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 injuries of unknown cause to the local Department as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse, for 3 of 3 sampled residents (#s 1, 2 and 4) with injuries. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 10/2024 with diagnoses including Alzheimer’s dementia. A review of the resident's clinical record, including progress notes and incident reports, identified the following: * On 05/27/26, staff identified a skin tear to the resident’s left arm. An incident investigation was requested during the survey. On 06/17/26 at 1:20 pm, Staff 3 (LPN) reported no incident investigation had been completed regarding the injury. The injury to Resident 1's left arm represented an incident that should have been reported to the local Department unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. There was no documented evidence the facility either reported the incident or immediately investigated the incident and ruled out abuse. At the request of survey, the facility reported the above injury of unknown cause and provided verification of reporting on 06/18/26 at 10:35 am. The need to ensure injuries of unknown cause were reported to the local Department as suspected abuse unless an immediate facility investigation reasonably concluded the physical injuries were not the result of abuse was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 on 06/18/26. They acknowledged the findings. 2. Resident 2 moved into the memory care community in 09/2025 with diagnoses including Alzheimer’s disease. The resident’s progress notes dated 03/15/26 through 06/14/26, and incident reports were reviewed. On 06/04/26, staff documented an “open wound” on Resident 2’s left knee “while changing [the resident] into pajamas.” Staff continue to document, “This MT cleaned and bandaged it back up from someone previously bandaging it.” There was no documented evidence of the resident having an “open wound” to his/her left knee prior to 06/04/26. An investigation was documented on 06/08/26, which was four days after the “open wound” was identified. At the request of survey, the facility reported the above injury of unknown cause and provided verification of reporting on 06/18/26 at 11:47 am. The need to ensure the facility immediately investigated injuries of unknown cause was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 06/18/26 at 12:08 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 05/2025 with diagnoses including Alzheimer’s disease. The resident’s clinical record, which included communication to the physician, skin monitoring notes, and incident reports, was reviewed. On 03/10/26, facility staff sent a fax to Housecall Providers, informing them that Resident 4 “has [two] bruises on [his/her] left wrist.” Staff described the bruises being “about a quarter size” and “about a nickel size.” On 06/18/26 at 11:48 am, Staff 3 (LPN) confirmed there was no documented evidence the facility investigated the bruising to Resident 4’s left wrist. At the request of survey, the facility reported the above injury of unknown cause and provided verification of reporting on 06/18/26 at 2:49 pm. The need to ensure the facility immediately investigated injuries of unknown cause was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 on 06/18/26 at 12:08 pm. They acknowledged the findings.

