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 a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to: The acuity interview, conducted on 02/02/26 at 1:00 pm with Staff 9 (CG) and Staff (14 MT), and review of resident information provided from Staff 1 (Administrator) identified: * The memory care community was home to 41 residents; * 19 residents required staff support and intervention for behavioral symptoms; * 19 residents required support due to cognitive impairment; * 13 residents required assistance in the dining room (observations, cueing, hand-over-hand, or physical assistance with eating); and * One resident required a two-person assist with transfers. Staffing schedules showed two direct care staff were assigned to the overnight (NOC) shift from 10:00 pm to 6:00 am. Review of staffing assignments identified all direct care staff were scheduled as universal workers whose duties included tasks such as housekeeping, laundry, and food service, in addition to providing direct resident care. Staffing was not increased to maintain adequate resident care and services while staff performed universal worker tasks. Interviews and observations conducted throughout the survey revealed the following: Interviews on 02/04/26 at 12:30 pm and 02/05/26 at 11:35 am with Staff 1 (Administrator) indicated there were two staff assigned to work on the night shift. The administrator acknowledged the current population of the facility was made up of several ambulatory residents. There were several residents that would be an elopement risk if they exited the secured area of the facility. When questioned, Staff 1 stated two staff on night shift might have difficulty getting all the residents out of the facility and keeping them safely contained at the designated meeting point in the event an evacuation of the building was required. She acknowledged the facility had very active residents and two staff on night shift would be insufficient to evacuate all residents. In an interview conducted on 02/05/26 at 1:30 pm, Staff 4 (MT/Infection Control Specialist) stated she conducted fire drills every other month on alternating shifts. She reported night shift staff did not move residents during drills. Staff 4 indicated two staff were assigned to the night shift and that night staff normally received verbal training and practiced moving a substitute item around the unit in place of residents. The last drill staff used cushions in place of the sleeping residents and moved the cushions away from the fire location. When asked whether two staff would be able to evacuate all 41 residents and keep them together in front of the building, Staff 4 stated she was unsure if two staff would be sufficient. Multiple daily observations completed between 02/02/26 and 02/05/26, of sampled and non-sampled residents, identified a minimum of 10 residents who were ambulatory without assistive devices, independently moving throughout all areas of the facility and requiring ongoing monitoring and direction from staff. Additional residents utilizing walkers and/or wheelchairs were also observed independently ambulating within the facility, increasing the need for sufficient staff to ensure supervision and safe evacuation in an emergency. Considering resident acuity, including the number of residents requiring behavioral supervision, cognitive support, and two-person assistance, the facility’s overnight staffing of two universal care workers did not provide adequate direct care staff to meet fire safety evacuation standards required by the Department. The need to ensure the facility increased staffing when universal workers performed additional duties and to ensure adequate direct care staff were present at all times to meet evacuation needs was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/04/26 at 1:30pm and on 02/05/26 at 2:45 pm. They acknowledged the findings.

The facility has permanently revised staffing plan to require a minimum of three scheduled staff members on every night shift regardless of census fluctuation unless reassessed by the RN and Administrator. The administrator will review the weekly schedule prior to posting to verify compliance with minimum staffing requirements.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured the care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 6 sampled residents (#1, 2, and 6) whose ABST data was reviewed. Findings include, but are not limited to: Review of the ABST data identified care time was not accurately captured for Residents 1, 2, and 6 in one or more of the following areas: * Providing non-drug interventions for behaviors; * Monitoring physical conditions or symptoms; * Assisting with leisure activities; * Cueing or redirecting due to cognitive impairment or dementia; * Providing non-drug interventions for pain management; * Supervising, cueing, or supporting while eating; and * Assisting with ambulation, escorting to and from meals or activities. Interviews with staff, conducted 02/02/26 through 02/05/26, indicated Resident 6 required continuous redirection, reassurance, and consoling, with staff providing redirection approximately every 30 to 60 minutes. In an interview on 02/05/26 at 1:50 pm, Staff 1 (Administrator) acknowledged the inaccuracies in care times. The need for the ABST to accurately capture care time and care elements that staff were providing to residents was discussed with Staff 1 and Staff 2 (RN) on 02/05/26 at 2:00 pm. They acknowledged the findings.

Upon identification of deficiency, the Administrator and RN immediately conducted a full reassessment of all current residents’ ABST evaluations to ensure accurate capture of: -Providing non-drug interventions for behaviors -Monitoring physical conditions and symptoms -Assisting with leisure activities -Cueing or redirecting due to cognitive impairment -Providing non-drug interventions for pain management -Supervising, cueing, or supporting while eating -Assisting with ambulation, escorting to and from meals or activities -Weekly ABST audits will be completed by the RN and administrator

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C510, C513, and H1517.

1. Please refer to tag C 510, C 513, Z 142, and H 1517.

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

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard smooth material and maintained in good repair and the grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to: On 02/03/24 at 10:02 am, the exterior of the facility was toured, and the following was identified: The facility was noted to have exterior pathways located in the front of the building and in the locked and secure courtyard. a. Exterior pathways were noted to have breaking, broken, missing, and/or damaged material and were not maintained with a smooth hard surface or in good repair. An additional pathway, in the locked and secure courtyard, was noted to have significant plant overgrowth and was not maintained in good repair. b. Facility grounds were noted to have litter around the entrance area and in the locked and secure courtyard. Additionally, the courtyard was noted to have what was determined to be excrement in two areas on the patio. A walk-through of the above noted areas was completed with Staff 1 (Administrator) on 02/04/26 at 10:24 am and on 02/04/26 at 1:13 pm with Staff 3 (Maintenance). The need to ensure all exterior pathways were made of hard, smooth material and were maintained in good repair and grounds were kept orderly and free of litter, was reviewed with Staff 1 and Staff 2 (RN) on 02/05/26 at 3:45 pm. They acknowledged the findings.

Contractors have been hired for the exterior pathways in the front of the building and in the locked and secure courtyard Maintenance will be responsible for daily walk through to ensure the grounds are free from litter and debris. Administrator will audit task sheet weekly

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard smooth material and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: On 05/27/26 at 1:00 pm, the exterior of the facility was toured, and the following was identified: Exterior pathways were noted to have breaking, broken, missing, and/or damaged material and were not maintained with a smooth, hard surface or in good repair. An additional pathway, in the locked and secure courtyard, was noted to have significant plant overgrowth and was not maintained in good repair. The need to ensure all exterior pathways were made of hard, smooth material and were maintained in good repair was reviewed with Staff 1 (Administrator) and Staff 16 (Administrator Assistant) on 05/27/26 at 5:10 pm. They acknowledged the findings.

1. The front entryway sidewalks have been repaired to ensure exterior pathways were made of hard, smooth materials and is now maintained in good repair. 2. An exterior checklist has been created for building maintenance personnel to monitor and inspect weekly. 3. Administration will monitor and enforce ,through visual inspection and audit at week's end (Fridays). 4. Building maintenance and Owners.

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure all surfaces were kept clean and in good repair and the interior of the facility was kept free from unpleasant odors. Findings include, but are not limited to: The environment was toured from 02/02/26 through 02/05/26, and the following was identified: * Carpeting had discolored areas located near rooms #s 105, 304, 403, 405, and 406, and was heavily worn and rippled in the area to the left of the entrance, outside the staff room, and medication room; * The flooring transitions located near the dining room and resident restroom were taped to the ground; * Fabric couches in the resident living corridors were observed to have discolored areas on the seat cushions and arm rests, and the chairs with wooden frames had scratched and chipped material on the arm rests; and * Ceiling fans throughout the facility, window coverings in the dining room, and multiple light fixtures in the dining room, had a significant build-up of dust and/or dirt. On 02/03/26 at 10:51 am, Staff 1 (Administrator) confirmed the large area of carpet, noted above, was previously identified and provided documentation of an estimated quote to replace. b. Odors were noted from 02/02/26 to 02/05/26, primarily located around the entry area and down the corridors to the left and right of the entry area. A walk-through of the above noted areas was completed with Staff 1 on 02/04/26 at 10:24 am and on 02/05/26 at 2:03 pm with Staff 1 and Staff 3 (Maintenance). The need to ensure the interior environment was clean, in good repair, and free from unpleasant odors was reviewed with Staff 1 and Staff 2 (RN) on 02/05/26 at 3:45 pm. They acknowledged the findings.

Carpeting to the left of the entrance is currently being replaced as well as the floor transitions. -Routine carpet cleaning is scheduled professionally every 6 months -Immediate cleaning of carpets and furniture will be documented in housekeeping log. -Routine professional cleaning hired for hard to reach dust/dirt -Housekeeping will ensure furniture and carpets are odor and free of soil. -Administrator will complete weekly audits. -Wooden chair arms and frames have been repaired. Administrator will audit condition weekly.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to: The interior environment was toured on 05/27/26 at 1:20 pm and the following was identified: Carpeting had discolored areas located near rooms 105, 304, 403, 405, and 406. A review of the discolored carpeted areas was completed with Staff 1 (Administrator) on 05/27/26 at 4:45 pm. The need to ensure the interior environment was clean and in good repair was reviewed with Staff 1 and Staff 16 (Administrator Assistant) on 05/27/26 at 5:10 pm. They acknowledged the findings.

1. Total carpet replacement will continue from previous start on Tuesday June 30, 2026. Facility is awaiting contractor schedule. 2. Carpet is brand new and will be monitored monthly for performance and cleanability based on manufacturer warranty and expectations for the product. 3. Monitoring of carpet performance, cleanability, and functionality wil be performed weekly by housekeeping and reported to owner monthly. Documentation of results will be logged in the weekly housekeeping log. 4. Housekeeping and ownership.

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

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 provide each individual privacy in his or her own unit for 1 of 1 sampled resident (#4) and multiple unsampled residents. Findings include, but are not limited to: a. The facility had multiple double occupancy rooms with a shared bathroom. On 02/03/26, a shared bathroom in a resident room was observed to have a pocket door and was not equipped with a way to lock the door from the inside. At 12:56 pm, Staff 1 (Administrator) reported all shared bathrooms in resident rooms had a pocket door that could not be locked. b. Resident 4 resided in a shared room with an unsampled resident who was observed to ambulate independently. Resident 4’s bed and living space were at the entry of the shared room. On 02/04/26, Resident 4 was observed to receive assistance with incontinence care while in bed. There were no observations of a privacy screen or use of something to provide the resident privacy if someone were to enter the room. On 02/05/26 at 3:21 pm, the resident’s room was toured with Staff 1 (ED) and Staff 2 (RN). They acknowledged Resident 4’s lack of privacy while receiving ADL care. The need to ensure each resident had privacy in his or her own unit was reviewed with Staff 1 and Staff 2 on 02/05/26 at 3:45 pm. They acknowledged the findings.

A portable privacy screen has been implemented and will be used for all residents requiring privacy during personal care, treatments and other care related services when doors cannot be fully closed or when roommates are present. The RN will conduct random weekly audits for 4 weeks to ensure compliance. An exception was submitted and requested to ODHS licensing unit regarding the structural limitations of the existing pocket doors. Staff have been educated to ensure resident privacy during use of bathrooms by knocking prior to entry.

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 provide each individual privacy in his or her own unit for 3 of 3 sampled residents (#8) and multiple unsampled residents who shared a bathroom. This is a repeat citation. Findings include, but are not limited to: The facility had multiple double occupancy rooms with a shared bathroom. On 05/27/26 at 1:30 pm, a shared bathroom in Resident 8’s room was observed to have a pocket door that was not equipped with a way to lock the door from the inside. At 3:00 pm, Staff 1 (Administrator) confirmed locks were not installed on shared bathroom doors. The need to ensure each resident had privacy in his or her own unit was reviewed with Staff 1 and Staff 16 (Administrator Assistant) on 05/27/26 at 5:10 pm. They acknowledged the findings.

1. Pocket door latches will be completely installed on 6/25/2026. All 30 shared bathrooms will be secured and residents will be able to effect privacy and operations of the doors as they need. 2. Building maintenance will monitor operations and functionality through regular inspection and maintenance as hardware requires. 3. Weekly inspections of hardware will be added to weekly log. 4. Building maintenance and ownership.

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:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C360, C362, C510, and C513.

Please refer to C360, C362, C510, and C513

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C510, C513, and H1517.

Please refer to C510, C513, H1517 above.

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 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents' rooms were individually identified to assist residents in recognizing their room. Findings include, but are not limited to: On 02/03/26 the facility was toured, and each room and room identifier was observed and referenced with the current resident roster, provided to survey on 02/02/26, which noted resident names and room numbers. The following was identified: Multiple resident rooms lacked individualized identification to assist residents in recognizing their room, six rooms lacked identification of at least one resident who currently lived in that room, and multiple rooms were noted to have names of former residents. On 02/05/26 at 2:03 pm, the above was reviewed with Staff 1 (Administrator) and the individual resident identifiers for room 102 were observed. She acknowledged the findings. The need to ensure each resident room was individually identified to assist residents in recognizing their room was discussed with Staff 1 and Staff 2 (RN) on 02/05/26 at 3:45 pm. They acknowledged the findings.

Individual room identifiers have been implemented for all resident rooms. Staff were educated on the importance of using these identifiers to assist residents with orientation and to promote independence. Any missing or damaged identifiers will be replaced immediately. Activity director will document weekly audits and replacements.

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: