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 related to meal service, medication assistance, and ADL care for 1 of 6 sampled residents (#6) and multiple unsampled residents who were dependent on staff for meal service and/or medication assistance. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 03/2026 with diagnoses including hypertensive chronic kidney disease and anxiety disorder. The resident was identified during the acuity interview on 03/23/26 as a recent move-in and had an emergency room visit related to high blood pressure. The resident's 03/12/26 through 03/23/26 clinical record, including the 02/19/26 service plan and evaluation were reviewed. The service plan and evaluation indicated Resident 6 relied on one staff to assist with toileting, transfers, dressing, and medication administration, was a high fall risk, alert and oriented to person, place, time and situation, used a call pendant to seek assistance, and had anxiety. The 03/12/26 through 03/23/26 MAR indicated morning blood pressure and anxiety medications were scheduled for 8:30 am. During an interview on 03/23/26 at 4:59 pm, Resident 6 was teary and identified the following: * Medications typically arrive late, including that morning; * A MT was not knowledgeable about his/her medications being provided; * Breakfast, lunch and dinner are “always late”; * Long call response times including staff promising to come back “but they never do.” S/he reported being left on the toilet as an example; and * S/he needed to direct his/her care with the day and evening staff and noted exhaustion. “I have to try and remember to tell them everything I need them to do, it’s exhausting and I can’t always remember. I just want someone to take care of me. I don't want to die here and I want to be taken care of properly. I keep pestering them and I get really worn out.” Observations and interviews with Resident 6 on 03/24/26 identified the following: * At 9:02 am, Resident 6 asked a caregiver where his/her breakfast and medications were and was told it should be delivered soon. * At 9:48 am a breakfast tray was delivered to his/her room. * At 9:55 am the MT provided medications for Resident 6. * At 11:05 am, the resident reported to the surveyor his/her medications were late again. “I was supposed to get my blood pressure pill at 8 am and it was close to 10 am. I also get anxiety pills, which I think both are very good pills to have on time for someone with high blood pressure.” * At 12:25 pm a caregiver provided ADL care that included bed mobility and transfer assistance, wheelchair escort to the bathroom and stand-by ambulation assistance from the bathroom and followed with the wheelchair. The resident provided direction for all steps of the care, including not leaving her apartment while on the toilet and what items needed to be in reach when back in bed. During an interview on 03/24/26 at 10:50 am, Staff 7 (MT) indicated the resident directed the care and acknowledged his/her service plan and evaluation had not been reviewed. The need to ensure residents were treated with dignity and respect regarding ADL needs, medication and meal service was discussed on 03/25/26 at 4:55 pm with Staff 1 (Regional Director of Operations). She acknowledged the findings. 2. Throughout the survey multiple unsampled residents complained of receiving meals and medications at unacceptable times. a. At 2:00 pm on 03/23/26 an unsampled resident approached the surveyor and reported they had not received their lunch yet. At 2:10 pm Staff 11 (Dining Services Assistant) was observed delivering lunch trays to resident rooms. Staff 11 reported meal delivery was running late that day. b. At 10:15 am on 03/24/26 Staff 10 (Dining Services Assistant) stated in an interview in the kitchen that they were currently getting breakfast trays ready to go to the rooms. At 10:20 am an unsampled resident approached the surveyor and stated she was hungry and hadn’t had breakfast yet. The resident stated, “Meals are always late and always cold.” At 10:26 am Staff 10 was seen coming off the elevator with a breakfast tray cart and walking toward the north hallway. The unsampled resident became upset and stated, “Why do they always have to go that way first? Why can’t they at least alternate which side of the floor they deliver trays to first, and come my way [indicating south hallway] first?” b. An unsampled resident was observed eating lunch in the dining room on 03/24/25 between 12:15 pm and 1:00 pm. After lunch the resident reported to the surveyor that they knew lunch was served between 12:00 and 1:00 in the dining room and didn’t understand why they had received their breakfast in their room at 11:00 am that morning, “an hour before lunch!” c. On 03/25/26 residents on the second floor were observed getting their breakfast trays at 10:47 am and their dinner (evening) trays at 4:09 pm. Both dining room servers delivering the trays reported these delivery times were typical with their current meal delivery system. d. At 9:50 am on 03/25/26 an unsampled resident approached the surveyor and stated s/he had not received his/her morning medications that should have been administered at 8:00 am. The surveyor and the unsampled resident walked to the Concierge desk and asked for a MT, who was paged. At 10:06 Staff 8 (MT) arrived at the resident’s room to administer the medications. Staff 8 reported that facility policy was to administer medications within one hour before and one hour after the scheduled administration time. Staff 8 stated they had stopped by the resident’s room shortly after 8:00 am and the resident was not in their room. Staff 8 stated they were relatively new to the facility and were “getting used to the residents’ schedules.” e. Review of resident council notes from 12/2025 to 02/2026 showed the following: * December 2025 – resident complaint of not getting food in time to participate in scheduled activities; * January 2026 – resident complaint of lack of consistency in mealtimes; and * February 2026 – resident complaint of late medications. On 03/25/26 at 2:30 pm the need to ensure all residents were treated with dignity and respect, including having meals delivered and medications administered at reasonable times was discussed with Staff 1 (Regional Director of Operations). She acknowledged the findings.

1. Community staff have reviewed and revised the meal and meal delivery times to be consistent with standard meal times. All times have been adjusted and meals are being served in accordance of the following times: Breakafast - Dining Room - 8-930a Breakfast - Trays - 730-9a (by floor) Lunch - Dining Room - 12-130p Lunch - Trays - 1130-130p (by floor) Dinner - Dining Room - 5-630p Dinner - Trays - 430-6p (by floor) Community ED and RN will review all medications and ensure that med times are appropriate and ensure that med passes are reasonable and adjust as needed to ensure timely administration 2. System will be corrected as stated above to ensure that resident rights are being honored at all times. 3. Continual evaluation of meal and med times will be monitored and audited. Management staff (ED, AED, RN) will track meal delivery times and med pass times to ensure that timely meals are provided and medications are administered appropriately, timely and according to physican orders. 4. ED, AED and RN will be responsible for auditing and ensuring corrections are being followed.

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 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications and treatments ordered by a physician or other legal prescriber and for which the facility was responsible to administer, including resident-specific parameters and instructions for PRN medications for 4 of 6 sampled residents (#s 3, 4, 6 and 7) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 04/2025 with diagnoses including liver failure and diabetes. The resident’s 03/01/26 through 03/23/26 MAR and current physician’s orders were reviewed. The following was identified: a. The resident’s MAR lacked a reason for use for the following medications: * Glipizide 5 mg tablet; * Duloxetine 60 mg capsule; * Levothyroxine 50 mcg tablet; and * Steglatro 5 mg tablet. b. The resident had the following PRN bowel medications that lacked clear instruction to staff, including order of administration: * Milk of magnesia (MOM) every day as needed for constipation. Instructions included “Resident prefers this medication first for constipation, if no relief proceed with MiraLAX, proceed to senna if MiraLAX is ineffective”. * MiraLAX once a day as needed for constipation; and * Senna/Docusate tablet every day as needed for constipation. The MAR indicated the resident received senna nine times. There was no documented evidence the MOM or MiraLAX was given and ineffective prior to the senna administration. c. The resident had the following PRN nausea medications that lacked clear instruction to staff for the order of administration: * Prochlorperazine; and * Zofran. The MAR indicated the resident received Zofran on five occasions. Interview with Staff 3 (Wellness Director/RN) on 03/24/26 at 11:45 am, acknowledged the directions were unclear. d. The resident had an order for a continuous blood glucose monitoring device, which instructed staff to apply to the back of the resident’s arm and to replace the sensor every 14 days. The order was not transcribed onto the MAR. There were no clear instructions to staff for monitoring and changing the device as indicated. During survey the resident was observed with the device in place on his/her arm at 12:50 pm on 03/24/26. In an interview on 03/25/26 at 9:45 am, Staff 5 (MT) confirmed he assisted the resident to change the sensor every 14 to 15 days and had not been documenting completion as the order was not on the MAR. The need to ensure MARs included the reason for use, provided clear instruction for the order of administration when multiple PRN medications were prescribed for the same diagnosis and recorded each treatment that the facility administered was reviewed with Staff 1 (Regional Director of Operations) and Staff 3 and Staff 4 (RCC) on 03/25/26 at 3:45 pm. They acknowledged the findings. 