The facility reviewed its Abuse Prevention, Reporting, and Investigation process to reinforce requirements for: •Immediate reporting of all injuries of unknown cause to APS unless an immediate investigation reasonably concludes and documents the injury was not the result of abuse. •Immediate initiation of an internal investigation upon identification of any injury of unknown cause. •Completion of all required investigation documentation, including: oDate, time, and location of the event oPersons involved oDescription of the injury/event oImmediate staff response oFollow-up actions taken oAdministrator review and final determination •Timely notification of law enforcement if necessary To prevent reoccurrence, the facility has reinforced its Abuse Prevention, Reporting, and Investigation process with staff. The Executive Director will monitor compliance through ongoing review of applicable incidents and documentation. Monitoring will occur weekly for four weeks, then monthly through the QAPI process to ensure continued 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: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs, provided clear direction to staff, and was implemented for 3 of 3 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the memory care community in 09/2025 with diagnoses including Alzheimer’s disease and post-traumatic stress disorder. Observations were made of the resident, interviews with the resident’s spouse and facility staff were conducted, and the 05/06/26 service plan was reviewed. Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Entering the unit disrobed; * Aggression towards other residents; and * An intimate relationship with another resident. In an interview on 06/16/26 at 11:26 am, Witness 1 (Spouse) identified that Resident 2 was in an intimate relationship with another resident who lived on the unit. Witness 1 approved of the relationship and expressed that the unsampled resident gave his/her spouse comfort when s/he was not visiting. Witness 1 also reported that Resident 2 had “sundowning” behaviors. This was not reflective in the resident’s service plan. On 06/17/26 at 4:06 pm, Staff 9 (CG) reported that the resident came out of his/her apartment without being clothed sometimes, stated that Resident 2 had a “friend” who calmed him/her down when s/he was exhibiting signs of stress, and verified s/he was involved in resident-to-resident altercations. This was not reflective in Resident 2’s service plan. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 06/18/26 at 12:08 pm. They acknowledged the findings. 2. Resident 4 moved into the memory care community in 05/2025 with diagnoses including Alzheimer’s disease. Observations were made of the resident, interviews with facility staff were conducted, and the 05/26/26 service plan was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * What actions the resident exhibited prior to his/her behaviors; * How the resident communicated the location of his/her pain; * Conflicting information relating to which language the resident primarily used; and * Aggression towards other residents. On 06/17/26 between 1:07 pm and 1:52 pm, Resident 4 was observed walking towards other residents. In an attempt to redirect, Staff 7 (MT/CG), stated, “Let’s be nice to our neighbors.” At 1:52 pm, Staff 12 (CG) confirmed Resident 4 had hit an unsampled resident during the observation. The resident’s history of aggression towards other residents was not reflective in his/her service plan. On 06/18/26 at 10:50 am, caregiving staff were attempting to help the resident with ADLs. Staff 6 (MT/CG) spoke to Resident 4 in Spanish and explained what the CGs were trying to help him/her with. The resident agreed to the care. Staff 6 went on to explain how she knew if Resident 4 was walking towards others for interaction versus if s/he was going to be aggressive. She also stated that the resident had a communication board which listed verbs (e.g. hungry, thirsty, pain) with a corresponding picture. During the same interview, Staff 7 confirmed the communication board did not consistently work as the words were in English. How Resident 4 exhibited aggression towards others and primarily speaking Spanish was not reflective in his/her service plan. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 06/18/26 at 12:08 pm. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 10/2024 and had diagnoses which included Alzheimer’s dementia. Resident 1’s clinical record, interviews with care staff, and observations during the survey revealed the resident required full assistance with all ADLs including eating assistance, needed two staff for mobility, was on a pureed diet with thickened liquids, and was receiving hospice services. Resident 1's current service plan, dated 04/26/26, was not implemented, reflective, or did not provide clear directions to staff in the following areas: * Thickened liquids; * Toothettes used for oral care; * Use of heel protectors; * Activity needs and participation; * Ability to make needs known; * Reminders for meals, hygiene and toileting; * Incontinence products used; * Fall risk interventions; * Side rail use; * Ability to manage a key to his/her apartment; and * Use of Geri-sleeves. The need to ensure the service plan was reflective of Resident 1's current needs, provided clear direction to staff, and was implemented was discussed with Staff 3 (LPN) on 06/17/26 26 at 1:10 pm, and with Staff 1 (ED), Staff 2 (RN) and Staff 3 on 06/18/26. The findings were acknowledged.

The facility reviewed and revised its Service Plan process to reinforce requirements that service plans: •Accurately reflect each resident's current assessed needs and preferences. •Provide clear, individualized directions regarding what care is to be provided, by whom, how, and how often. •Be updated following: oSignificant changes in condition or behavior. oNew physician orders. oNew safety concerns. oQuarterly evaluations. •Be readily available to staff and consistently implemented during care delivery. A standardized Service Plan Review Checklist has been implemented to verify that all required care areas are addressed before a service plan is finalized or revised. Starting July 6, 2026, Facility to re-evaluate 2-3 service plans a week until all 16 residents have accurate service plans. To prevent reoccurrence, the facility has reinforced its Service Plan process with staff. The Executive Director will monitor service plans through routine audits to ensure they are accurate, current, and implemented. Monitoring will occur on an ongoing basis through the facility's QAPI process.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for short-term changes of condition, communicate the action or intervention to staff on each shift and document progress through resolution for 1 of 2 sampled residents (# 4) who were reviewed for resident-to-resident altercations. Findings include, but are not limited to: Resident 4 moved into the memory care community in 05/2025 with diagnoses including Alzheimer’s disease. The resident's progress notes dated 05/13/26 through 06/10/26, service plan addendums (SPAs), and facility incident reports were reviewed. Staff documented in an incident report on 05/30/26 that Resident 4 scratched "another resident on arm near elbow". Staff "separated residents and redirected." On 06/01/26, staff documented in a progress note, "Resident scratched another resident over the weekend. Resident was redirected and notifications made per policy." There was no documented evidence the facility determined and documented what action or intervention was needed for the resident-to-resident altercation, communicated the action or intervention to staff on each shift and monitored Resident 4 with documented progress through resolution. On 06/18/26 at 11:48 am, Staff 3 (LPN) confirmed there was no documented evidence a SPA was created with actions or interventions determined which would have communicated any actions or interventions to staff on each shift or monitoring occurred through resolution for Resident 4's resident to resident altercation. The need to ensure the facility determined and documented what action or intervention was needed, communicate the action or intervention to staff on each shift and documented progress through resolution was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 on 06/18/26 at 12:08 pm. They acknowledged the findings.

The facility reviewed and revised its Change of Condition process to reinforce that any resident experiencing a short-term change of condition, including: •Resident-to-resident altercations •Behavioral changes •New injuries •Acute illnesses •Skin concerns •Changes in mobility •Falls •Significant pain or discomfort Will receive: •A documented nursing or management assessment. •A determination of required interventions. •A resident-specific Short-Term Change of Condition/SPA. •Written communication of interventions for all shifts. •Ongoing monitoring with documented progress until the condition resolves. •Review for service plan revision if the condition becomes significant or ongoing. To prevent reoccurrence, the facility has reinforced its Change of Condition process with staff. The Executive Director will monitor compliance through routine review of change of condition documentation and interventions. Monitoring will occur on an ongoing basis through the facility's QAPI process.

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, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's service plan for 1 of 1 sampled resident (#3) who had side rails on their bed. Findings include, but are not limited to: Resident 3 was admitted to the facility on 05/2026 with diagnoses which included dementia. On 06/16/26 at 10:50 am, the resident's bed was observed to have bilateral half-length side rails in the up position. There was no documented evidence that the device with restraining qualities had been assessed by an RN, PT or OT, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's service plan. The above information was discussed with Staff 2 (RN) and Staff 3 (LPN) on 06/16/26 at 3:20 pm. They acknowledged the resident's record lacked an assessment by an RN, PT or OT, instruction to caregivers on correct use and precautions, and documentation in the service plan.

A review was completed for all residents currently using restrictive devices to ensure a current RN assessment is present and service plans accurately reflect interventions. •A task for caregivers will be added for all restrictive devices to notify if they are not working properly. •Quarterly assessments will be completed using PCC as a tracker. To prevent reoccurrence, the facility has reinforced its process for assessing and monitoring restrictive devices. The Executive Director will conduct routine audits to ensure required assessments and documentation are completed. Monitoring will occur on an ongoing basis through the facility's QAPI process.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have two direct care staff scheduled and available at all times on the overnight shift whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: During the entrance conference on 06/16/26 with Staff 1 (RN) and Staff 2 (LPN), review of the facility’s ABST, and review of the posted staffing plan, the following was identified: * The MCC was home to 16 residents; * Six residents required a two-person assist for transfers and/or care at all times; * Two direct care staff were scheduled for the overnight shift (10:00 pm to 6:00 am); and * Staff meal breaks were 30 minutes. During an interview with Staff 1 (ED) on 06/18/26 at 9:30 am, he said he was unsure if night shift staff left the MCC for their 30-minute meal break. Additionally, there was currently no plan in place to ensure two staff were available in the MCC when a staff person was on their break. He stated he would make a change to ensure two staff were available at all times on the overnight shift whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. The need to ensure the facility had two direct care staff scheduled and available at all times on the overnight shift whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs was discussed with Staff 1, Staff 2 (RN) and Staff 3 (LPN) on 06/18/26. The findings were acknowledged.

To ensure continuous staffing while maintaining required resident supervision, the facility will implement paid, on-duty 30-minute meal periods for overnight Memory Care staff. During the meal period, staff will remain on the premises and will be compensated for the full 30-minute break. Staff will be expected to use this time as their meal period and will only be interrupted in the event of an emergency or an urgent resident care need requiring the assistance of the second caregiver. To prevent reoccurrence, the facility has reinforced overnight staffing expectations with staff. The Executive Director will monitor staffing practices and compliance through routine review. Monitoring will occur on an ongoing basis through the facility's QAPI process.

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 the Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements staff were providing to residents for 3 of 6 sampled residents (#s 2, 4, and 6) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the memory care community in 09/2025 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the clinical record and the ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to Resident 2: * Leisure activities; * Treatments; and * Dressing and undressing. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 06/18/26 at 12:08 pm. They acknowledged the findings. 2. Resident 4 moved into the memory care community in 05/2025 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the service plan, dated 05/26/26, and the ABST data were completed. The following areas listed zero minutes relating to time staff spent providing assistance to the resident: * Monitoring behavioral conditions or symptoms; and * Assisting with leisure activities. On 06/17/26, between 1:07 pm to 1:52 pm, staff were observed attempting to redirect Resident 4 from other residents who lived on the unit. At 1:12 pm, it appeared that the resident hit the side of a couch and walked away. An unsampled resident who was sitting on the couch stood up. S/he wanted to know where Resident 4 was going and implied s/he needed to “watch out” for the resident. At 1:14 pm, Staff 12 (CG) confirmed she witnessed Resident 4 hit the unsampled resident who was sitting on the couch. On 06/18/26 at 9:59 am, Resident 4 was observed to attempt to pinch a CG. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 06/18/26 at 12:08 pm. They acknowledged the findings.

The Registered Nurse, Licensed Practical Nurse and Resident Care Coordinator reviewed all current resident ABSTs to verify that required care minutes are documented accurately and reflect the care being provided. All identified inaccuracies have been corrected. Residents that attend group activities will have a number of minutes added to each of them. To prevent the reoccurrence all new residents and existing residents ABST tool will be reviewed and updated on move in, change of condition and/or every 90 days. This will be monitored through PCC and the clinical meeting held Monday through Friday.

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 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, C360 and C362.

The Executive Director and Registered Nurse reviewed the facility's policies and procedures to ensure ongoing compliance with the Oregon Administrative Rules for Assisted Living and Memory Care Communities. Oversight has been strengthened to ensure: •Injuries of unknown cause are reported and investigated. •Service plans accurately reflect each resident's current needs and are updated following significant changes in condition. •Short-term and significant changes of condition are documented, communicated to staff, monitored through resolution, and incorporated into resident care planning Refer to C231, C360, and C362

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, C270 and C340.

The facility has reviewed the findings associated with this citation and has implemented corrective actions for the deficiencies under C260, C270, and C340. Affected residents were assessed, and corrective measures were completed as outlined in the Plans of Correction for those citations. Processes have been reinforced to ensure: •Resident assessments are completed timely and accurately. •Changes in resident condition are identified, documented, communicated, and followed with appropriate interventions. •Resident service plans are current, individualized, and implemented consistently. •Nursing oversight and documentation meet regulatory requirements. •Health care services are provided according to physician orders, resident assessments

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements and develop an individualized activity plan based on their activity evaluation for 3 of 3 sampled residents (#s 1, 2 and 4) whose evaluations and service plans were reviewed. Findings include, but are not limited to: Observations of Residents 1, 2 and 4 were conducted from 06/16/26 to 06/18/26. One resident was observed to exhibit behaviors, and one resident was observed to remain in bed. The residents’ current service plans were reviewed and the following was identified: a. Although some elements were addressed in Resident 1, 2 and 4’s service plan, there was no documented evidence an activity evaluation had been completed that addressed the following: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no documented evidence an individualized activity plan was developed for each resident. During an interview on 06/18/26 at 12:08 pm, Staff 1 (ED) confirmed the facility had not evaluated the residents for activities or documented an individualized activity plan based on their evaluation. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1, Staff 2 (RN) and Staff 3 (LPN) on 06/18/26 at 12:08 pm. They acknowledged the findings.

RN to receive activities form Activities Director to go through with all residents and give a copy to the nurse’ to action as needed. To prevent reoccurrence the facility has reinforced its process for communicating resident activity information. The Executive Director will monitor compliance through routine review. Monitoring will occur on an ongoing basis through the facility's QAPI process.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height and constructed to reduce the risk of elopement, and outdoor furniture was of sufficient weight to prevent resident injury or aid in elopement. Findings include, but are not limited to: A tour of the facility's memory care courtyard was conducted on 06/16/26 at 9:21 am and the following was identified: a. Sections of fencing was less than six feet in height. Three sections located in a bark dust border ranged in height from approximately 5 foot 9 inches to 5 foot 11 inches in height. b. Two chairs located on the patio in the secured courtyard were not of sufficient weight to prevent resident injury or aid in elopement. On 06/16/26 at 1:42 pm, Staff 4 (Maintenance Director) measured an area of the fence and confirmed it was not six feet in height. During the same time as the fence was being measured, Staff 1 (ED) confirmed he had spoken to staff previously about not bringing chairs out of the unit to the secured courtyard. On 06/17/26 at 8:58 am, the two chairs were no longer on the patio. The fencing sections that were less than six feet in height and the furniture that was not of sufficient weight were shown to and discussed with Staff 1 and Staff 4 on 06/16/26 at 1:42 pm. They acknowledged the findings.

Maintenance Director to purchase multiple Lattice strips and add on top of the current fence. Maintennace Director to ensure that the fence is at least 6 feet tall. To prevent reoccurence the Maintenance Director will measure the fence when he conducts his QAPI.