identified in the survey have had their service plans reviewed and corrections made, to include Pain management and denture status. 2- The process and the system of generating and reviewing service plans has been changed. A new template for generating and updating service plans has been implemented. 3- The service planning process will be reviewed weekly for compliance. 4- The Administrator will be responsible for overall compliance. JP 11/21/2025 9:45 am- #1 spoke with Amber Marchese (RN consultant) confirmed service plan has been updated for resident 2 to include behaviors and corrections made relating to invega injections.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to monitor the change of condition at least weekly until resolved, and/or to monitor each resident consistent with his/her evaluated needs and service plan for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition; and the facility failed to have written policies to ensure a resident monitoring and reporting system was implemented 24-hours a day. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 11/2006 with diagnoses including heart failure. During the acuity interview on 10/15/25 at 9:47 am, Resident 1 was identified to have a skin rash that resolved. The resident’s clinical chart was reviewed between 10/15/25 and 10/17/25. On 09/13/25, Resident 1 was prescribed triamcinolone 0.1% cream to be applied topically two times daily for 14 days to rash on bilateral feet and ankles (for skin inflammation). On 10/16/25 at 10:42 am, documentation of Resident 1’s skin monitoring was requested. On 10/16/25 at 3:05 pm, Staff 1 (Administrator/Owner) acknowledged there was no documentation of monitoring the resident’s skin rash through resolution or monitoring the resident for adverse effects due to the triamcinolone cream. On 10/16/25 at 1:11 pm, Staff 3 (CG/MT) and this surveyor observed the resident’s feet and ankles. The resident appeared to have red scab-like areas on both feet. When the resident was asked about his/her rash, Resident 1 stated it has gotten better. The facility failed to document, at least weekly progress, of the resident’s skin rash until the condition resolved, and failed to monitor the resident’s use of the triamcinolone cream for adverse side effects through resolution. The survey team was unable to share the findings regarding the need to ensure the facility monitored short-term changes of condition at least weekly through resolution. 2. Resident 2 moved into the community in 04/2024 with diagnoses including dementia. The resident’s clinical record was reviewed and revealed the following short-term change of condition: a. Resident 2 had an order dated 06/20/25 to increase hydrochlorothiazide from 25mg daily to 50mg daily for high blood pressure. On 10/16/25 10:42 am survey requested documentation of monitoring related to hydrochlorothiazide increase from Staff 1 (Administrator/Owner). On 10/16/25 at 2:30 pm Staff 1 confirmed the facility did not have documentation of monitoring. The facility failed to document monitoring of adverse effects and/or progress related to increase in hydrochlorothiazide dose at least weekly progress through resolution. b. On 10/16/25 at 10:42 am, Staff 1 was asked to provide a copy of the facility’s written policy to ensure a resident monitoring and reporting system was implemented 24-hours a day. Staff 1 reported the facility did not have written policies for monitoring and reporting. The survey team was unable to share the findings regarding the need to ensure the facility monitored the resident for progress at least weekly through resolution and lack of written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day.

C0270- Change of Condition and monitoring: 1- The resident (Resident #1 & resident #2) in the survey have been reassessed and their new baseline has been determined. The community has implemented written policies to ensure that there is resident monitoring and reporting system is in place 24-hours/day. 2- The community has implemented a new electronic EMAR and documentation system, to ensure that all resident orders have been reviewed and that there is proper monitring in place. 3- The clinical dashboard will be ran daily, to ensure that orders are properly implemented and that proper monitoring is in place. 4-The Wellness Director will be responsible for initiation and oversight. The Administrator will be responsible for overall compliance. JP 11/21/2025 9:45 am- # 2 spoke with Amber Marchese (RN consultant) confirmed utilizing an electronic platform(careright solutions) for documentation, which has alerts, ISPs and monitoring for short term changes of condition.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have systems in place to respond to the 24-hour care needs of residents including an Oregon licensed nurse who was regularly scheduled for onsite duties at the facility and written policies and procedures on medical emergency response for all shifts. Findings include, but are not limited to: a. In an interview with Staff 1 (Administrator/Owner) on 10/16/25 at 2:30 pm, he stated the RN was a consultant who only came to the facility upon request and billed the facility hourly. Survey requested records of the last time Witness 1 (RN/Certified Registered Nurse Practitioner) was in the facility. Review of the invoice received revealed Witness 1 was last in the facility on 02/03/25. In a phone interview on 10/16/25 at 3:51 pm, Witness 1 stated her services were on demand; therefore, she did not have regularly scheduled hours in the building. She confirmed the invoice indicated the last time she was in the building. She billed the facility a total of 11 hours; five hours for the fourth quarter of 2024, two hours for 12/27/24, and four hours for 02/03/25. b. Staff 1 was asked to provide written policies and procedures on medical emergency response for all shifts. On 10/16/25 at 2:30pm, Staff 1 reported the facility did not have any written policies. The survey team was unable to share the findings to ensure a system was in place that included an Oregon licensed nurse who was regularly scheduled for onsite duties at the facility and written policies and procedures on medical emergency response for all shifts.

C0280- Resident Health Services: 1- The community has secured an RN who will be making routine visits to the community to ensure that the residents are monitored and assessed timely, and that there are now policies and procedures to reflect this oversight. 2- The Administrator will ensure that there is ongoing RN oversight for the residents living in the community, and that there is 24-hour availability to the staff for emergency direction and consultations. 3- This will be reviewed on a weekly basis for compliance. 4- The Administrator will be responsible for overall compliance.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to ensure they had established and maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment including protocols to prevent the development and transmission of communicable diseases; and failed to establish and maintain effective infection prevention and control protocols for unsampled residents during meal service. Findings include, but are not limited to: a. On 10/15/25 the survey team requested a copy of the facility's infection prevention and control protocols. In an interview with Staff 1 (Administrator/Owner) on 10/15/25 at 12:55 pm, it was confirmed the facility did not have any written policies around infection control protocols to prevent the development and transmission of communicable diseases including Norovirus and other gastrointestinal outbreaks. b. Lunch service was observed on 10/16/25 at 11:14 am. Staff 2 (CG/MT) was observed to transport uncovered plates of food to the dining room. She delivered all trays of food to the residents within the dining room. She then left two uncovered plates on unoccupied tables. One resident arrived shortly after his/her plate was placed. No one arrived for the second plate. Staff 2 returned to the kitchen, doffed her gloves and donned new gloves without performing hand hygiene. She then transported seven uncovered beverages from the kitchen to the dining room via a tiered cart. On 10/16/25 at 11:27 am, an unsampled resident reported, “[CGs] don’t tell us it’s lunch time, they leave the food on the table.” The second plate of food that was left remained uncovered on the table until 11:58 am. The survey team was unable to share the findings regarding the need to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment including protocols to prevent the development and transmission of communicable diseases including gastrointestinal outbreaks and maintain effective infection prevention and control protocols during meal service.

C0295- Infection Prevention and Control 1- The community has adopted and implemented policies for Infection Control protocols for the prevention of the development and transmission of communicable diseases. Staff #2 has been reeducated on the need to transport ony covered food & beverage items from the kitchen area, and the need to properly don and doff gloves. 2- Staff have been retrained on the proper meal delivery process, to include gloving and manners in which to invite residents to their meals. 3- This area will be evaluated weekly by the RN & dailyby the Wellness Director. 4- The Administrator will be responsible for overall compliance.

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

OAR 411-054-0055 (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 interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: During the relicensure survey, conducted 10/15/25 through 10/17/25, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas: * C 303: Systems: Medication and Treatment Orders; * C 310: Systems: Medication Administration; * C 320: Systems: Medication and treatment-General; and * C 372: Training within 30 days, direct care staff. The survey team was unable to share the findings regarding the failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration.

C0300- Medication and Treatment Administration Systems ***Refer to c 303, C 310, C 320, C 372, for compliance details***

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)(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 and treatment orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 11/2006 with diagnoses including hypertension (high blood pressure) and heart failure. The resident’s MAR, dated 09/01/25 through 10/14/25, and signed prescriber orders were reviewed. The following was identified: a. Resident 1 had a signed order dated 08/08/25 for Glucerna Shake – one carton by mouth three times daily. May give one additional carton as need if [Resident 1] refused a meal. The MAR indicated Resident 1 received the nutritional supplement two times a day between 09/01/25 and 10/14/25. Therefore, treatment orders were not followed as written on 44 occasions. On 10/15/25 at 1:48 pm, Staff 2 (CG/MT) and this surveyor reviewed the resident’s MAR. She confirmed the resident received the nutritional supplement scheduled twice a day and not three times a day per the prescriber order. b. Resident 1 had a signed order dated 09/13/25 for triamcinolone 0.1% cream – apply topically two times daily for 14 days to rash on bilateral feet and ankles (for skin inflammation). The MAR indicated the resident's treatment was initiated on 09/13/25 with the 14-day treatment to end on 09/27/25. * The resident’s MAR was blank on five occasions during the prescribed treatment course. On 10/16/25 at 2:03 pm, Staff 2 and this surveyor reviewed the MAR and medication supply. Staff 2 confirmed she was unable to determine if the cream was administered per prescriber orders on those five occasions. * The resident’s MAR indicated the resident received the cream on 09/30/25, or outside the prescribed 14-day treatment course. On 10/16/25 at 2:03 pm, Staff 2 confirmed she administered the dose on 09/30/25, and she continued to administer the cream during the morning medication pass with the resident having received the cream on 10/16/25. However, she was not documenting the continued administrations. The order to continue the resident’s triamcinolone cream was requested on 10/16/25 at 1:20 pm. No additional order was received. c. The MAR was blank for the following medications or treatments: * Boost (for nutritional supplement) on one occasion; * Melatonin (for sleep aid) on three occasions; * Metoprolol (for high blood pressure) on one occasion; and * Tamsulosin (for enlarged prostate) on one occasion. On 10/16/25 at 2:03 pm, Staff 2 and this surveyor reviewed the resident’s MAR and the medication supply. Staff 2 was unable to determine if these medications were administered as ordered. The survey team was unable to share the findings regarding the need to ensure all medication orders were carried out as prescribed. 2. Resident 2 moved into the facility in 04/2024 with diagnoses including paranoid schizophrenia. The resident’s facility records, including MARs dated 08/01/25 through 10/15/25, and signed physician’s orders revealed the following: Resident 2 physician’s orders dated 08/07/25 indicated to discontinue Ensure clear one carton as needed for meal refusals and start Ensure clear one carton once daily for nutritional supplement. The order was not transcribed to the MAR; therefore, the resident did not receive the ensure clear daily as ordered on 50 occasions. The survey team was unable to share the findings regarding the need to ensure the facility followed the physician’s orders.

C0303- Systems: Treatment Orders 1- The residents (Resident # 1 & Resident #2) identified in the survey have been reviewed and their orders have been clarified, and their MARS have been updated to reflect current PCP orders. 2- The community has implemented a new electronic EMAR system, that will allow for all orders to be reviewed, clarified if needed and activated in the EMAR to ensure that all orders are reflective of the the PCP orders. All residents been have had their orders reviewed, clarified and their MARS updated to reflect current PCP orders. The clinical dashboard will be reviewed daily to ensure that all orders are carried out per the PCP orders. 3- The Medication Administration Records will be audited 3 times per week to ensure that the orders are being followed. Staff will receive immediate re-training for any findings. 4- The Administrator and Wellness Director will be responsible for overall compliance.

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 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific instructions and parameters for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 11/2006 with diagnoses including heart failure. The resident’s 09/01/25 through 10/14/25 MAR and prescriber orders were reviewed. The following were identified: a. Resident 1’s paper MAR presented with staff initials circled without corresponding exception notes on the following occasions: * Atorvastatin (for heart attack) on one occasion; * Boost (for nutritional supplement) on 15 occasions; * Docusate sodium (for constipation) on one occasion; and * Melatonin (for sleep aid) on two occasions. On 10/16/25 at 2:03 pm, Staff 2 (CG/MT) and this surveyor reviewed the circled initials on the resident’s MAR. She stated the circled initials indicated the resident refused the medication or the medication was not available. She then acknowledged there was no writing on the resident’s MAR to identify the reason for the exception. b. The following medications lacked reason for use or route of administration: * Boost; * Docusate sodium; * Metformin; * Risperidone; and * Triamcinolone. The survey team was unable to share the findings regarding the need to ensure MARs were accurate. 2. Resident 2 was admitted to the community in 04/2024 with diagnoses including paranoid schizophrenia. Resident 2’s MARs dated 08/01/25 through 10/15/25 were reviewed. a. Resident 2 had two PRN medications for pain, acetaminophen 325 mg, take 2 tablets every six hours as needed for pain and oxycodone 5 mg, take 1 tablet every six hours as needed for pain. The MAR lacked staff instruction on the sequential order in which to administer the medications. The oxycodone was administered on 08/08/25 and 09/13/25. b. The following medications lacked reasons for use on the MAR: * Finasteride 5mg; * Multivitamin; * Vitamin D 2000IU; and * Ensure as needed. c. Resident 2’s MAR had two days on 09/11/25 and 9/12/25 with initials circled for multivitamin adult tab, take one tablet daily. The facility utilized paper MARs, and there was no documentation indicating reason for the circle on MAR. Interviewed Staff 2 (CG/MT) on 10/16/25 at 2:00 pm, she stated the circled MAR indicated the resident was either out of medication and was pending refill or resident refused. Staff 2 acknowledged on these instances the exception was not documented. The survey team was unable to share the findings regarding the need to ensure medications on the MARs included reason for use, resident-specific parameters for PRN medications and documentation of exceptions when medications were not administered.

C0310- Systems: Medication Administration 1- The residents (Resident #1 & Resident #2) identified in the survey have been reassessed and their MARS reviewed for accuracy. 2- The community has implemented an Electronic EMAR system, Care Right Solutions, that has the ability to prompt, guide and direct Med Techs to properly and clearly document the medication and treatment orders correctly, and to account for the exceptions as indicated. The choices of exceptions are built inot the EMAR system for clarificiation of the choices for exceptions. 3- The clinical dashboard will be ran daily to ensure timely compliance. The Medication Administration Records will be audited 3 times per week to ensure that the orders are being followed. Staff will receive immediate re-training for any findings. 4- The Administrator and Wellness Director will be responsible for overall compliance.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0055 (4) Systems: Medication & Treatment-General (4) MEDICATION AND TREATMENT - GENERAL. The facility must maintain legible signatures of staff that administer medications and treatments, either on the MAR or on a separate signature page, filed with the MAR.(a) If the facility administers or assists a resident with medication, all medication obtained through a pharmacy must be clearly labeled with the pharmacist's label, in the original container, in accordance with the facility's established medication delivery system.(b) The facility shall ensure that prescription drugs dispensed to residents are packaged in a manner that reduces errors in the tracking and administration of the drugs, including, but not limited to, the use of unit dose systems or blister packs.(A) The facility shall have as its primary goal dispensing prescription drugs in unit dose systems, blister packs or similar packaging.(B) When unit dose packaging cannot be reasonably achieved, the facility shall have a written policy describing how prescription drugs that are not prepared as unit dose or blister packs shall be dispensed. Written policies shall be in effect not later than October 1, 2018.(C) Subsection (b) of this rule does not apply to residents receiving pharmacy benefits through the United States Department of Veterans Affairs, if the pharmacy benefits do not reimburse cost of such packaging.(c) Over-the-counter medication or samples of medications must have the original manufacturer's labels if the facility administers or assists a resident with medication.(d) All medications administered by the facility must be stored in locked containers in a secured environment such as a medication room or medication cart.(e) Medications that have to be refrigerated must be stored at the appropriate temperature in a locked, secure location.(f) Order changes obtained by telephone must be documented in the resident's record and the MAR must be updated prior to administering the new medication stated on the order. Telephone orders must be followed-up with written, signed orders.(g) The facility must not require residents to purchase prescriptions from a pharmacy that contracts with 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 written policy that described how prescription drugs, not prepared as unit dose or blister packs, shall be dispensed to reduce errors in the tracking and administration of the drugs. Findings include, but are not limited to: A copy of the facility's medication administration policy that addressed how prescription medications that were not packaged as unit dose or blister packs (such as tablets, ointment, cream, liquids, etc.) were dispensed was requested on 10/15/25. In an interview on 10/15/25 at 12:55 pm, Staff 1 (Administrator/Owner) stated he was not aware of the policy, and he asked the surveyor to explain what the policy meant. After the surveyor reviewed the regulation with Staff 1, he confirmed there was no facility policy which described the process of dispensing prescription drugs that were not in unit dose packaging. He stated, “I will create one”. No further documentation was provided. The survey team was unable to share the findings regarding the need to develop a facility policy to ensure accurate administration of prescription drugs that were not prepared as unit dose or blister packs.

C0320- Systems: Medication & Treatment – General 1- Policies and Procedures have been developed to reflect the regulations regarding how prescription drugs, not prepared as unit dose or blister packs, shall be dispensed to reduce errors in the tracking and administration of the drugs. 2- These policies and procedures have been implemented. 3- Policies and Procedures will be reviewed minimally by Administration to ensure that the polices are current with regulations. 4- The Administrator will ensure overall compliance.

OAR 411-054-0055 (4) Systems: Medication & Treatment-General (4) MEDICATION AND TREATMENT - GENERAL. The facility must maintain legible signatures of staff that administer medications and treatments, either on the MAR or on a separate signature page, filed with the MAR.(a) If the facility administers or assists a resident with medication, all medication obtained through a pharmacy must be clearly labeled with the pharmacist's label, in the original container, in accordance with the facility's established medication delivery system.(b) The facility shall ensure that prescription drugs dispensed to residents are packaged in a manner that reduces errors in the tracking and administration of the drugs, including, but not limited to, the use of unit dose systems or blister packs.(A) The facility shall have as its primary goal dispensing prescription drugs in unit dose systems, blister packs or similar packaging.(B) When unit dose packaging cannot be reasonably achieved, the facility shall have a written policy describing how prescription drugs that are not prepared as unit dose or blister packs shall be dispensed. Written policies shall be in effect not later than October 1, 2018.(C) Subsection (b) of this rule does not apply to residents receiving pharmacy benefits through the United States Department of Veterans Affairs, if the pharmacy benefits do not reimburse cost of such packaging.(c) Over-the-counter medication or samples of medications must have the original manufacturer's labels if the facility administers or assists a resident with medication.(d) All medications administered by the facility must be stored in locked containers in a secured environment such as a medication room or medication cart.(e) Medications that have to be refrigerated must be stored at the appropriate temperature in a locked, secure location.(f) Order changes obtained by telephone must be documented in the resident's record and the MAR must be updated prior to administering the new medication stated on the order. Telephone orders must be followed-up with written, signed orders.(g) The facility must not require residents to purchase prescriptions from a pharmacy that contracts with the facility. This Rule is not met as evidenced by:

OAR 411-054-0065 (1-3) Administrator Qualification and Requirements (1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below: Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the licensed residential care facility employed a full-time administrator that was scheduled to be on-site in the facility at least 40 hours per week, and ensure the individual serving as an administrator of the residential care facility obtained an administrator’s license from the Health Licensing Office, Oregon Health Authority, as required. The findings include, but are not limited to: A survey team entered the RCF on 10/15/25 for the facility’s relicensure survey. Verification of the facility’s licensed administrator was requested from Staff 1 (Administrator/Owner) on 10/15/25 at 9:50 am. On 10/16/25 at 10:17 am, Staff 1 acknowledged his administrator’s license had expired in 2023, and he had “overnighted” the required documentation to reinstate his administrator’s license. There was no documented evidence the facility provided the requested information to the Department or employed a licensed full-time administrator. The survey team was unable to share the findings regarding the need to ensure the facility employed a full-time administrator that was scheduled to be on-site in the facility at least 40 hours per week and ensure the individual serving as an administrator of the residential care facility obtained an administrator’s license from the Health Licensing Office.

C0350- Administrator Qualifications and Requirements 1- The required posting for the Administrator license has been posted in the main entrance to the community lobby. 2- The Owner will ensure that the license will be maintained and in good standing and that the required CEU's are completed timely and accurately per requirements. 3- The Administrator License will be monitored annually for compliance. 4- The Owner of the community will be responsible for ongoing compliance.

OAR 411-054-0065 (1-3) Administrator Qualification and Requirements (1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below: Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0065 (2-6) Administrator: Administrator Requirements (2) FULL ADMINISTRATOR LICENSE. (a) Individuals who applied to the Health Licensing Office by July 1, 2019 and met all requirements of OAR chapter 853, were issued a full residential care administrator license. (b) At any time, individuals who apply to the Health Licensing Office and complete all requirements in OAR chapter 853, including passing the Oregon laws and rules examination, will be issued a full administrator license. (c) By January 1, 2022, all individuals working as an administrator of a residential care or assisted living facility must have obtained this full license. (d) All individuals holding a full administrator license must comply with the annual training requirements and the standards of practice and professional conduct established by the Long Term Care Administrators Board, as outlined in OAR chapter 853, in order to maintain this license, (3) PROVISIONAL ADMINISTRATOR LICENSE. (a) Individuals who applied to the Health Licensing Office by July 1, 2019 but did not meet all requirements in OAR chapter 853, were issued a provisional administrator license. This provisional license expires on December 31st, 2020. Individuals holding a provisional license are required to pass the Oregon laws and rules examination before January 1, 2022 as outlined in OAR chapter 853, in order to continue to work as an administrator. (b) All individuals holding a provisional administrator license must comply with the annual training requirements and the standards of practice and professional conduct established by the Long Term Care Administrators Board, as outlined in OAR chapter 853est. (4) DHS-APPROVED ADMINISTRATOR REQUIREMENTS. (a) Individuals may continue to serve as administrators under the original Department-approved program until January 1, 2022. This Department-approved program requires potential administrators meet the following: (A) Be at least 21 years of age: (B) Possess a high school diploma or equivalent; and (i) Have at least two years professional or management experience that has occurred within the last five years, in a health or social service related field or program, or have a combination of experience and education; or (ii) Possess an accredited Bachelor's Degree in a health or social service related field (b) Facility administrators must meet the following training requirements before employment: (A) Complete a Department approved classroom administrator training program of at least 40 hours; (B) Complete a Department approved administrator training program that includes both a classroom training of less than 40 hours and a Department approved 40-hour internship program with a Department approved administrator; or (C) Complete another Department approved administrator training program. (c) Administrators must have 20 hours of documented Department-approved continuing education credits each year. The approved administrator training program fulfills the 20-hour continuing education requirement for the first year. (d) Persons who have met Department approved training program requirements, but have been absent from an administrator position for five years or less, do not have to re-take the administrator training, but must provide evidence of 20 hours of annual continuing education until January 1, 2022, by which date all administrators must have obtained a residential care administrator license. (e) Before employment as a facility administrator, persons must complete the criminal records check requirements in OAR 407-007-0200 to 407-007-0370 and comply with the tuberculosis screening recommendations in OAR 333-019-0041. An administrator of a facility may not have convictions of any of the crimes described in OAR 407-007-0275. (f) Newly hired administrators are responsible for the completion of form SDS 0566, Administrator Reference Summary, and are required to email or fax the completed form to the Department upon hire. The Department may reject a form that has been falsified or is incomplete. (5) DESIGNEE WHEN ADMINISTRATOR TEMPORARILY ABSENT. The administrator must appoint a staff member as designee to oversee the operation of the facility in the temporary absence of the administrator. Whomever is in charge, whether the administrator or the temporary designee, must at all times: (a) Be in charge on-site. (b) Ensure there are sufficient, qualified staff. (c) Ensure the care, health, and safety needs of the residents are met. (d) If the absence of the administrator is to exceed 30 days, the facility must notify the Department and obtain approval for arrangements prior to the absence. (6) INTERIM ADMINISTRATOR. During times of transition, when the facility does not have a licensed or approved administrator, the facility is responsible for providing administrator functions. In such a situation, the facility must contact the Department immediately and provide the following: (a) Documentation of the background and qualifications of the proposed interim administrator. (b) A completed background check request. Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the administrator had 20 hours of department approved continuing education credits each year. Findings include, but are not limited to: Records of the administrator’s continuing education credits were requested from Staff 1 (Administrator/Owner) on 10/16/25 at 10:42 am. Review of records revealed the following: * Administrator’s license expired 10/31/23; * Continued education reviewed from 11/01/23 through 10/31/24 total was 15.50 hours; and * Continued education reviewed from 11/01/24 through 10/17/25 total was 17.50 hours. The survey team was unable to share findings regarding the need to ensure the administrator had 20 hours of department approved continuing education credits each year.

C0355- Administrator: Administrator Requirements 1- The Administrator of record has completed the required 20 hours of training as required by this regulation. 2- The hours that are required for continuing education will be tracked annually for compliance. 3- The training records will be audited annually for compliance. 4- The Owner will be responsible for overall compliance.

OAR 411-054-0065 (2-6) Administrator: Administrator Requirements (2) FULL ADMINISTRATOR LICENSE. (a) Individuals who applied to the Health Licensing Office by July 1, 2019 and met all requirements of OAR chapter 853, were issued a full residential care administrator license. (b) At any time, individuals who apply to the Health Licensing Office and complete all requirements in OAR chapter 853, including passing the Oregon laws and rules examination, will be issued a full administrator license. (c) By January 1, 2022, all individuals working as an administrator of a residential care or assisted living facility must have obtained this full license. (d) All individuals holding a full administrator license must comply with the annual training requirements and the standards of practice and professional conduct established by the Long Term Care Administrators Board, as outlined in OAR chapter 853, in order to maintain this license, (3) PROVISIONAL ADMINISTRATOR LICENSE. (a) Individuals who applied to the Health Licensing Office by July 1, 2019 but did not meet all requirements in OAR chapter 853, were issued a provisional administrator license. This provisional license expires on December 31st, 2020. Individuals holding a provisional license are required to pass the Oregon laws and rules examination before January 1, 2022 as outlined in OAR chapter 853, in order to continue to work as an administrator. (b) All individuals holding a provisional administrator license must comply with the annual training requirements and the standards of practice and professional conduct established by the Long Term Care Administrators Board, as outlined in OAR chapter 853est. (4) DHS-APPROVED ADMINISTRATOR REQUIREMENTS. (a) Individuals may continue to serve as administrators under the original Department-approved program until January 1, 2022. This Department-approved program requires potential administrators meet the following: (A) Be at least 21 years of age: (B) Possess a high school diploma or equivalent; and (i) Have at least two years professional or management experience that has occurred within the last five years, in a health or social service related field or program, or have a combination of experience and education; or (ii) Possess an accredited Bachelor's Degree in a health or social service related field (b) Facility administrators must meet the following training requirements before employment: (A) Complete a Department approved classroom administrator training program of at least 40 hours; (B) Complete a Department approved administrator training program that includes both a classroom training of less than 40 hours and a Department approved 40-hour internship program with a Department approved administrator; or (C) Complete another Department approved administrator training program. (c) Administrators must have 20 hours of documented Department-approved continuing education credits each year. The approved administrator training program fulfills the 20-hour continuing education requirement for the first year. (d) Persons who have met Department approved training program requirements, but have been absent from an administrator position for five years or less, do not have to re-take the administrator training, but must provide evidence of 20 hours of annual continuing education until January 1, 2022, by which date all administrators must have obtained a residential care administrator license. (e) Before employment as a facility administrator, persons must complete the criminal records check requirements in OAR 407-007-0200 to 407-007-0370 and comply with the tuberculosis screening recommendations in OAR 333-019-0041. An administrator of a facility may not have convictions of any of the crimes described in OAR 407-007-0275. (f) Newly hired administrators are responsible for the completion of form SDS 0566, Administrator Reference Summary, and are required to email or fax the completed form to the Department upon hire. The Department may reject a form that has been falsified or is incomplete. (5) DESIGNEE WHEN ADMINISTRATOR TEMPORARILY ABSENT. The administrator must appoint a staff member as designee to oversee the operation of the facility in the temporary absence of the administrator. Whomever is in charge, whether the administrator or the temporary designee, must at all times: (a) Be in charge on-site. (b) Ensure there are sufficient, qualified staff. (c) Ensure the care, health, and safety needs of the residents are met. (d) If the absence of the administrator is to exceed 30 days, the facility must notify the Department and obtain approval for arrangements prior to the absence. (6) INTERIM ADMINISTRATOR. During times of transition, when the facility does not have a licensed or approved administrator, the facility is responsible for providing administrator functions. In such a situation, the facility must contact the Department immediately and provide the following: (a) Documentation of the background and qualifications of the proposed interim administrator. (b) A completed background check request. Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0037 (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 complete or update and review the ABST evaluation for before resident moved in and/or no less than quarterly at the same time the resident's service plan was updated for 2 of 2 sampled residents (#s 1 and 2) and 6 unsampled residents whose ABST evaluations was reviewed. Findings include, but are not limited to: A review of the facility’s ABST on 10/15/25 indicated Resident 1 and 2 and 6 of 6 unsampled residents were not updated prior to move in and/or quarterly as required. The survey team was unable to share the findings regarding 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.

C0363- Acuity Based Staffing Tool- Updates & Staffing Plan 1- Resident's # 1 & #2 have been reviewed and their care needs are currently updated in the ABST system. The ABST has been updated to reflect the current residents’ needs and staffing patterns. 2- The ABST has been updated to reflect all of the current residents care needs and the ABST is currently reflective of the staffing plan that is posted. 3- The ABST will be reviewed and updated on a weekly basis and with any changes to the residents’ care needs, and as per the regulation. 4- The Administrator of record will ensure ongoing compliance

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 (2) Staffing Rqmt and Training: Training Rqmts (2) REQUIREMENTS APPLICABLE TO ALL TRAINING. The facility shall:(a) Have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. Facility shall also maintain documentation regarding each direct care staff ' s demonstrated competency.(b) Maintain written documentation of all trainings completed by each employees. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing and maintain documentation regarding each direct care staff’s demonstrated competency. Findings include, but are not limited to: Staff training records were reviewed on 10/16/25 and 10/17/25. The following was revealed: Staff 3 (CG/MT) and Staff 5 (CG/MT), hired 07/04/25 and 07/18/25, respectively, lacked documented evidence of demonstrating competency in all duties they were assigned within 30-days of hire. On 10/17/25 at 10:35 am, Staff 1 (Administrator/Owner) was asked to explain the facility’s process for training direct care staff and ensuring staff were competent in all duties they were assigned. Staff 1 stated the facility did not document competency reviews for direct care staff in the facility because “everything was verbal.” The survey team was unable to share the findings regarding the need to ensure the facility had a training program that included methods to determine competency of direct care staff and that each direct care staff’s demonstrated competency was documented.

C0365- Staffing Rqmt and Training 1- Staff # 3 & # 5- had been reviewed to ensure that their competencies in all duties has been completed. Other Employee files have been reviewed, and employees have been reevaluated for the competencies for their positions. 2- New employees will be evaluated for their competencies on hire to ensure that their required assignments are completed within the 30 day requirements. Current employees will be evaluated annually and as needed for compliance. Other Employee files have been reviewed, and employees have been reevaluated for the competencies for their position. All staff competnecies will be documented in writing and NOT verbal instructions. 3- Staff competencies will be audited, on hire, 30 days and annually for compliance. 4- The Administrator of record will ensure ongoing compliance.

OAR 411-054-0070 (2) Staffing Rqmt and Training: Training Rqmts (2) REQUIREMENTS APPLICABLE TO ALL TRAINING. The facility shall:(a) Have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. Facility shall also maintain documentation regarding each direct care staff ' s demonstrated competency.(b) Maintain written documentation of all trainings completed by each employees. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics was completed prior to beginning job duties for 2 of 2 newly hired staff (#s 3 and 5) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 10/16/25 and 10/17/25; the following was identified: a. There was no documented evidence Staff 3 (CG/MT), hired on 07/04/25, and Staff 5 (CG/MT), hired on 07/18/25, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Written job description; and * An approved LGBTQIA2S+ course. On 10/17/25 at 10:35 am, Staff 1 (Administrator/Owner) was asked to explain the facility’s system for training. He stated, “everything is verbal.” b. Staff 5, hired 07/18/25, completed pre-service dementia training on 08/19/25. There was no documented evidence Staff 5 had completed pre-service dementia training prior to providing care to residents. The survey team was unable to share the findings regarding the need to ensure staff completed all required pre-service orientation trainings prior to beginning their job responsibilities and for direct care staff to complete required pre-service dementia training prior to providing care to residents.

C0370- Staffing Requirements and training- Pre-Service 1- Staff # 3 & # 5- have completed the training requirements, this is to include; * Resident rights & values of CBC care * Abuse reporting requirements * Written Job Descriptions * Completion of an approved LGBTQIA2S+ course All employee files have been audited to ensure that the required training has been completed. 2- The employee education requirements will be audited on hire and prior to their starting their work with the residents, and the required ongoing training will be assigned and monitored for completion prior to be assigned to resident care for compliance. 3- Employee files will be audited via a spreadsheet to ensure timely and ongoing compliance. 4- The Wellness Director will be responsible for compliance. The Administrator of record will ensure ongoing compliance.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable 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 2 of 2 newly hired direct care staff (#s 3 and 5) had documented evidence of demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 10/16/25 and 10/17/25. The following was revealed: There was no documented evidence Staff 3 (CG/MT), hired on 07/04/25, and Staff 5 (CG/MT), hired on 07/18/25, demonstrated competency within 30 days of hire in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * Other duties as applicable (Med pass, treatments). In an interview on 10/17/25 at 10:35 am, Staff 1 (Administrator/Owner) indicated Staff 3 and Staff 5 did not have documented evidence they were observed and evaluated to perform safe medication and treatment administration unsupervised. On 10/17/25 at 12:45 pm, Staff 1 documented a plan to ensure Staff 3 and Staff 5 were supervised and trained by Staff 4 (CG/MT) during their upcoming shifts. Additionally, Witness 1 (RN/Certified Nurse Practitioner) would provide further training and determine full competency during the week of 10/20/25. The survey team was unable to share the findings regarding the need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire.

C0372- Training Within 30 Days of Hire- Direct Care Staff 1- Staff # 3 & # 5- have had their files reviewed to ensure the following is in place; * Role of the service plans in providing indiviualized care; * Providing assistance with ADL's Changes associated withnormal aging * Idnetification, documentation and reporting changes of condition * Conditions that require assessment, treatment, observation and reporting; and * Other duties as applicable (med pass, treatments) All employee files have been audited to ensure that the required training has been completed. 2- The employee education requirements will be audited within the required 30 day window, and the required ongoing training will be assigned and monitored for completion via the spreadsheet for compliance. 3- Employee files will be audited within the the 30 day window, and monthly for ongoing compliance. 4- The Wellness Director will be responsible for compliance. The Administrator of record will ensure ongoing compliance. JP 11/21/2025 9:45 am- #2 spoke with Amber Marchese (RN consultant) confirmed facility has a competency checklist with elements for training.

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 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were 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. Findings include, but are not limited to: Fire and life safety records dated 05/2025 through 10/2025 were reviewed on 10/15/25. The following deficiencies were identified: There was no documentation that fire and life safety training was provided to residents within 24 hours of move in and/or that residents were re-instructed at least annually. In an interview with Staff 1 (Administrator/Owner) on 10/16/25, he acknowledged the facility did not have documentation of resident instruction within 24 hours of admission and/or re-instruction at least annually. The survey team was unable to share findings regarding the need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually.

C0422- Fire and Life Safety; training for the Residents? 1- Current residents have been re-educated on the general safety procedures, evacuation methods, responsibilities during a fire drill, and the designated meeting place outside of the community, this has been documented in their records. 2- Fire safety training will be reviewed for new residents on admission (within 24 hours) and then annually for compliance, and documented in their medical records. 3- Fire safety training will be reviewed on admission for new residents and then annually for compliance. 4- The Administrator of record will ensure ongoing compliance.

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

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair; locked storage for all chemicals and other toxic materials; and storage for all maintenance equipment. Findings include, but are not limited to: Between 10/15/25 and 10/17/25 the facility grounds were toured, and the following was identified: * Drop-offs measuring between 1.25 inches and five inches were noted along pathway edges of the stairs and the ramp leading to the facility’s entrance. Those drop-offs created tripping hazards; * The top step of the concrete stairs leading to the facility’s entrance had two large gouges on either side of the railing with both measuring over 30 inches long and approximately 1.5 inches deep. Additionally, one concrete step had a large, dislodged portion of concrete surrounding the railing. The gouges and cracks of concrete created tripping hazards; * The top of the facility’s entrance ramp had missing stone approximately 11 inches long and 1.25 inches deep which created a tripping hazard; * The facility’s second floor janitorial closet, which stored toxic chemicals, was observed to be unlocked and toxic chemicals were noted to be left near resident rooms on multiple occassions; and * Power tools from the facility’s flooring project were left unsecured in the facility’s backyard. At 1:03 pm on 10/15/25, Staff 1 (Administrator/Owner) and this surveyor reviewed the power tools left in the backyard. It was determined the tools were unable to receive power based on their location, and the tools were not sharp. The surveyor requested Staff 1 properly store the power tools, because they were not being used or supervised. The tools were not observed for the remainder of the survey. On 10/17/25 at 12:53 pm, the interior and exterior of the building were toured with Staff 1. He acknowledged the need to ensure pathways were maintained in good repair, locked storage for chemicals, and storage for all maintenance equipment.

C0510- General Building Exterior 1- The areas that were identified in the survey have been corrected, to include but not limited to the following; * Exterior apthways have been repaired * Chemilcas and other toxic materials have been secured * Storage for all maintainance equiptment has been secured * Drop-offs causing trip hazards on the pathwat stairs has been repaired * Contrete steps leading into the facility have been repaired * The entrance ramp stones, have been replaced * Second floor janitorial closet, has been secured * Power tools from the flooring project have been secured 2- Daily walk throughs of the property will be completed by maintenance director to ensure compliance with the rules and ensure resident safety. 3- The walk through’s will be completed daily and reports to the Administrator for repairs will be made by the Maintainance Director. 4- The Administrator of record will ensure ongoing compliance. JP 11/21/2025 9:45 am- spoke with Amber Marchese (RN consultant) confirmed walkthroughs will be completed by maintainance director. # 2 updated.

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was clean and in good repair. Findings include, but are not limited to: The interior of the building was observed between 10/15/25 and 10/17/25. The following areas needed cleaning and/or repair: * Resident rooms 1, 2, and 8 had cracks and/or holes in the walls and in the ceilings; * Room 1 had brown staining on the ceiling; * Room 2 lacked a threshold which created uneven flooring and was a tripping hazard; * Room 8 had broken window blinds; * The wall of the stairway had a hole in the plaster; and * Walls throughout the facility’s corridors had large, mismatched paint splotches. The areas needing repair were shown to and discussed with Staff 1 (Administrator/Owner) on 10/17/25 at 12:53 pm. He acknowledged the findings.

C0513- Doors, Walls, Elevators, Odors 1- The areas that were identified in the survey have been corrected, to include but not limited to ; * Resident rooms 1, 2, and 8 have had the cracks and/or holes repaired in the cileings and walls * Stains on the ceiling of room # 1 has been corrected * The threshold to room # 2 that was causing a trip hazard has been repaired * The broken blinds in room 3 8 has been replaced * The wall in the stairway with holes in the plaster, has been repaired * Walls throughout the facilities corridors have been repainted, correcting the paint splotches 2- Daily walk throughs of the property will be completed to ensure compliance with the rules, these will be completed by the maintianance director. 3- The daily walk through’s will be completed by the Maintainance Director and reported to the Administrator for timely repairs. 4- The Administrator of record will ensure ongoing compliance.

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

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure resident areas maintained a minimum temperature of no less than 70 degrees Fahrenheit (F) during the day. Findings include, but are not limited to: a. Observations of the interior of the facility on 10/16/25 revealed temperatures below 70 degrees F during daytime hours in resident rooms and in common spaces. Temperatures obtained on 10/16/25 included the following: * 11:27 pm – Unsampled resident’s personal temperature sensor read 67 degrees F; * 11:50 pm – Second floor bathroom thermostat was locked and turned below 40 degrees F; * 12:05 pm – Two electronic temperature sensors near the dining room read 64 degrees F; * 12:07 pm – Using a probe thermometer the ambient temperature near the medication room was approximately 65 degrees F; and * 12:35 pm – First floor bathroom thermostat was locked and turned below 40 degrees F. b. Unsampled residents were interviewed on 10/16/25 between 11:27 am and 11:59 am. They reported the following: * “There is no heat in here” and “last night I had my coat on”; * “Always cold in here” and “I usually use the blanket”; and * “I think it’s cold” and “[it’s] cold all day.” On 10/16/25 at 12:39 pm, the need to ensure resident areas were maintained at a minimum of no less than 70 degrees during the day was discussed with Staff 1 (Administrator/Owner). He acknowledged the heat had not been turned on, and he reported he would “go take care of it.” The facility’s common space temperature sensors were above 70 degrees F for the remainder of the survey.

C0540- Heating and Ventilation 1- The areas that were identified in the survey have been corrected, this s to iclude but is not limited to the following; * Unsampled residents personal temperature sensor has been reset * The second floor bathroom thermostat has been recalibrated to ensure that temperatures do not fall below 70 degrees * The 2 electronic temperature sensors near the dining room have been recalibrated to reflect tempatures that will not fall below 70 degrees * The temperature settings in the medication room have been recalibrated to reflect a proper temperature of 70 degrees * The first floor bathroom thermostat has been reclaibrated to reflect a proper tempeature of 70 degrees * The resident that were unsampled and indicated in the survey are unknown to this writer, but all residents have been interviewed to ensure that the over all room temperatures are comfortable to them 2- All thermostats and sensors in the community have been tested and recalibrated to reflect proper temperatures of at least 70 degress. 3- The temperatures of the rooms and the common areas will be monitored daily with the walk through throughs and as needed to maintain the required temperatures of 70 degrees. 4- The Administrator of record will ensure ongoing compliance.

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

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors, which included the LGBTQIA2S+ rights and protections and non-discrimination notice. Findings include, but are not limited to: Refer to C 152.

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

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (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. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled staff (#5) completed the department approved LGBTQIA2S+ training prior to beginning their job responsibilities. Findings include, but are not limited to: Refer to C 370.

L0370- Staffing Requirements and Training- Pre-Service *** Refer to C 370 ***

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (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. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: