OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report possible neglect for 1 of 1 sampled resident (#1) whose record was reviewed for a fall. Findings include, but are not limited to: Resident 1 was admitted to the Memory Care Facility in 05/2025 and had diagnoses which included Alzheimer’s dementia and required staff assistance for transfers and mobility. In an interview with Witness 1 on 04/01/26 at 10:35 am, s/he said s/he installed a camera in the room that recorded interactions between Resident 1 and staff. During the interview, s/he reported that Resident 1 had a fall on 03/04/26 that was recorded on the video. S/he showed the video to the surveyor and explained how the CG did not engage the wheelchair brake on the left side. When the resident attempted to stand, the wheelchair on that side moved, the resident was unable to maintain his/her balance, and fell. Witness 1 said s/he felt the CG’s failure to engage the wheelchair brake contributed to the fall. The facility investigation of the fall indicated a CG was assisting the resident from his/her wheelchair to a recliner. During the transfer, “one of [the resident’s] brakes on [his/her] wheelchair was not clamped tight by mistake” and the wheelchair slid out from under the resident “causing [him/her] to fall…” The investigation indicated abuse and neglect was “ruled out as this was a witnessed fall and care plan was followed.” The incident was not reported to the local SPD office as suspected neglect. During a conversation with Staff 1 (ED), Staff 2 (VP of Operations), Staff 3 (Assistant ED - Ramp) and Staff 4 (Assistant ED – Douglas) on 04/02/26 at 11:20 am, Staff 1 stated the investigation was completed by staff that no longer worked at the facility. The circumstances surrounding the fall, failure to ensure the left brake was locked in place, and failure to follow the plan of care was discussed. Staff 1 and Staff 2 agreed the incident should have been reported to the local SPD office. The surveyor directed the facility to self-report the incident to the local SPD or AAA office. Confirmation the facility reported the incident was received on 04/02/26.

Pacific Living Centers of Roseburg at Ramp will implement the following: 1. All incidents that relate to any injuries or investigations that show service plans were not followed will be reported in a timely manner per OAR. 2. All incident reports will be reviewed by ED/RN within 24 hours, investigation will be completed, and self report done if needed. 3. With each and every incident report done 4. The Executive Director will be responsible to see that corrections are completed and monitored. The clinical team will be checking weekly.

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

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to: The facility was divided into two memory care houses, Douglas House and Ramp House. At the time of the survey the facility was home to 23 residents: 13 and 10, respectively. At the time of the survey, the facility did not have specific activity staff and had universal workers (direct care staff) who were expected to provide a daily program of social and recreational activities. The posted activity calendar showed the following activities were scheduled for 04/01/26: *Chair yoga; *Sing along; *Sensory game; *Reverse coloring; *Group puzzle; and *Music and dance. Observations during the survey on 04/01/26 at 9:15 am to approximately 5:00 pm identified the following activities were observed: * Group puzzle; and * Reverse coloring. In each unit during the survey, there were some residents who were in their rooms all day, a few residents would sit in the living room watching a television show that played continuously throughout the day and occasionally, when staff had time, a universal worker would sit and talk with some residents. On 04/02/26 at approximately 10:00 am, unsampled resident was overheard talking to Staff 2 (Vice President of Operations) saying “there isn’t much to do around here.” The facility lacked a daily program of social and recreational activities that was based on individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in their community. The need to develop and implement a daily program of social and recreational activities was discussed with Staff 1 (ED), Staff 2, Staff 3 (Assistant ED-Ramp) and Staff 5 (Regional Director of Operations) on 04/02/26 at 11:00 am. They acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following: 1. All residents' activity forms are being redone with caregivers and families involvement to meet each of their needs and requests. Activity calendar will be reviewed and updated to meet the residents needs and wants each month. 2. Activity forms will be evaluated with every quarterly or change of condition being done. 3. The Executive Director and or Assistants will be responsible for audits weekly for 1 month and then monthly thereafter to ensure activities are being implemented and met for all residents. 4. The Executive Director and or Assistants will be responsible for activities being completed and monitored.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction for staff for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the Memory Care Facility in 05/2025 and had diagnoses which included Alzheimer’s dementia. During the entrance conference on 04/01/26, staff reported the resident had a recent significant decline in health. Resident 1’s clinical record, interviews with care staff, an interview with Witness 1 (family), and observations during the survey revealed s/he was “high care”, needed staff assistance for ADLs, was on oxygen, had a foley catheter, and had skin breakdown to his/her bottom. Resident 1's current service plan, updated 02/13/26, was not reflective of the following areas: * Activity participation; * Bathing assistance; * Meal monitoring; * Meal location preferences; * Non-drug interventions for PRN psychoactive medications; and * Mobility and wheelchair use. The need to ensure the service plan was reflective of Resident 1's current needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (VP of Operations), Staff 3 (Assistant ED - Ramp) and Staff 4 (Assistant ED – Douglas) on 04/02/26 at 11:20 am. They acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided. ?

Pacific Living Centers of Roseburg at Ramp will implement the following: All Service Plans are reviewed and updated to meet all residents' needs. * Activity participation; * Bathing assistance; * Meal monitoring; * Meal location preferences; * Individualized Care plans PRN psychoactive medications; and * Mobility and wheelchair use to include locking the breaks Care plans are reflective of current care needs and provided with clear direction. 2.all level of care assessments including pre move in will address all Service plan items including but not limiting all ADLs and preferences. 3. ED and RN will review all level of care assessments completely before locking and putting out for staff. Service plan changes will be implemented in between level of care assessments to ensure service plan is up to date and accurate. 4. The Executive Director will be responsible for monitoring and be sure all service plans are completed

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 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications for 1 of 2 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the Memory Care Facility in 05/2025 and had diagnoses which included Alzheimer’s dementia. The resident's 02/01/26 through 03/31/26 physician orders and MARs were reviewed. The following was identified: * Resident 1 had an order for a Lidocaine patch twice a day for pain. The MAR instructed staff to document that the patches were applied and removed. According to the MARs, between 02/20/26 and 03/31/26, staff noted on several occasions the patch was removed when the documentation from the earlier administration times indicated the patch had not been applied because it was either refused or out of supply. * Resident 1 had orders for Albuterol two puffs every four hours for chronic obstructive pulmonary disease, and cranberry capsules 500 mg one daily for urinary tract infections. According to the MAR, staff documented on several occasions between 03/20/26 and 03/31/26 that the inhaler and/or cranberry capsules were not available. However, there were also multiple occasions when staff initialed the medications were administered during the same time frame. The MARs were reviewed with Staff 1 (ED) and Staff 3 (Assistant ED – Ramp) on 04/26/26 at 8:30 am. They viewed the MARs and stated staff had documented in error. They acknowledged the MARs were inaccurate. The need to ensure MARs were accurate was discussed with Staff 1 Staff 2 (VP of Operations), Staff 3 and Staff 4 (Assistant ED – Douglas) on 04/02/26 at 11:20 am. They acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following: 1.Med techs will be retrained by Nurse and ED, on how to correctly communicate and document for any medications or treatments that are out of stock, so the next shift is aware too. 2. Retraining med techs on the 8 rights of med administration to ensure medications are being documented and administered appropriately. 3.ED/RN to do weekly audits on med administration weekly for 1 month and then monthly thereafter. 4. ED will be responsible to ensure these corrections are implemented and being followed.

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 411-057-0140(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 C231 and C242.

Refer to C231 and C242.

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 and C310.

Refer to C260 and C310

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: