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 resident care needs, provided clear direction regarding the delivery of services, and were implemented for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 02/2024 with diagnoses including dementia, peripheral vascular disease, and late onset Alzheimer’s disease. The resident’s 12/03/25 through 03/02/26 clinical record was reviewed. Observations of the resident were made, and interviews were conducted with staff. The 09/24/25 and 03/02/26 service plan and 01/06/26 to 02/28/26 temporary service plans were not reflective of the resident’s current status, lacked clear instructions for staff, or were not implemented in the following areas: * Use of a cushion while in the wheelchair; * Eating status, including the level of staff assistance required during meals; * Use of a gait belt during transfers; * Instructions/precautions to staff regarding use of a half-length side rail; * Use of a floor mattress, including when the mattress should be in place; * Compression stockings; * Use of overhead trapeze; * Incontinence care status; * Shower status, including responsibility for providing the service -- hospice team versus facility staff members; and * Fall prevention interventions. During the acuity interview on 03/02/26, staff reported the resident had frequent falls. The 09/24/25 and 03/02/26 service plan showed the resident required two-staff members’ assistance for transfers using a gait belt, two-staff members’ assistance for all ADLs, and one staff member to assist with applying and removing compression stockings daily. During an observation on 03/02/26, two staff members assisted the resident with a transfer and incontinence care without using a gait belt. Meal observations on 03/02/26 and 03/03/26 showed the resident needed physical assistance to maintain intake and complete meals, and s/he was not observed wearing compression stockings. Additionally, the resident was observed in a hospital bed; at times, a half-length side rail was in the raised position, and at other times, it was in the lowered position. On 03/03/26 at approximately 8:50 am, Staff 17 (CG) reported she was unsure when the half-length side rail should be used. Staff 18 (CG) reported she had previously observed the resident using the half-length side rail to assist with turning and bed mobility. Staff 18 further stated the half-length side rails were not to be used because they functioned as a restraint for the resident. On 03/03/26 at approximately 3:24 pm, Staff 14 (CG) and Staff 20 (CG) reported that the half-length side rails should be raised when the resident was in bed. The need to ensure service plans were reflective of the resident’s status, provided clear direction to staff regarding the delivery of services, and were implemented was reviewed with Staff 1 (ED), Staff 2 (Health Service Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of clinical Operations) on 03/04/26 at 11:16 am. They acknowledged the findings. 2. Resident 4 moved into the MCC in 01/2025 with diagnoses including dementia and had a history of falls. Staff reported in the acuity interview on 03/02/26 the resident used side rails on his/her bed to help prevent falls. The resident’s 11/28/25 to 02/27/26 clinical record was reviewed, observations of the resident were made, and staff were interviewed. The 01/16/26 service plan and 11/28/25 to 02/27/26 temporary service plans were not reflective of the resident’s needs and/or did not provide clear direction to staff in the following areas: * Pain, including left knee and back pain and need for wheelchair when having pain; * Food and liquid preferences and level of assistance needed at meals; * Whether the resident’s door should be open for safety due to high fall risk; and * Instructions/precautions to staff regarding use of bilateral half-length side rails. Observations of the resident during meals on 03/02/26 and 03/03/26 showed the resident needed assistance to initiate eating, cut up food, and maintain attention to eating. In an interview at 12:25 pm on 03/02/26, Staff 23 (CG) stated the resident’s favorite beverage was hot chocolate. She also stated s/he sometimes refused meals offered but could not verbalize preference for an alternative, so staff offered him/her choices. Resident 4 was observed sleeping in a hospital bed at 8:28 am on 03/03/26, with bilateral half-length side rails in the down position. In an interview at 8:51 am on 03/03/26, Staff 15 (CG) stated the resident did not use the side rails. In an interview at 3:36 pm on 03/03/26, Staff 9 (MT) stated the resident used the side rails while in bed for fall prevention, as s/he had fallen out of bed while sleeping. The need to ensure the service plan was reflective of the resident’s needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of Clinical Operations) at 11:11 am on 03/04/26. They acknowledged the findings.

Plan of Correction – C0260 1. What actions will be taken to correct the rule violation for each example/resident? For all cited residents (Resident #1 and Resident #4), corrective actions were completed immediately. A comprehensive clinical reassessment was conducted by the Health Services Director (LPN) in collaboration with the RCC to ensure all current care needs, risks, and preferences were accurately identified. Service plans and Temporary Service Plans (TSPs) were revised to reflect the resident’s current status and required care, including gait belt use for all transfers, clear instructions for side rail use including when it is appropriate and safety precautions, wheelchair cushion use, meal assistance level including initiation and physical assistance, compression stocking application and removal, incontinence care needs, shower responsibilities between hospice and facility staff, floor mattress use including when it should be in place, trapeze use, individualized fall prevention interventions, pain management, and food preferences. All interventions were rewritten in clear, step-by-step language to ensure staff understanding and proper implementation. Direct care staff were re-educated on updated service plans prior to the next shift. Return demonstrations were completed for transfers and gait belt use. An audit of care implementation was completed through observation to ensure staff followed the updated service plans, including transfers and meal assistance. Physicians and POAs were notified as appropriate. All corrections were completed by: __________ 2. How will the system be corrected so this violation will not happen again? The facility has implemented system changes to ensure ongoing compliance. A standardized service plan format has been implemented requiring clear, task-specific instructions that outline how care is to be provided, when it is to be provided, and by whom. All required equipment such as gait belts, side rails, and trapeze must be clearly addressed. Staff assistance levels for all ADLs must be defined, along with safety precautions including fall prevention. A side rail and equipment clarification process has been implemented to ensure service plans clearly define the purpose of use, when the equipment should be in use, and required safety precautions. Staff have been educated on the difference between enablers and restraints to ensure compliance with Oregon regulations. The change of condition process has been reinforced to require immediate nurse assessment, same-day initiation of a Temporary Service Plan, and prompt updating of the permanent service plan to reflect ongoing needs. A Service Plan Audit Tool has been implemented to ensure plans are reflective of the resident’s current condition, aligned with observed care, and inclusive of all required interventions. Staff have completed retraining on service plan implementation, gait belt use, fall prevention, and meal assistance. New staff will complete competency validation prior to working independently. Clinical oversight has been strengthened. RCCs are responsible for documentation accuracy and service plan updates. The nurse is responsible for clinical validation and oversight. Daily clinical stand-up meetings have been implemented to review changes in condition, falls, and required service plan updates. 3. How often will the area needing correction be evaluated? Weekly audits of all service plans were conducted for four weeks following the survey. Monthly audits will be conducted thereafter to ensure ongoing compliance. Daily spot checks will be conducted to monitor transfers, including gait belt use, meal assistance, and fall prevention interventions. Quarterly service plan reviews will be tracked to ensure completion every 90 days in accordance with Oregon requirements. All identified issues will be corrected immediately upon discovery. 4. Who will be responsible to see that the corrections are completed/monitored? The Health Services Director (LPN/DHW) is responsible for overall clinical oversight, ensuring service plans reflect current resident conditions, conducting audits, and providing staff education. Resident Care Coordinators are responsible for service plan updates, documentation accuracy, and ensuring Temporary Service Plans are initiated and transitioned appropriately. The Executive Director is responsible for administrative oversight and ensuring compliance systems are maintained. The Regional Nurse and VP of Clinical Operations provide additional oversight, review audit outcomes, and ensure sustained compliance.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 2) who received incontinence care and for multiple unsampled residents during medication administration. Findings include, but are not limited to: 1. Throughout the re-licensure survey, from 03/02/26 through 03/04/26, the following observations were made to determine adherence to universal precautions for infection control: a. Resident 2 moved into the MCC in 01/2022 with diagnoses including Alzheimer’s disease. Per the service plan, dated 02/13/26, Resident 2 was dependent on two staff members to provide incontinence care. Two observations were made of caregivers providing incontinence care for Resident 2. Staff 11 (CG) and Staff 21 (CG) were observed on 03/02/26 at 12:55 pm, and Staff 21 and Staff 13 (CG) were observed on 03/03/26 at 8:47 am. During both observations, Staff 11, Staff 13, and Staff 21 entered the resident’s room and donned gloves without first performing hand hygiene. On 03/02/26, Staff 11 removed a soiled brief, assisted Resident 2 with perineal care, doffed gloves, donned new gloves, and re-positioned the resident in bed without completing hand hygiene between dirty and clean tasks. Staff 11 left the unit without completing hand hygiene. On 03/03/26, Staff 21 removed the resident’s soiled brief and tossed it on the bathroom floor. With soiled gloves, Staff 21 turned on the bathroom sink and obtained incontinence wipes. Staff 21 doffed and then donned new gloves without performing hand hygiene, performed additional perineal care, and doffed gloves without performing hand hygiene between dirty and clean tasks. b. Observations of medications passes were made on 03/03/26 at 12:15 pm. Staff 10 (MT) was observed pouring and passing medications, touching a computer and the medication cart, pouring a single pill into her hand prior to handing it to the resident, grabbing a resident’s used lunch spoon to administer a pill, entering a resident’s room, grabbing an unused medication cup and water cup by placing her finger in the cups and then restocking them to be used later without changing gloves and/or performing hand hygiene between dirty and clean tasks. The need to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during ADL care and during medication administration was discussed with Staff 1 (ED), Staff 2 (Health Service Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of Clinical Operations) on 03/04/26 at 11:45 am. They acknowledged the findings. 2. Observations were made during the survey, from 03/02/26 through 03/03/26, to determine adherence to universal precautions for infection control. Resident 1 moved into the MCC in 02/2024 with diagnoses including dementia, peripheral vascular disease, and late onset Alzheimer’s disease. On 03/02/26 at approximately 1:23 pm, the surveyor obtained permission and observed Staff 16 (CG) and Staff 17 (CG), and on 03/03/26 at approximately 8:38 am, Staff 17 and Staff 18 (CG), provide incontinence care to Resident 1. During the observations, Staff 16, Staff 17, and Staff 18 failed to change gloves after removing a soiled incontinence product and wiping the resident’s bottom area. Staff 16, Staff 17, and Staff 18 applied a new brief to the resident and touched the resident's pants and the manual wheelchair while wearing the same soiled gloves. When Staff 16, Staff 17, and Staff 18 were finished providing incontinence care they removed the gloves. During the observations, staff failed to change gloves between clean and dirty tasks. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (Health Service Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of clinical Operations) on 03/04/26 at 11:16 am. They acknowledged the findings.

Plan of Correction – C0295 1. What actions will be taken to correct the rule violation for each example/resident? For Residents #1 and #2, as well as all other residents receiving care, immediate corrective actions were taken. A full review of infection control practices was conducted by the Health Services Director (LPN) and leadership team. All staff involved were immediately re-educated on proper infection prevention and control protocols, including hand hygiene, glove use, and prevention of cross-contamination. Return demonstrations were completed with all caregiving and medication staff to ensure proper technique, including performing hand hygiene before and after resident care, changing gloves between dirty and clean tasks, and avoiding contamination of clean supplies and surfaces. Incontinence care procedures were corrected to require hand hygiene before donning gloves, between dirty and clean tasks, and after glove removal. Staff were instructed not to touch clean surfaces or supplies with soiled gloves and to properly dispose of soiled briefs in designated receptacles. Medication administration practices were corrected to ensure staff perform hand hygiene and/or glove changes between tasks, avoid touching medications with bare hands, avoid contamination of medication cups and supplies, and maintain clean technique throughout medication pass. All residents were assessed for any potential adverse outcomes related to infection control breaches. No negative outcomes were identified at the time of review. All corrections were completed by: Clinical Team 2. How will the system be corrected so this violation will not happen again? The facility has implemented the following system changes to ensure ongoing compliance with infection prevention and control requirements. An Infection Control Specialist has been designated and meets qualifications as required by OAR. The designee has completed or is scheduled to complete required infection control training within the required timeframe. A standardized infection control protocol has been reinforced and includes clear expectations for hand hygiene, glove use, clean versus dirty task separation, and prevention of cross-contamination during both ADL care and medication administration. A mandatory infection control in-service was conducted for all staff, including caregivers and medication technicians, with emphasis on universal precautions, proper glove use, and hand hygiene compliance. A competency-based training program has been implemented requiring all staff to demonstrate proper infection control practices prior to working independently. Visual reminders and infection control signage have been placed in staff areas and medication rooms to reinforce expectations. Medication administration processes have been revised to ensure clean technique is maintained at all times, including proper handling of medication cups, avoidance of hand-to-medication contact, and required hand hygiene between residents and tasks. A monitoring system has been implemented, including routine observation of staff during care and medication passes to ensure adherence to infection control practices. 3. How often will the area needing correction be evaluated? Daily observations of caregiving and medication administration practices was conducted for four weeks following the survey. Weekly audits will be conducted for infection control compliance, including hand hygiene, glove use, and adherence to clean versus dirty task protocols. Monthly infection control audits will be conducted thereafter to ensure ongoing compliance. Competency validation will be completed for all new hires prior to independent work and re-evaluated annually. All identified concerns will be addressed immediately upon discovery. 4. Who will be responsible to see that the corrections are completed/monitored? The Health Services Director (LPN/DHW) is responsible for overall infection control oversight, staff training, competency validation, and audit completion. The designated Infection Control Specialist is responsible for implementation and ongoing monitoring of infection prevention and control protocols and serving as the point of contact for infection-related concerns. Resident Care Coordinators are responsible for reinforcing infection control practices during daily operations and ensuring staff adherence. The Executive Director is responsible for ensuring systems are in place and maintained for compliance. The Regional Nurse and VP of Clinical Operations provide additional oversight, review audit results, and ensure sustained compliance.

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

OAR 411-054-0090 (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 conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 03/02/26, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed the following: Staff were not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered, and comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated. In an interview on 03/03/26 at 11:00 am, Staff 5 (Physical Plant Director) confirmed the facility staff were not evacuating or relocating residents during fire drills. The requirements regarding fire drills were discussed with Staff 5 on 03/03/26 at 11:16 am, and Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RCC), Staff 4 (RCC), Staff 6 (Regional RN), and Staff 7 (VP of Clinical Operations) on 03/04/26 at 11:31 am. They acknowledged the findings.

POC C420 What Actions will be taken to correct the rule violations for each example? Staff were not evacuating or relocating residents during fire drills: Therefor Facility fire drill documentation did not include info on escape route used, problems encountered and comments relating to residents who resisited or failed to participate in drill and number of occupants evacuated. Immediately after this survey the Maintenance Director contacted our local Fire Marshall to get documentation on the rule. Our company was still under the impression that we were to shelter in place. We received the Fire Marshall documentation that shelter in place was not longer acceptable and residents in the fire area needed to be evacuated or moved beyond the fire doors to a safe area. This info was sent to our Home office and our frire drill form that is required for our drills was immediately updated to include a section that gives a place to document What escape route was used, how many occupants were moved or evacuated, residents who resisited or failed to participate. This form is now being used company wide for all fire drills. Clinical team has been educated that if we have a resident who is coninually resisitant to evacuating that this info will be documented into their service plan. We held an al staff meeting on March 19th where the new procedure was gone over with all staff and what they are to do when they hear the fire alarm go off and how to move residents and to lock and mark their doors once a room is cleared. This was gone over verbally at all staff and also printed and passed out at al lstaff. 2. How will the system be corrected so that this violation will not happen again? We use tels as our system that schedules our yearly fire drills. The Maintenance Director looks at his Tels tasks daily to know what regulatory items is needed to be done for that month. All of our fire drill sfor the 3 different shaits are scheduled in this system. The new form is downloaded into Tels and is attached to each scheduled fire drill. This reminds the maintenance man that he must use this form and fill it out completely and upload back into Tels as proof the task was completed along with staff signature log. The form has been updated so that anyone who does the drill will have the correct form to fill out with all required info. 3.How often will the area be evaluated? We do fire drills every other month. When they are due the Maintenance Director will conduct the drill and the ED will be the final staff to sign off and at that time the ED will verify that all required info has been filled out and that residents were moved or evacuated during each drill. 4. Who will be responsible to see that the corrections are completed and monitored? The ED has already verified that the form and the staff education has been completed. The ED will also verify at every fire drill that residents were evacuated and moved and the ED will verify that all info is filled out on the drill form that will be uploadced.

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

OAR 411-057-0140(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. Refer to: C295 and C420.

Tag Z142 Community will follow the POC outlined under tag C295 and C 420 C295 POC Plan of Correction – C0295 1. What actions will be taken to correct the rule violation for each example/resident? For Residents #1 and #2, as well as all other residents receiving care, immediate corrective actions were taken. A full review of infection control practices was conducted by the Health Services Director (LPN) and leadership team. All staff involved were immediately re-educated on proper infection prevention and control protocols, including hand hygiene, glove use, and prevention of cross-contamination. Return demonstrations were completed with all caregiving and medication staff to ensure proper technique, including performing hand hygiene before and after resident care, changing gloves between dirty and clean tasks, and avoiding contamination of clean supplies and surfaces. Incontinence care procedures were corrected to require hand hygiene before donning gloves, between dirty and clean tasks, and after glove removal. Staff were instructed not to touch clean surfaces or supplies with soiled gloves and to properly dispose of soiled briefs in designated receptacles. Medication administration practices were corrected to ensure staff perform hand hygiene and/or glove changes between tasks, avoid touching medications with bare hands, avoid contamination of medication cups and supplies, and maintain clean technique throughout medication pass. All residents were assessed for any potential adverse outcomes related to infection control breaches. No negative outcomes were identified at the time of review. All corrections were completed by: Clinical Team 2. How will the system be corrected so this violation will not happen again? The facility has implemented the following system changes to ensure ongoing compliance with infection prevention and control requirements. An Infection Control Specialist has been designated and meets qualifications as required by OAR. The designee has completed or is scheduled to complete required infection control training within the required timeframe. A standardized infection control protocol has been reinforced and includes clear expectations for hand hygiene, glove use, clean versus dirty task separation, and prevention of cross-contamination during both ADL care and medication administration. A mandatory infection control in-service was conducted for all staff, including caregivers and medication technicians, with emphasis on universal precautions, proper glove use, and hand hygiene compliance. A competency-based training program has been implemented requiring all staff to demonstrate proper infection control practices prior to working independently. Visual reminders and infection control signage have been placed in staff areas and medication rooms to reinforce expectations. Medication administration processes have been revised to ensure clean technique is maintained at all times, including proper handling of medication cups, avoidance of hand-to-medication contact, and required hand hygiene between residents and tasks. A monitoring system has been implemented, including routine observation of staff during care and medication passes to ensure adherence to infection control practices. 3. How often will the area needing correction be evaluated? Daily observations of caregiving and medication administration practices was conducted for four weeks following the survey. Weekly audits will be conducted for infection control compliance, including hand hygiene, glove use, and adherence to clean versus dirty task protocols. Monthly infection control audits will be conducted thereafter to ensure ongoing compliance. Competency validation will be completed for all new hires prior to independent work and re-evaluated annually. All identified concerns will be addressed immediately upon discovery. 4. Who will be responsible to see that the corrections are completed/monitored? The Health Services Director (LPN/DHW) is responsible for overall infection control oversight, staff training, competency validation, and audit completion. The designated Infection Control Specialist is responsible for implementation and ongoing monitoring of infection prevention and control protocols and serving as the point of contact for infection-related concerns. Resident Care Coordinators are responsible for reinforcing infection control practices during daily operations and ensuring staff adherence. The Executive Director is responsible for ensuring systems are in place and maintained for compliance. The Regional Nurse and VP of Clinical Operations provide additional oversight, review audit results, and ensure sustained compliance. C240 POC POC C420 What Actions will be taken to correct the rule violations for each example? Staff were not evacuating or relocating residents during fire drills: Therefor Facility fire drill documentation did not include info on escape route used, problems encountered and comments relating to residents who resisited or failed to participate in drill and number of occupants evacuated. Immediately after this survey the Maintenance Director contacted our local Fire Marshall to get documentation on the rule. Our company was still under the impression that we were to shelter in place. We received the Fire Marshall documentation that shelter in place was not longer acceptable and residents in the fire area needed to be evacuated or moved beyond the fire doors to a safe area. This info was sent to our Home office and our frire drill form that is required for our drills was immediately updated to include a section that gives a place to document What escape route was used, how many occupants were moved or evacuated, residents who resisited or failed to participate. This form is now being used company wide for all fire drills. Clinical team has been educated that if we have a resident who is coninually resisitant to evacuating that this info will be documented into their service plan. We held an al staff meeting on March 19th where the new procedure was gone over with all staff and what they are to do when they hear the fire alarm go off and how to move residents and to lock and mark their doors once a room is cleared. This was gone over verbally at all staff and also printed and passed out at al lstaff. 2. How will the system be corrected so that this violation will not happen again? We use tels as our system that schedules our yearly fire drills. The Maintenance Director looks at his Tels tasks daily to know what regulatory items is needed to be done for that month. All of our fire drill sfor the 3 different shaits are scheduled in this system. The new form is downloaded into Tels and is attached to each scheduled fire drill. This reminds the maintenance man that he must use this form and fill it out completely and upload back into Tels as proof the task was completed along with staff signature log. The form has been updated so that anyone who does the drill will have the correct form to fill out with all required info. 3.How often will the area be evaluated? We do fire drills every other month. When they are due the Maintenance Director will conduct the drill and the ED will be the final staff to sign off and at that time the ED will verify that all required info has been filled out and that residents were moved or evacuated during each drill. 4. Who will be responsible to see that the corrections are completed and monitored? The ED has already verified that the form and the staff education has been completed. The ED will also verify at every fire drill that residents were evacuated and moved and the ED will verify that all info is filled out on the drill form that will be uploadced.

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

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

Tag Z162 community will follow POC outlined under C260 POC 260 Plan of Correction – C0260 1. What actions will be taken to correct the rule violation for each example/resident? For all cited residents (Resident #1 and Resident #4), corrective actions were completed immediately. A comprehensive clinical reassessment was conducted by the Health Services Director (LPN) in collaboration with the RCC to ensure all current care needs, risks, and preferences were accurately identified. Service plans and Temporary Service Plans (TSPs) were revised to reflect the resident’s current status and required care, including gait belt use for all transfers, clear instructions for side rail use including when it is appropriate and safety precautions, wheelchair cushion use, meal assistance level including initiation and physical assistance, compression stocking application and removal, incontinence care needs, shower responsibilities between hospice and facility staff, floor mattress use including when it should be in place, trapeze use, individualized fall prevention interventions, pain management, and food preferences. All interventions were rewritten in clear, step-by-step language to ensure staff understanding and proper implementation. Direct care staff were re-educated on updated service plans prior to the next shift. Return demonstrations were completed for transfers and gait belt use. An audit of care implementation was completed through observation to ensure staff followed the updated service plans, including transfers and meal assistance. Physicians and POAs were notified as appropriate. All corrections were completed by: __________ 2. How will the system be corrected so this violation will not happen again? The facility has implemented system changes to ensure ongoing compliance. A standardized service plan format has been implemented requiring clear, task-specific instructions that outline how care is to be provided, when it is to be provided, and by whom. All required equipment such as gait belts, side rails, and trapeze must be clearly addressed. Staff assistance levels for all ADLs must be defined, along with safety precautions including fall prevention. A side rail and equipment clarification process has been implemented to ensure service plans clearly define the purpose of use, when the equipment should be in use, and required safety precautions. Staff have been educated on the difference between enablers and restraints to ensure compliance with Oregon regulations. The change of condition process has been reinforced to require immediate nurse assessment, same-day initiation of a Temporary Service Plan, and prompt updating of the permanent service plan to reflect ongoing needs. A Service Plan Audit Tool has been implemented to ensure plans are reflective of the resident’s current condition, aligned with observed care, and inclusive of all required interventions. Staff have completed retraining on service plan implementation, gait belt use, fall prevention, and meal assistance. New staff will complete competency validation prior to working independently. Clinical oversight has been strengthened. RCCs are responsible for documentation accuracy and service plan updates. The nurse is responsible for clinical validation and oversight. Daily clinical stand-up meetings have been implemented to review changes in condition, falls, and required service plan updates. 3. How often will the area needing correction be evaluated? Weekly audits of all service plans were conducted for four weeks following the survey. Monthly audits will be conducted thereafter to ensure ongoing compliance. Daily spot checks will be conducted to monitor transfers, including gait belt use, meal assistance, and fall prevention interventions. Quarterly service plan reviews will be tracked to ensure completion every 90 days in accordance with Oregon requirements. All identified issues will be corrected immediately upon discovery. 4. Who will be responsible to see that the corrections are completed/monitored? The Health Services Director (LPN/DHW) is responsible for overall clinical oversight, ensuring service plans reflect current resident conditions, conducting audits, and providing staff education. Resident Care Coordinators are responsible for service plan updates, documentation accuracy, and ensuring Temporary Service Plans are initiated and transitioned appropriately. The Executive Director is responsible for administrative oversight and ensuring compliance systems are maintained. The Regional Nurse and VP of Clinical Operations provide additional oversight, review audit outcomes, and ensure sustained compliance.

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: