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 interview and record review, it was determined the facility failed’ to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large for residents. Findings include, but are not limited to: The current month’s activity calendar was requested at survey entrance on 06/01/26. The facility provided the activity calendar for the month of 05/2026 and not the current month of 06/2026. During an interview on 06/02/26 at 11:35 am, Staff 1 (Senior ED) reported the 06/2026 activity calendar had not been completed and the facility was “still working on it”. When asked what activities the facility had planned for the residents, Staff 1 stated “bible study is today…bingo is on Wednesdays and most of the residents are independent, they like to do their own thing.” Staff 1 did not provide any additional information as to what activities were planned for the residents during the month of 06/2026. There were no structured activities observed for the afternoon of 06/01/26 and morning through the middle of the afternoon on 06/02/26. Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 and Staff 3 (RN) on 06/03/26 at 9:35 am. They acknowledged the findings.

CO242 OAR411-054-0030 (1)(c-d) Resident Services: Activities Activity calendar has been completed and posted with structered activities for residents to participate in. During the vacancy of LEC the Executive Director will be responsible for instructing, and or conducting meaningful activities for the residents. The life enrichment program will monitored daily. Ensuring activities are provided per monthly calendar. The Executive Director will be responsible during the vacancy of the LEC that activities are provided per the monthly calendar until position is filled.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 5 and 6) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (ED) on 06/02/26 at 3:25 pm. The following was revealed: a. There was no documented evidence Staff 5 (CG), hired 09/02/25, had demonstrated competency in: * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * First Aid certification. b. There was no documented evidence Staff 6 (CG), hired 11/12/25, had demonstrated competency in: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure caregiving staff demonstrated satisfactory performance in all required areas within 30 days of hire was reviewed with Staff 1 (Senior ED), Staff 2, and Staff 3 (RN) on 06/03/26 at 9:22 am. They acknowledged the findings.

C0372 OAR 411-054-0070 (5 & 9-10) Training within 30 days for direct care staff. a.Changes associated with normal aging; Identification, documentation and reporting of changes of condition; Conditions that require assessment, treatment, observation and reporting; First Aid certification. A training guide was presented to us for required trainings at the 30 day mark for onboarding which has been added to our onboarding requirements with a column to document completion due date. This will be monitored by Executive Director on a bi-weekly audit of new hires and existing staff. Required trainings have been assigned to staff #5 & #6 for completion.*Role of service plans in providing Idividualized care; *Changes associated with normal aging; *Identification, documentation and reporting of changes of condition; and *Conditions that require assessment, treatment, observation and reporting. These have been assigned to staff #6 for completion. Onboarding requirements has been added to a column to document completion due date. This will be monitored by the Executive Director on a bi-weekly audit.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 06/01/26 at 1:40 pm. The following areas required cleaning or repair: * Multiple doors and doorframes throughout the facility had scrapes, gouges, and/or marks; * The drywall across from room 126 had a gouge/hole; * Metal sewer covers near rooms 102 and 118 were bowed and not flush with the ground which created a potential tripping hazard; and * Carpeting in apartments 105 and 124 had dark stains. The areas in need of cleaning and/or repair were shown to and discussed with Staff 4 (Maintenance Director) on 06/03/26 at 8:43 am and were discussed with Staff 1 (Senior ED) on 06/03/26 at 9:18 am. The staff acknowledged the findings.

C0613 OAR 411-054-0300 (4)(d-i) General building: Doors Walls, cleanable * Multiple doors and doorframes throughout the facility had scrapes, gouges, and/or marks; Weekly walk arounds by the maintenance, and Executive Director will be done weekly to help identify any areas that may need attention for scrapes, gouges, and/or marks. This will be documented on our maintenance checklist. * Metal sewer cover near room 102 and 118 were bowed and not flush wth the ground which created a potential tripping hazard; the ground which created a potential tripping hazard; The area #102 have since been covered by an end table to protect anyone that may be walking over this. The Director and maintenance will conduct weekly walk arounds to monitor for any harm or trip hazard for #102 clean out. As for the clean out by #118 is flush to the ground with no potential threat and/or harm to anyone that would walk over it. As for lifting on the clean out by #118 it appears to be properly in place. * Carpeting in apartments #105 & 124 had dark stains. Carpet in #105 was shampooed the day survey was here. As for #124 it has since been shampooed. These carpets and any others will be monitored by the maintenance, and Executive Director during weekly walk arounds to ensure cleanliness. If needing shampooed the apartments will be added to maintenance log for cleaning.