OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure residents were treated with dignity and respect. Findings include, but are not limited to: 1. On 12/16/25 during the lunch service, at approximately 12:00 pm, three residents were seated at the same table. A staff served lunch to two of the residents in dining room and at 12:20 pm, staff served the last resident at the table, by which time the other two residents had nearly finished their lunch. 2. On 12/16/25 and 12/17/25 during lunch service Staff 11 (CG) was observed standing while assisting an unsampled resident who required cueing and one-on-one physical meal assistance. The resident was seated in a manual wheelchair in the dining room, while Staff 11 remained standing while assisting the resident, rather than positioning at eye level or sitting beside the resident. The need to ensure residents were treated with dignity and respecting during the meal service was discussed with Staff 1 (ED) on 12/18/25 at 2:33 pm and 12/19/25 at 2:10 pm with Staff 2 (RN), Staff 3 (Health Service Director) and Staff 4 (RCC). They acknowledged the findings. 3. On 12/17/25 during lunch service Staff 6 (CG) and Staff 8 (CG) were observed by survey team having conversations with each other that did not involve Resident 1 and an unsampled resident whom they were assisting with meal service. Staff 6 stopped providing meal assistance with the unsampled resident to go provide incontinence care for Resident 1 with Staff 8. The unsampled resident, who required assistance, was left with food in front of him/her. Staff 6 returned to assist the unsampled resident for about two minutes, after a brief conversation Staff 8 took over continued to assist till end of meal. The need to ensure residents were treated with dignity and respect regarding meal service was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 12/19/25 at 12:15 pm. They acknowledged the findings. 4. On 12/16/25 and 12/19/25 the surveyors observed written PHI (Personal Health Information) for multiple sampled and unsampled residents in a file box hanging on a wall on the hallway that was visible to individuals who should not have had access to the information. The need to ensure medical and other records were kept confidential was discussed with Staff 1 (ED), Staff 2 (Nurse), Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 12/19/25 at 12:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? - We ensured that staff are feeding all residents at the same time, sit down while feeding the residents and not get up until they're all done eating. Staff no longer are having personal conversations while working with residents and any given time. Resident documents are held confidential. 2. How will the system be corrected so this violation will not happen again? - ED will be out in the common area during meals. We will have more training with staff and ensure they respect the residents dignity. We are reviewing our process and training. 3. How often will the area needing correction be evaluated? - Daily 4. Who on your staff will be responsible for seeing that the corrections are completed/monitored? - ED, RCC, HSD

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

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure an injury of unknown case and repeated incidents of being found on the floor were promptly investigated to rule out abuse/neglect and were reported to the local SPD office when unable to reasonably conclude the incidents were not abuse and/or neglect for 3 of 4 sampled residents (#s 1, 2 and 5) who experienced repeated falls and/or injury of unknown cause. Findings include but are not limited to: 1. Resident 1 moved into the memory care facility in 12/2024 with diagnoses including Alzheimer’s and Parkinson’s disease. The resident's 12/11/25 service plan, temporary service plans (TSPs), progress notes and incident reports dated 09/15/25 – 12/15/25 were reviewed. On 10/24/25, staff created a TSP (Temporary Service Plan) identifying “abrasion to right hand ring finger”. On a progress note, dated 11/12/25 staff identified a “bruise to right hand/thumb area”. There was no documented evidence that either injury of unknown cause was immediately investigated to rule out abuse. On 12/19/25 at 10:20 am, Staff 1 (ED) and Staff 3 (Health Services Director) confirmed the above injuries lacked investigation and had not been reported to the local SPD office. The surveyor requested the above injuries be reported to the local SPD office, and confirmation was received at 3:10 pm on 12/19/25. The need to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse unless an immediate facility investigation reasonably ruled out abuse was reviewed with Staff 1, Staff 2 (Nurse), Staff 3 and Staff 4 (Resident Care Coordinator) on12/19/25 at 12:15 pm. They acknowledged the findings. 2. Resident 5 moved into the memory care facility in 07/2024 with diagnoses including dementia. During the survey, the resident was observed to require the assistance of two staff members for transfers and toileting. The resident's 10/12/25 service plan, 09/23/25 – 12/16/25 temporary service plans (TSPs) and 09/11/25 – 12/14/25 incident reports were reviewed. The 10/12/25 service plan and temporary service plans indicated to continue 15-minute or frequent checks, provide reminders for the resident to use call system, routine toileting assistance, and closely monitor the resident when in common areas. The service plan noted the resident was unable to use the call system to request assistance. a. The clinical records showed the following: The 09/23/25 incident report noted the resident was found on the floor near the nurse office, and the resident was unable to state what occurred; and The 10/23/25 and the 12/14/25 incident reports noted the falls were unwitnessed falls, and the resident was unable to state what occurred. The facility’s incident report did not adequately rule out the possibility of abuse, there was insufficient supporting evidence. It remains unclear whether staff followed the 15-minute or frequent checks as outlined in the service plan. b. The clinical records showed the following: The 10/05/25 incident report showed the resident was found on the floor outside the bathroom with visibly soiled pants. The resident was unable to verbalize what happened. The facility’s incident report did not adequately rule out the possibility of abuse, as there was insufficient supporting evidence. Specifically, it remains unclear whether staff provided toileting assistance in accordance with the individual’s service plan. c. The clinical records showed the following: The 11/04/25 incident report noted the resident had bruising on the left arm and left forearm. The bruises were dark blue and purple in color. The facility’s incident report did not adequately rule out the possibility of abuse, there was insufficient supporting evidence. It remains unclear the cause of the bruises. During an interview at 1:28 pm on 12/18/25, Staff 1 (ED) confirmed the above incidents lacked investigations and had not been reported to the local SPD office. The surveyor requested the above incidents be reported to the local SPD office, and confirmations were received at 2:32 pm on 12/18/25. The need to investigate injuries of unknown cause and repeated unwitnessed falls, when the resident was dependent on staff for care, to rule out abuse or neglect of care, and to notify the local SPD if abuse could not be ruled out was discussed with Staff 1 on 12/18/25 at 2:33 pm. She acknowledged the findings. 3. Resident 2 moved into the memory care facility in 09/2025 with diagnosis including vascular dementia and urinary incontinence. The resident’s record was reviewed, including the service plan, temporary service plans, and incident reports. Interviews with staff were conducted and the following was identified: The resident’s service plan noted the resident required staff assistance to transfer in and out of bed safely, to ensure the call button was within reach, encourage him/her to use the call system when s/he needed to use the bathroom, remind the resident not to transfer without staff assistance, frequent checks throughout the day and night, ensure floors are free of clutter, and ensure resident is wearing shoes. Resident 2’s clinical record revealed the resident experienced seven unwitnessed falls from 09/30/25 through 11/09/25. The facility investigation lacked documented evidence on how abuse and neglect was reasonably ruled out, what necessary measures were taken to protect resident and prevent the reoccurrence of the repeated falls, and/or lacked documentation the incidents were reported to local SPD on the following occasions: * 09/30/25 – staff documented the resident was found on the floor beside his/her bed with a blanket and had complaints of back pain. The resident stated, “The ladies [that] put [him/her] into bed didn’t check to see if [s/he] was on the bed all the way.” An investigation was completed on 10/01/25, however it did not reasonably rule out abuse and neglect. * 10/06/25 – staff documented the resident was found on his/her bathroom floor. An investigation was completed on 10/08/25, however it did not reasonably rule out abuse and neglect. * 10/09/25 – staff documented the resident had an unwitnessed injury fall to his/her head and buttocks. An investigation was completed on 10/14/25, five days after the incident and therefore lacked an immediate investigation. * 10/16/25 – staff documented the resident was found on the floor beside his/her bed and reported to staff s/he “slid out of bed when attempting to put [his/her] socks on”. The resident’s service plan indicated s/he required assistance with dressing and undressing. An investigation was completed on 10/16/25, however it did not reasonable rule out abuse and neglect. * 10/18/25 – staff documented the resident was found on the floor in his/her room. An investigation was completed on 10/21/25, however it did not reasonably rule out abuse and neglect. * 10/31/25 – staff documented the resident had an unwitnessed injury fall. An investigation was completed on 11/04/25, four days after the incident, and noted it was “unknown” if the injury was from this fall or a prior fall. The facility lacked an immediate investigation to reasonably rule out abuse and neglect and the investigation completed was unable to rule out abuse and neglect. * 11/04/25 – staff documented the resident had an unwitnessed fall in his/her room. An investigation was completed on 11/04/25, however did not reasonably rule out abuse and neglect. * 11/09/25 – staff documented the resident had an unwitnessed injury fall in his/her bathroom. An investigation was completed on 11/10/25, however it did not reasonably rule out abuse and neglect. On 12/19/25 at 10:45 am, the incidents and documentation were reviewed with Staff 1 (ED), Staff 2 (Nurse), and Staff 3 (Health Services Director). Staff 1 and Staff 3 confirmed the above incidents were not investigated immediately or lacked documented evidence of how abuse and neglect was reasonably ruled out. Staff 1 confirmed the above incidents were not reported to local SPD office. It was requested the above incidents be reported to the local SPD office, and confirmation was received at 3:13 pm. The need to ensure the facility completed an immediate investigation to reasonably rule out abuse and neglect, and report to local SPD if an immediate investigation could not take place or abuse and neglect could not reasonably be ruled out, and take necessary measures to protect the resident and prevent the reoccurrence of the repeat falls was reviewed with Staff 1, Staff 2, Staff 3, and Staff 4 (Resident Care Coordinator) on 12/19/25 at 1:05 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? - ED ensured that reporting was done and we reported the finding by State Surveyors. 2. How will the system be corrected so this violation will not happen again? - Investigate more thorough for instance we will talk to all the care staff that was on shift and see when the last time it was when they were checked on, what interventions were successful and not successful, what they could have done to prevent the indicent. And make sure the Service Plans are being followed 3. How often will the area needing correction be evaluated? - Everytime there are multiple incident reports about the same thing for example repeated falls or when incidents occur. Every incident 4. Who will be responsible to see that the corrections are completed/monitored? - HSD and ED

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

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interest. Findings include, but are not limited to: During the observations on 12/16/25 through 12/17/25, the posted scheduled activity calendar activities did not take place. The monthly activity calendar posted in the dining/common area indicted the following: On 12/16/25, the following: 10:00 am - Funny Animal 11:00 am - Word search 1:00 pm - Shoulder massage 3:00 pm - Music On 12/17/25, the following: 09:00 am - Morning Yoga 10:00 am - Bingo 11:20 am - Music 1:00 pm - December Birthday On 12/16/25, from 9:30 am to 2:30 pm and on 12/17/25 from 9:20 am to 1:50 pm, there were no activities provided for the residents as scheduled. A few small activities were observed, such as spontaneous coloring activities. On 12/17/25 Christmas music from the television was playing throughout the observation period. No structured activities or staff engagement were observed at that time. During the survey conducted from December 16 through 17, 2025, multiple residents were observed sitting in common areas for extended periods, often sleeping while a television played continuously. Other residents were noted walking the halls or remaining in their rooms without engagement in individual or group activities. On 12/19/25 at 2:33 pm, the failure to provide an activity program based on individual needs and as a group was reviewed with Staff 1 (ED). She acknowledged the findings.

1. What actions will be taken to correct the rule violation? - Ensure that the activities will be followed throughout the day. In instances where residents do not want to do that activity the activity calendar will be updated and changed to a different activity that residents prefer 2. How will the system be corrected so this violation will not happen again? - The ED and Activity Director will go over the activity calendar to see what residents like to do and what they do not like to do. Will also cross check with the service plans to incorporate more 1:1 time with residents that require 1:1 time. 3. How often will the area needing correction be evaluated? - Monthly 4. Who will be responsible to see that the corrections are completed/monitored? - ED

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 observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, or were implemented, for 4 of 5 sampled residents (#s 1, 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the memory care facility in 12/2025 with diagnosis including dementia, dysphasia, and peripheral vascular disease. The resident’s record was reviewed, including the current service plan dated 12/02/25 and temporary service plans. Interviews with staff were conducted and observations were made. Resident 3’s service plan lacked clear direction regarding the delivery of services and/or were not implemented in the following areas: * Instruction related to bed changes; * Dining assistance including encouraging the resident to swallow food and offer small sips of water/juice; * Provide oral care as needed throughout and after meals to remove pocketed food; * Use of fall matt; * Clear instruction related to floating and/or offloading heels when in wheelchair and in bed; * Repositioning in bed and while in wheelchair every hour and a half to two hours; * When sleeping in common areas, staff were to wake and ask if the resident wanted to go to his/her room or to bed; and * Hearing aide use. The need to ensure service plans provided clear direction regarding the delivery of services and was implemented, was reviewed with Staff 1 (ED), Staff 2 (Nurse), Staff 3 (Health Services Director), and Staff 4 (Resident Care Coordinator) on 12/19/25 at 1:33 pm. They acknowledged the findings. 2. Resident 2 moved into the memory care facility in 09/2025 with diagnosis including vascular dementia and urinary incontinence. The resident’s record was reviewed, including the current service plan dated 10/28/25 and temporary service plans. Interviews with staff were conducted and observations were made. Resident 2’s service plan lacked clear direction regarding the delivery of services and/or was not implemented in the following areas: * Dining assistance including monitoring during meals to provide cueing, providing a meal replacement if food served is not preferred; * Instruction related to aspiration precautions; * Fall preventions including use of fall mat and frequency of checks on each shift; * Frequency of toileting assistance on each shift; and * Medication assistance including to administer medication on a spoon. The need to ensure service plans provided clear direction regarding the delivery of services and was implemented, was reviewed with Staff 1 (ED), Staff 2 (Nurse), Staff 3 (Health Services Director), and Staff 4 (Resident Care Coordinator) on 12/19/25 at 1:05 pm. They acknowledged the findings. 3. Resident 5 moved into the memory care facility in 07/2024 with diagnoses including dementia and anxiety. Observations of the resident, staff interviews, and review of the service plan dated October 12, 2025, along with temporary service plans from December 16–18, 2025, revealed that Resident 5’s service plan was not reflective of his/her current needs. The plan lacked clear directions for the delivery of services and was not implemented as intended in the following areas: * Providing activities as outlined; * Dentures or oral care status; * Conflicting information regarding meal assistance; * Evacuation status; * Use of a cushion while in the wheelchair; * Use of an air mattress while in bed; and * Providing a mechanical soft diet as outlined. The need to ensure service plans were reflective of resident care needs, provide instructions for staff and implement the plans was reviewed with Staff 1 (ED) on 12/18/25 at 2:33 pm. She acknowledged the findings. 4. Resident 1 moved into the memory care facility in 12/2024 with diagnoses including Alzheimer’s and Parkinson’s disease. Resident 1 was identified on acuity interview on 12/15/25 to be utilizing siderails and receiving hospice services. The resident’s service plan, dated 12/11/25, was reviewed, observations were made, and staff were interviewed. The service plan lacked implementation of services in the following areas: * Service plan directed staff to “check siderail at least once per shift and med tech to document weekly safety check, to make sure side rails was not loose and the gap between the mattress and the rail is minimized and resident is using them safely [sic]’’. Observation on 12/17/25, resident had bilateral half siderails to bed. The left side siderail was loose upon surveyor inspection. During interview on 12/18/25 at 2:55pm, Staff 4 (Resident Care Coordinator) and Staff 2 (Nurse) were made aware of the side rail being loose. * Service plan indicated Resident 1 was utilizing an air mattress topper. Directions to staff was to “ensure air mattress topper in on and inflated, firmness middle [sic]” Observation on 12/17/25 at 11:20 am, Staff 10(CG) and Staff 19 (CG) assisted Resident 1 out of bed. When Staff 19 removed the bedsheet, the air mattress topper was observed to be deflated. Surveyor asked Staff 19 if he noticed it was deflated “he answered, I can hear it running”. Surveyor asked if he could check if it’s plugged into the air mattress and it wasn’t, so he connected the tubing and air mattress started inflating. The need to ensure service plans were implemented was discussed with Staff 1 (ED), Staff 2 (Nurse), Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 12/19/25 at 12:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? - Resident's individual service plans were updated to reflect each resident's current condition/abilities/ interest. Instructions in service plans were updated to be clear and easy to follow, which was verified by polling care staff following updates. Assistive device checks are now verified by MedTechs to ensure caregiver completed check and device is in proper working order, which is documented each shift by the MedTech in MAR. 2. How will the system be corrected so this violation will not happen again? - During monhtly staff meetings Management will specifically ask caregivers if all care plan instruction is clear and easy to follow, updates are completed as needed. Assistive device checks are now verified by MedTech's to ensure caregiver completed check and device is in proper working order, which is documented each shift by MedTech in MAR 3. How often will the area needing correction be evaluated? - Daily on MAR and monthly meetings 4. Who on your staff will be responsible to see that the corrections aree completed/monitored? - RCC and HSD

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition were evaluated, specific resident interventions were determined and documented, communicated to staff on each shift, and/or interventions were monitored for effectiveness, for 3 of 3 sampled residents (#s 2, 4 and 5) who experienced repeated falls. Findings include, but are not limited to: 1. Resident 2 moved into the memory care facility in 09/2025 with diagnosis including vascular dementia and urinary incontinence. The resident’s record was reviewed, interviews with staff were conducted, and observations were made. The following was identified: On 12/15/25 during the acuity interview, Resident 2 was identified to have a history of falls. From 12/16/25 through 12/19/25, the resident was observed to self-propel short distances in his/her wheelchair and required assistance from one direct-care staff for escorts to and from the resident’s room for toileting assistance. The resident’s service plan noted the resident required staff assistance to transfer in and out of bed safely, to ensure the call button was within reach, encourage him/her to use the call system when s/he needed to use the bathroom, remind the resident not to transfer without staff assistance, frequent checks throughout the day and night, ensure floors were free of clutter, and ensure resident was wearing shoes. The resident was unable to use the call system. a. The resident experienced seven unwitnessed falls, between 09/30/25 and 11/09/25, and lacked documented evidence previous interventions were evaluated for effectiveness and resident specific interventions were determined and documented in the resident’s record as a result of the following repeated falls: * 09/30/25, 10/06/25, 10/09/25, 10/16/25, 10/18/25, 10/23/25 and 11/04/25 - Staff documented unwitnessed fall; and * 10/31/25 and 11/09/25 – Staff documented an unwitnessed injury fall. The facility failed to review each incident to identify the circumstances of the falls, determine whether staff followed the current interventions, evaluate the effectiveness of the current interventions, and determine if alternative interventions were needed to prevent further falls. b. Clinical records revealed the following changes of condition: * 10/16/25 – disorientation; * 10/21/25 – required assistance with medication administration; * 10/30/25 – having difficulty holding cups and eating; * 10/31/25 – spilling beverages when attempting to drink; and * 10/31/25 – increased confusion. The above changes of condition lacked documented evidence resident specific interventions were determined and documented and communicated to staff on each shift. On 12/19/25 at 11:35 am, the above was reviewed with Staff 2 (Nurse) and Staff 3 (Health Services Director) and they confirmed there was no documented evidence the facility developed or implemented interventions and communicated the interventions to staff on each shift. The need to ensure the facility evaluated and determined what resident-specific actions or interventions were needed following repeat falls and evaluate the effectiveness of the current interventions to determine if additional interventions were needed and developed and implemented interventions as a result of a short term change of condition and communicated the interventions to staff on each shift was reviewed with Staff 1 (ED), Staff 2, Staff 3, and Staff 4 (Resident Care Coordinator) on 12/19/25 at 1:05 pm. They acknowledged the findings. 2. Resident 5 moved into the memory care facility in 07/2024 with diagnoses including dementia and hypertension. Resident 5 was observed sitting in a manual wheelchair, able to self-propel, and using a hospital bed with a fall mat. The resident's 10/12/25 service plan, 09/23/25 – 12/16/25 temporary service plans (TSPs), 09/15/25 – 12/15/25 progress notes and 09/11/25 – 12/14/25 incident reports were reviewed. The 10/12/25 service plan and TSPs indicated continuation of 15-minute or frequent checks, reminders for the resident to use call system, routine toileting assistance, and close monitoring when the resident was in common area. The resident was unable to use the call system appropriately to request assistance. The clinical record showed the following: * The 09/23/25 fall incident report noted fall interventions to be 15-minute checks and offering assistance. The 09/23/25 TSP showed continued 15-minute checks; * The 10/05/25 incident report showed the resident was found on the floor outside the bathroom with visibly soiled pants. TSP noted frequent checks and reminder for the resident to use the call system; however, the service plan indicated the resident was unable to use the call system; and * The 10/23/25 incident report noted the resident was found outside the medication room. The TSP indicated monitor closely when the resident was in the common area. Review of the resident’s clinical record showed, the resident experienced approximately 10 repeated falls. All documentation, including the report and TSPs, indicated frequent checks. The facility continued to implement frequent checks without evaluating the effectiveness of the current interventions. The need to ensure the facility evaluated and determine what resident-specific actions or interventions were needed following repeated falls including evaluating the effectiveness of current interventions and determining if alternative interventions were needed was discussed with Staff 1 (ED) on 12/18/25 at 2:30 pm. She acknowledged the findings. 3. Resident 4 moved into the memory care facility in 10/2025 with diagnoses including dementia and diabetes. The resident's 11/19/25 service plan, temporary service plans (TSPs), progress notes and incident reports, dated 10/16/25 through 12/15/25, were reviewed and interviews with staff were conducted. The following was identified: On 12/05/25 the resident experienced a fall with an injury of laceration to his/her right palm. Resident was transferred to emergency department after the fall related to behaviors. There was no documented evidence the facility developed and implemented interventions as a result of the fall and communicated the interventions to staff. On 12/19/25 at 10:20 am, Staff 1 (ED) and Staff 3 (Health Services Director) confirmed there was no documentation of interventions related to the resident’s fall with injury on 12/05/25. The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift for short-term changes of condition, was reviewed with Staff 1, Staff 2 (Nurse), Staff 3, and Staff 4 (Resident Care Coordinator) on 12/19/25 at 12:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? - Interventions in place are reviewed each time there is an incident effectiveness is determined by talking to staff as well as changes in occurances. Non-effective interventions are not carried over and instead replaced with new interventions that may be effective. A TSP is put in place to communicate to staff the change of interventions and monitoring, ABST is updated too reflect additional time this change requires 2. How will the system be corrected so this violation will not happen again? - A (locked) Reporting/Comment Box was placed outside RCC/RN office where staff have 34/7 access to place information regarding any changes/ out of baseline condition/ behaior/ ability for any resident. The box is checked dail and information reviewed with RN & PCP, resident is placed on alert charting, TSP in place and RN completes COC eval for long term changes of condition 3. How often will the area needing correction be evaluated? - Daily Who on your staff will be responsible to see that the corrections are completed/monitored? - RCC, ED, HSD, RN and HR

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 3 sampled residents (# 1) who received incontinence care and for multiple sampled and unsampled residents during meal service. Findings include, but are not limited to: 1. During the survey, the following were observed: a. On 12/17/25 at 12:12 pm, during lunch service, Staff 22 (Kitchen Aide) provided Resident 2 a peanut butter and jelly sandwich observed to be cut in half. The resident was observed to use a fork on the table to try and cut the sandwich and was unsuccessful. An unsampled resident sitting next to Resident 2 grabbed Resident 2’s fork and plate and was observed to touch the sandwich while cutting a piece in half. Resident 2 attempted to pick up the fork, and it fell to the floor. The unsampled resident picked the fork up off the floor and placed it on Resident 2’s plate. Resident 2 picked up the fork and proceeded to lick both sides of the fork and placed it back on his/her plate. b. On 12/17/25 at 12:18 pm, Staff 22 was observed to give Resident 2 a blue cup with a lid and straw with another resident name written on the reuseable cup. Resident 2 was observed to drink out of the straw and to put his/her open mouth on the side of the cup and lid throughout lunch service. The facility did not maintain infection prevention and control protocols during dining service which resulted in Resident 2 licking an unsanitary fork and using another resident’s reuseable cup. The need to ensure infection prevention and control protocols were maintained during meal service was reviewed with Staff 1 (ED), Staff 2 (Nurse), Staff 3 (Health Services Director), and Staff 4 (Resident Care Coordinator) on 12/19/25 at 1:05 pm. They acknowledged the findings. 2. During the survey from 12/16/25 through 12/18/25, observations during dining services showed Staff 6 (CG), Staff 10 (CG), Staff 11 (CG) and Staff 16 (CG) served breakfast and lunch and provided meal assistance to multiple unsampled residents and Resident 5 in the dining room without wearing any barrier protection or an apron. The need to ensure infection prevention and control practices were followed during meal service was discussed with Staff 1 (ED) on 12/18/25 at 2:33 pm. She acknowledged the findings. 3. Resident 1 moved into the memory care community in 12/2024 with diagnoses including Alzheimer’s and Parkinson’s disease. Observations were made during the survey on 12/15/25 through 12/19/25 to determine adherence to universal precautions for infection control. During meal service and an ADL observation on 12/17/25 the following was noted: a. Staff 6 (CG) and Staff 8 (CG) provided meal assistance to Resident 1 and unsampled resident on the same table. Both caregivers did not wear protective apron while assisting with meal. b. Resident 1 was served lunch (Pulled pork, mixed vegetables, beans and dinner roll) at 12:05 pm, resident 1 grabbed the pulled pork with hand and put it in his/her mouth. No hand hygiene was performed for Resident 1 prior to meal service. c. When Resident 1 completed his/her meal at 12:28 pm, Staff 6 and Staff 8 assisted to room and transferred to bed and then provided incontinence care. Both Staff were utilizing the same gloves they were wearing during meal service. Staff 8 obtained a clean brief and wipes from the shelf and proceeded to provide incontinence care with Staff 6 assisting with repositioning. Both caregivers used the same soiled gloves throughout the care and did not change gloves from dirty to clean tasks. No hand hygiene was performed between tasks. Staff 6 returned to the table to continue assisting unsampled resident with meal and then was relieved by Staff 8 who continued to assist the resident. Both caregivers were not utilizing protective aprons. The observations and the need to implement effective methods of infection control were discussed with Staff 1(ED), Staff 2 (Nurse), Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 12/19/25 at 12:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? - The management team will ensure that proper training is implemented to prevent infections. We will add the infection prevention control training during all staff meetings. Management team will be out in the community more to check that proper protocols are followed and will do room checks as well. Care staff will also be wearing aprons while they're feeding residents. Kitchen staff will ensure that residents will be given hand towels or hand sanitizer before all meals. 2. How will the system be corrected so this violation will not happen again? - Staff assessments on their compliance with policies. Management team will be out in the building more to shadow staff and make sure they’re following proper protocols and policies. 3. How often will the area needing correction be evaluated? - Daily 4. Who on your staff will be responsible to see that the corrections are completed/monitored? - ED, RCC, HSD, HR

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have sufficient direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On 12/16/25, an ABST Facility Entrance Questionnaire was completed by Staff 4 (Resident Care Coordinator) and provided to the survey team. The following was documented: * The facility was currently home to 56 residents; * Seven residents required multi-person transfers or ADL care including the use of mechanical lifts; * 12 residents required assistance in the dining room; and * Direct care staff were noted to assist with feeding tasks during resident meals. 1. Three of five sampled residents (#s 1, 2, and 3) whose individual ABST time was reviewed revealed the time documented was not reflective of the time spent providing ADL care. The increase in care time indicated additional staff were required. Refer to C362. 2. The facility ABST was not updated before a resident moved in, whenever a resident experienced a significant change of condition, and no less than quarterly at the same time as the resident’s service plan, for five of five sampled residents (#s 1, 2, 3, 4, and 5) reviewed. The lack of ABST updates could indicate inaccurate staffing levels. Refer to C363. 3. From 12/16/25 through 12/19/25, observations were conducted during meal service and revealed direct care staff were unable to provide consistent meal assistance. Meal observations determined a lack of care staff available to complete meal assistance for residents who required supervision and support while eating, without leaving the resident to complete another resident’s ADL care. Refer to C200, example 3. Refer to C295, examples 1 a and b, and 3 c. The need to ensure the facility had sufficient direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 1, Staff 2, Staff 3 (Health Services Director), and Staff 4 on 12/19/25 at 12:58 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? - HR hired more staff and they are scheduled for each shift based off of ABST time 2. How will the system be corrected so this violation will not happen again? - Ensure that we have enough staff hired for each shift based off of ABST, work with agency if we do not have enough staff. 3. How often will the area needing correction be evaluated? - With changes of condition and future admits. 4. Who on your staff will be responsible to see tha the corrections are completed/monitored? - RCC and HR

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) accurately captured care time staff were providing to each resident as outlined in each individual service plan for 3 of 5 sampled residents (#s 1, 2, and 3) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the memory care facility on 12/02/25 with diagnosis including dementia, dysphasia, and peripheral vascular disease. During the acuity interview on 12/15/25, the resident was reported to require two staff for transfers with the use of a Hoyer lift and to complete incontinent care. The resident’s record, including service plan, dated 12/02/25, temporary service plans, and individual ABST time were reviewed, interviews with staff were conducted, and observations of the resident were made. The resident’s care time was found not reflective in the following areas: * Supervising, cueing, supporting while eating; * Ambulation, escorting to and from meals or activities; * Transferring in or out of bed or a chair; and * Bowel and bladder management. The total care time noted on the resident’s ABST for transferring and bowel and bladder management accounted for one direct-care staff however, through observation and interview the resident required the assistance of two direct-care staff. Additionally, both care areas were noted to occur twice daily, however the service plan indicated each occurred at least five times a day. When the time and frequency for transferring and bowel and bladder management are accurately captured, it revealed a total discrepancy of approximately 12 to 17.5 hours per week. On 12/18/25 at 11:52 am, Staff 1 (ED) and Staff 4 (Resident Care Coordinator) confirmed the total time indicated in Resident 3’s individual ABST for transferring and bowel and bladder management accounted for one direct-care staff instead of two, and did not accurately capture the frequency of each task. The need to ensure each resident’s individual ABST accurately captured care time staff provided as outlined in each individual service plan, was reviewed with Staff 1, Staff 2 (Nurse), Staff 3 (Health Services Director), and Staff 4 on 12/19/25 at 1:33 pm. They acknowledged the findings. 2. Resident 2 moved into the memory care facility in 09/2025 with diagnosis including vascular dementia, gastro-esophageal reflux disease, and urinary incontinence. The resident’s record, including service plan, dated 10/28/25, temporary service plans, and individual ABST time were reviewed, interviews with staff were conducted, and observations of the resident were made. The resident’s care time was found not reflective in the following areas: * Supervising, cueing, and supporting while eating; * Dressing and undressing; and * Safety checks and fall prevention. The resident’s individual ABST noted the resident required 0-minutes for supervising, cueing, and supporting while eating, however the resident’s interim service plans indicated the resident required cueing, redirect and re-orient back to plate, assist as needed if unable to eat on own, provide encouragement, reminders, meal replacements, and nutritional shakes between meals. On 12/18/25 at 11:52 am, Staff 4 (Resident Care Coordinator) confirmed the above noted areas were not reflective of the resident’s current care time. The need to ensure each resident’s individual ABST accurately captured care time staff provided as outlined in each individual service plan, was reviewed with Staff 1 (ED), Staff 2 (Nurse), Staff 3 (Health Services Director), and Staff 4 on 12/19/25 at 1:05 pm. They acknowledged the findings. 3. Resident 1 moved into the memory care community in 12/2024 with diagnoses including Alzheimer’s and Parkinson’s disease. The resident’s record, including service plan, dated 12/11/25 and individual ABST time were reviewed. Interviews with staff were conducted, and observations were made. Resident 1 was non-verbal and communicated by blinking eyes. The resident’s care time was found not reflective in the following areas: * Assisting with communication; * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; * Cueing or redirecting due to cognitive impairment or dementia; * Supervising, cueing, and supporting while eating; and * Escorting to and from meals. The resident’s individual ABST noted the resident required 0-minutes on all above areas except for supervising, cueing, and supporting while eating which stated 6 minutes. Observation of resident during meal service on 12/17/25 and 12/18/25, resident required 30 minutes and 25 minutes respectively. When resident was out of bed before meal was served, during mealtime and after meal, resident required 1:1 staff observation and redirection related to behaviors ensuring safety for resident and other residents due to frequent rolling of wheelchair backwards and attempting to grab other residents passing near him/her. On 12/18/25 at 2:55 pm, Staff 4 (Resident Care Coordinator) confirmed the above noted areas were not reflective of the resident’s current care time. The need to ensure each resident’s individual ABST accurately captured care time staff provided as outlined in each individual service plan, was reviewed with Staff 1 (ED), Staff 2 (Nurse), Staff 3 (Health Services Director), and Staff 4 on 12/19/25 at 12:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? - RCC did a resident specific care time audit and will continue to do that when there is a change so the times in ABST accurately reflect the time needed. 2. How will the system be corrected so this violation will not happen again? - Averaging the care time audit sheets to obtain a realistic time needed for each task and reporting them to ABST 3. How often will the area needing correction be evaluated? - Every 90 days, change in condition and new move ins 4. Who on your shift will be reponsible to see that the corrections are completed/monitored? - RCC

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) was updated before a resident moved in, whenever a resident experienced a significant change of condition, and no less than quarterly at the same time as the resident’s service plan, for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose ABST were reviewed. Findings include, but are not limited to: On 12/15/25 after survey entered the building, the facility ABST data was downloaded for review and after the acuity interview, each sampled resident’s individual ABST was also downloaded. Interviews with staff were conducted and the following was identified: 1. Residents 1, 2, 3, 4, and 5’s move-in dates and dates noted as entered in the ABST were confirmed with Staff 1 (ED) and Staff 4 (Resident Care Coordinator) and revealed the facility ABST was not updated before each sampled resident moved into the facility. 2. Residents 2, 4, and 5 experienced significant changes of condition, however the ABST updates were not reflective of when each resident experienced a significant change of condition. 3. The facility ABST was not updated to be reflective of Resident 1’s quarterly service plan update. On 12/18/25 at 11:52 am, the facility ABST entry and update data was reviewed with Staff 1 and Staff 4. They confirmed the facility ABST was not updated before a resident moved in, when a resident experienced a significant change of condition, or at the same time of a quarterly service plan update. The need to ensure the ABST was updated before a resident moved in, whenever a resident experienced a significant change of condition, and no less than quarterly at the same time as the resident’s service plan was reviewed with Staff 1, Staff 2 (Nurse), Staff 3 (Health Services Director), and Staff 4 on 12/19/25 at 1:05 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? - ED will make new move in ABST file to ensure that we have the correct amount of staff at move in. When there are quartly reviews or significant changes we will go into ABST and update it that day. 2. How will the system be corrected so this violation will not happen again? - It will be entered into ABST prior to move in, day of quartly review and any Change of Condition 3. How often will the area needing correction be evlauated? - Everytime a new resident moves in, review date and change in condition 4. Who on your staff will be responsible to see that the corrections are completed/monitored? - ED and RCC

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the unannounced fire drills were conducted every other month at different times of the day and written fire drill record included all required elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 07/2025 through 11/2025 was reviewed on 12/18/25. The following was identified: 1.The facility conducted announced fire drills every other month following all-staff meeting, indicating the drills were not unannounced as specified in the regulation. 2. Fire drill documentation did not include one or more of the following required elements: * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Evacuation time needed. The need to ensure unannounced fire drills were conducted every other month at different times of the day and all required elements were documented was discussed on 12/18/25 at 1:17 pm with Staff1 (ED). She acknowledged the findings.

1. What actions will be taken to correct the rule violation? - ED ensured that the fire drills are no longer announced and there are proper written fire drill records to meet the Fire Drill regulation 2. How will the system be corrected so this violation will not happen again? - Ensure that the correct form for Fire drills with time it took to evacute, who evauate and what are the fire was is propperly filled out. Also ensured that fire drills are no longer accounced to staff 3. How often will the area needing correction be evaluated? - Every other month 4. Who on your staff will be responsible to see that the corrections are completed/monitored? - ED

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

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) and multiple unsampled residents who shared bathrooms. Findings include, but are not limited to: Observations of the MCC were conducted during survey on 12/15/25 through 12/19/25. Residents 1, 2, 3, 4, 5 and multiple unsampled residents were noted to share a bathroom. The bathrooms had sliding pocket doors. The pocket doors did not have the capability to lock from inside the bathroom. Therefore, each individual was not ensured privacy when using his/her shared restroom. During an environment walkthrough with Staff 23 (Maintenance Director) on 12/16/25 at 1:45 pm, it was confirmed all resident bathrooms had pocket doors and did not have a locking mechanism in each resident’s room. The need to ensure privacy in individual resident units was reviewed with Staff 1(ED), Staff 2 (Nurse), Staff 3 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 12/19/25 at 12:15 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? -ED contacted Policy Analyst to get an exception for pocket door locks. Policy Analyst approved a lock that works for pocket doors so Maintenance will be installing locks for each bathroom to ensure privacy 2. How will the system be corrected so this violation will not happen again? - Locks will be installed for each bathroom pocket door. 3. How often will the area needing correction be evaluated? - Once a month when Maintenance does his monthly checks to make sure they're still attached to the door. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? - Maintenance Director

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: Review of records for Residents 1, 2, 3, 4 and 5 showed no documented evidence the residents had been provided a key to their rooms. During the survey on 12/16/25 through 12/19/25, observation and interviews with staff confirmed residents did not have keys to their units. The need to ensure all residents were provided keys to their units was discussed with Staff 1 (ED) and Staff 5 (Operation Manager/Owner) on 12/18/25 at 2:33 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation. - ED and Maintenance Director bought hooks to put in resident closet incase they do not want a key. Keys were given to all residents 2. How will the system be corrected so this violation will not happen again? - Keys in closets as well as giving a key to each new admit upon move in. 3. How often will the area needing correction be evaluated? - If a resident says they lost their key and needs a new one, and during monthly maintenance checks they will make sure the extra key is in the closet. 4. Who on your staff will be reponsible to see that the corrections are completed/monitored? - ED and Maintenance Director

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C200, C231, C242, C295, C360, C362, C363 and C420

see C200, C231, C242, C295, C360, C362, C363, C420

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 15, 16, 17 and 18) completed all required pre-service orientation, 3 of 3 staff (#s 15, 16 and 17) completed pre-service dementia training and 4 of 4 staff (#s 13, 15, 16 and 17) completed competency training within 30 days of hire. Findings include, but are not limited to: The facility’s training records were reviewed on 12/16/25 at 1:15 pm with Staff 7 (Human Resources). The following was identified: 1. Staff 15 (MT), was hired 07/14/25, Staff 16 (CG), was hired 10/19/25, Staff 17 (CG) was hired 10/24/25 and Staff 18 (Cook) was hired 11/05/25. There was no documented evidence the staff had completed orientation and the pre-service training on the following required topics: * Resident rights and values and CBC care; and * Fires safety and emergency procedures. 2. Staff 15 (MT), was hired 07/14/25, Staff 16 (CG), was hired 10/19/25 and Staff 17 (CG) was hired 10/24/25. There was no documented evidence the staff had completed the pre-service dementia training on the following required topics: * Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; and * Use of supportive deices with restraining qualities in memory care communities. 3. Staff 13 (MT), hired 05/05/25, Staff 15 (MT), hired 07/14/25, Staff 16 (CG), hired 10/19/25 and Staff 17 (CG) was hired 10/24/25. There was no documented evidence staff had demonstrated competency in one or more of the following required topics: * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The facility failed to ensure all required training was completed and staff demonstrated competency was discussed with Staff 1 (ED) on 12/18/25 at 2:33 pm. She acknowledged the findings.

1. What actions will be taken to correct the rule violation? - HR had all staff complete all trainings before they started working with residents. 2. How will the system be corrected so this violation will not happen again? -Staff will not start working until they finished all of their classes 3. How often will the area needing correction be evaluated? - Everytime there is a new hire 4. Who on your staff will be reponsible to see that the corrections are completed/monitored? -HR and ED

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

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

see C260 and C270

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