2. Resident 6 moved into the facility in 03/2026 with diagnoses including hypertensive chronic kidney disease and anxiety disorder. The resident’s MAR dated 03/12/26 through 03/23/26, and physician’s orders were reviewed. The following was identified: a. The resident had the following four PRN medications for constipation, which lacked clear parameters for order of administration: * Bisacodyl 5 mg, take one to three tablets every 24 hours PRN for bowel care. Instructions included “[u]se this medication if no BM in 24-48 hours”; * Docusate sodium 100 mg, take four capsules every 24 hours PRN for bowel care; * Milk of magnesia, take 30 mL every 24 hours for PRN bowel care; and * Polyethylene glycol powder, dissolve 17 gm in 4-8 oz or juice or water and take every 24 hours PRN if no BM in two days. The resident was administered docusate sodium and three tablets of bisacodyl on 03/14/26 and polyethylene glycol on 03/18/26. The resident had not taken PRN milk of magnesia during the reviewed period. b. The bisacodyl lacked specific instruction on how many tablets to administer. The need to ensure MARs included the dose for each medication and provided clear instruction for the order of administration when multiple PRN medications were used was reviewed with Staff 1 (Regional Director of Operations), Staff 3 (Wellness Director/RN), and Staff 4 (RCC) on 03/25/26 at 4:55 pm. They acknowledged the findings. 3. Resident 7 moved into the facility in 12/2023 with diagnoses including failure to thrive and asthma. The resident’s MAR dated 03/01/26 through 03/23/26, and physician’s orders were reviewed. The resident had the following three PRN medications for constipation, which did not have clear parameters for order of administration: * Milk of magnesia, take 30 ml PRN if no bowel movement in three days. Instructions included “Use first for constipation. If ineffective, see senna-docusate order.” * Senna/docusate 8.6-50 mg, take 1 tablet every day for PRN bowel management. Instructions included “Use 2nd after no result from milk of magnesia.” * Polyethylene glycol powder, dissolve 17 gm in 4-8 oz of liquid every 12 hours PRN for constipation. During an interview on 03/25/26 at 1:20 pm, Staff 3 (Wellness Director/RN) acknowledged the instructions for the PRN bowel medication were confusing and would get clarification from the physician. The need to ensure PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (Regional Director of Operations), Staff 3 and Staff 4 (RCC) on 03/25/26 at 4:55 pm. They acknowledged the findings. 4. Resident 4 moved into the facility in 05/2025 with diagnoses including asthma and COPD. The resident’s 03/01/26 through 03/23/26 MAR and corresponding physician orders were reviewed. The facility had physician orders for the following medication: * Risperidone 0.5 mg tablet – take 1 tablet by oral route 2 times every day; may increase to 2 tablets daily if needed for behavioral disturbances. The resident’s March MAR indicated the resident received 1 tablet twice daily at 8 am and 8 pm, and a PRN dose of 2 tablets on 03/15/26 at 11:52 am. In an interview on 03/25/26 at 11:30 am, Staff 3 (Wellness Director/RN) reported that the MT who had administered the PRN dose on 03/15/26 had called Staff 3 to clarify the order and that Staff 3 had directed the MT to administer a PRN dose of 2 tablets. Staff 5 (MT) reported in an interview at 4:20 pm on 03/25/25 that they had never administered Risperidone as a PRN medication, and that it was not clear to them whether this order was for a scheduled dose and a PRN dose, or whether it was for a scheduled dose to be changed to a higher dose if needed. The need to ensure resident MARs were accurate, including clear instructions to staff, was discussed with Staff 1 (Regional Director of Operations), Staff 3, and Staff 4 (RCC) on 03/25/26 at 2:30 pm. They acknowledged the findings.

1. Resident 3, 4, 6, 7 MARs were reviewed during survey and corrected to reflect the findings during survey. All other residents MARs will be audited to ensure proper administration, parameters, and diagnosis. 2. ED and RN will complete a full audit of all MARs for all residents to ensure proper components of all orders for residents including time, diagnosis, parameters, non-pharm interventions, etc. 3. One full evaluation of MARs will be completed, and then ED and RN will monitor via auditing weekly for 60 days and then monthly thereafter to ensure compliance. 4. ED and RN will be responsible for corrections and monitoring of resident MARs and Physician Orders

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

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 2 of 2 sampled residents (#6 and 7) who had supportive devices with restraining qualities. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 03/2026 with diagnoses including hypertensive chronic kidney disease and anxiety disorder. Observations of the resident and the resident's room on 03/23/26 at 4:59 pm showed bilateral quarter-length side rails were on each side of the bed in the up position and represented a device with restraining qualities. Review of Resident 6's record revealed there was no documented evidence the devices with restraining qualities had been assessed by an RN, PT, or OT, no documentation of other less restrictive alternatives evaluated prior to use of the devices, no documentation of instruction to caregivers on correct use of and precautions for the device, and no documentation of the use of the side rails in the resident's service plan. During an interview on 03/24/26 at 1:08 pm, Staff 3 (Wellness Director/RN) acknowledged no assessment had been completed for Resident 6's side rails. The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and the device was included in the resident's service plan was discussed with Staff 1 (Regional Director of Operations), Staff 3 and Staff 4 (RCC) on 03/25/26 at 4:55 pm. They acknowledged the findings. 2. Resident 7 moved into the facility in 12/2023 with diagnoses including failure to thrive and asthma. During the acuity interview on 03/23/26, Resident 7 was identified as having side rails on each side of the bed. Observations of the resident and the resident's room on 03/24/25 at 3:13 pm showed the half-length side rails were on each side of the bed in the up position and represented a device with restraining qualities. Additionally, both of the rails were loose, and Resident 7 acknowledged the rails needed to be secured. Although the resident had a quarterly assessment for the side rails, dated 01/13/26, there was no documented evidence of the use of the side rails in the resident's service plan. Additionally, caregivers interviewed on 03/25/26 regarding the side rails could not provide information on the correct use of and precautions for the device. On 03/24/26, Staff 3 (Wellness Director/RN) was notified both rails were loose by the surveyor and she stated she would have maintenance secure it immediately. On 03/25/25 at 9:33 am Staff 12 (Maintenance Technician) confirmed the rails had been addressed. The need to ensure the use of a supportive device with potentially restraining qualities was included in the resident's service plan was discussed with Staff 1 (Regional Director of Operations), Staff 3 and Staff 4 (RCC) on 03/25/26 at 4:55 pm. They acknowledged the findings

1. Resident 6 & 7 Supportive Device Assessments have been updated and completed for use. Community RCC will conduct a full audit of resident rooms to ensure all supportive devices with restraining qualities are captured for RN assessment appropriately. 2. A full room audit for all community residents will be completed to ensure that all supportive devices are captured. Any missing assessments will be completed accordingly. All past due assessments in EHR system will be caught up and updated accordingly. During this time ED and RN will review service plan to ensure that resident service plan reflects the need for use in of supportive device and what to do if in disrepair. ED will conduct training during all staff on what to do if we see supportiv devices and who to report to. 3. ED and RN will complete monthly audits of all resident charts to ensure that any assessments that are needed are completed and meet requirements. ED/RN will ensure service plan is reflective of the supportive device and what to do if in disrepair. 4. ED and RN will be responsible for correction and on-going monitoring

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 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 care time and care elements that staff provided were captured accurately for 5 of 6 sampled residents (#s 1, 2, 4, 6 and 7) whose ABSTs were reviewed. Findings include, but are not limited to: Resident 1, 2, 4, 6 and 7’s service plans and facility ABST entries were reviewed. The following was identified: Multiple care areas had no recorded minutes, incorrect minutes and/or did not reflect two-person assistance was provided in one or more of the following areas: * How much time was spent providing treatments; * How much time was spent providing non-drug interventions for pain management; * How much time was spent providing non-drug interventions for behaviors; * How much time was spent repositioning in bed or chair; * How much time was spent monitoring behavioral conditions or symptoms; * How much time was spent with medication administration, passing out medications; * How much time was spent transferring in or out of bed or a chair; * How much time was spent responding to call lights; * How much time was spent helping with bowel and bladder management; and * How much time was spent monitoring physical conditions or symptoms. In a group interview on 03/25/26 with Staff 1 (Regional Director of Operations), Staff 3 (Wellness Director/RN) and Staff 4 (RCC), Resident 1, 2, 4, 6 and 7’s ABST minutes and service plans were reviewed. The staff acknowledged there were several care areas that were not reflective of the care time the residents received. The staff acknowledged the findings.

1. Resident 1,2,4.6.7 ABST will be updated to reflect correct/appropriate times for tasks and are reflected in the ABST appropriately. 2. ED will review service plans upon completion and signing and ensure that the ABST hours are correct and reasonable for the care provided for every resident. ED will complete full audit of resident times in ABST for accuracy. 3. Once audit is completed ED will review weekly with service plan meetings to ensure the accuracy of ABST and staffing plan. 4. ED will be responsible for corrections and monitoring.

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: