OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 2 of 2 sampled residents (#s 1 and 2) who were prescribed modified texture diets and fluid consistencies. The residents’ prescribed diets were not administered by the facility, placing them at risk of aspiration, choking, and/or death. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2026 with diagnoses including Alzheimer’s disease. During the acuity interview on 06/22/26 at 12:04 pm, Resident 1 was identified to be bedbound and was receiving end of life care. Resident 1's 03/24/26 through 06/22/26 clinical record, including physician orders, service plan, and progress notes were reviewed, and the following was noted: * A physician order, dated 02/16/26, changed the resident’s diet texture to “Pureed diet, honey liquids consistency.” According to the International Dysphagia Diet Standardization Initiative (IDDSI), pureed texture diets need to be a smooth texture with no lumps and must not be sticky. Honey-thick liquids need to pour slowly and have the consistency of natural honey. The service plan dated 05/13/26 indicated that the resident was on a pureed diet texture and one staff member was to provide full feeding assistance. On 06/23/26 at 11:55 am, the surveyor entered Resident 1’s room. Resident 1 was observed lying in bed with the head of the bed at approximately 90 degrees. Staff 27 (CG) was observed to provide full meal assistance with lunch. For dessert, this surveyor observed Staff 27 provide Resident 1 with cheesecake ice cream. The cheesecake ice cream was considered a thin liquid and did not meet the prescribed fluid consistency. On 06/23/26 at 3:20 pm, a surveyor shared the observation with Staff 1 (ED) and Staff 3 (Health and Wellness Director/RN). They acknowledged the cheesecake ice cream did not meet the proper fluid consistency and would ensure there were other alternatives for dessert. Additionally, they stated care staff would receive training on what was an appropriate dessert to meet the residents’ pureed diet and honey thick fluid consistency. Observation of the resident’s plate on 06/24/26 at 8:25 am consisted of pureed scrambled eggs, pureed sausage and oatmeal. The oatmeal had a lumpy texture, was sticky, and whole grains of oats were visible. During an interview on 06/24/26 at 8:20 am, Staff 13 (Cook) acknowledged the oatmeal served to Resident 2 had not been put in the blender to puree and he was re-making the oatmeal at the request of staff. On 06/24/26, Staff 13 received instruction in providing puree texture food and the training was documented on an “Instant In-Service” form. On 06/24/26 at 12:20 pm the survey team requested the facility provide training to all staff who prepared pureed food prior to the survey team exiting the facility. On 06/24/26 at 2:00 pm, the facility provided documentation the in-service training had been provided to the cooks. Observation of the resident’s plate on 06/25/26 at 8:12 am consisted of puree scrambled eggs, puree sausage and oatmeal. The oatmeal was not pureed to the correct consistency and had whole grains of oats visible. The oatmeal was taken to the kitchen, and an interview with Staff 14 (Cook) was conducted at 8:30 am. When asked how the oatmeal was pureed, he stated, “Took oatmeal and put it into the robo-blender.” When asked whether any liquid was put in the blender, Staff 14 stated, “no.” Staff 14 was asked whether he knew how to test the oatmeal to determine the right consistency, and he said he did not know. Staff 14 confirmed he had received an in-service on 06/24/26 regarding pureed diets. The resident was served the incorrect texture diet despite prescriber orders for a pureed texture diet. SB The failure to follow prescriber orders and take reasonable precautions in the preparation of a modified diet and fluid consistency placed Resident 1 at risk for choking, aspiration, and/or death. An immediate plan of correction to address the reasonable precautions was requested from Staff 2 (ED Brookdale Bend MCC) and Staff 3 on 06/25/26 at 10:31 am. The plan of correction was received and accepted by the survey team on 06/25/26 at 2:30 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure reasonable precautions were exercised against any condition that could threaten the health and safety of a resident was discussed with Staff 2 and Staff 3 at 10:31 am on 06/25/26. They acknowledged the findings. 2. Resident 2 moved into the facility in 09/2025 with diagnoses including Alzheimer’s disease and dysphagia (difficulty swallowing). During the acuity interview on 06/22/26 at 12:04 pm, Resident 2 was identified to require a puree diet texture and nectar thick fluid consistency. The resident’s 03/26/26 to 06/22/26 clinical record including physician orders, service plan, and progress notes were reviewed, and the following was noted: * A physician order, dated 06/18/26, changed the resident’s diet texture to “Pureed diet, nectar thick liquids.” According to the International Dysphagia Diet Standardization Initiative (IDDSI), pureed texture diets need to be a smooth texture with no lumps and must not be sticky. Nectar-thick liquids flow at a slower rate than thin liquids. On 06/23/26 at 12:06 pm, Resident 2 was seated in the dining room for lunch. For dessert, Resident 2 received cheesecake flavored ice cream. The ice cream did not meet the prescribed nectar thick fluid consistency. On 06/23/26 at 3:20 pm, a surveyor shared the observation with Staff 1 (ED) and Staff 3 (Health and Wellness Director/RN). They acknowledged the cheesecake ice cream did not meet the proper fluid consistency and would ensure there were other alternatives for dessert. Additionally, they stated care staff would receive training on what was an appropriate dessert to meet the residents’ pureed diet and nectar thick fluid consistency. Observation of the resident’s plate on 06/24/26 at 8:04 am consisted of pureed scrambled eggs, pureed sausage and oatmeal. The oatmeal had a lumpy texture, was sticky, and whole grains of oats were visible. During an interview on 06/24/26 at 8:20 am, Staff 13 (Cook) acknowledged the oatmeal served to Resident 2 had not been put in the blender to puree and he was re-making the oatmeal at the request of staff. On 06/24/26 Staff 13 received instruction in providing puree texture food, and the training was documented on an “Instant In-Service” form. On 06/24/26 at 12:20 pm the survey team requested the facility provide training to all staff who prepared pureed food prior to the survey team exiting the facility. On 06/24/26 at 2:00 pm, the facility provided documentation the in-service training had been provided to the cooks. Observations of Resident 2’s plate on 06/25/26 at 8:12 am consisted of puree scrambled eggs, puree sausage and oatmeal. The oatmeal was not pureed to the correct consistency and had whole grains of oats visible. The oatmeal was taken to the kitchen, and an interview with Staff 14 (Cook) was conducted at 8:30 am. When asked how the oatmeal was pureed, he stated, “Took oatmeal and put it into the robo-blender.” When asked whether any liquid was put in the blender, Staff 14 stated, “no”. Staff 14 was asked whether he knew how to test the oatmeal to determine the right consistency, and he said he didn’t know. Staff 14 confirmed he had received an in-service on 06/24/26 regarding pureed diets. The resident was served the incorrect texture diet despite prescriber orders for a pureed texture diet. The failure to follow prescriber orders and take reasonable precautions in the preparation of a modified diet and fluid consistency for a resident with dysphagia placed him/her at risk for choking and aspiration. An immediate plan of correction to address the reasonable precautions was requested from Staff 2 (ED Brookdale Bend MCC) and Staff 3 on 06/25/26 at 10:31 am. The plan of correction was received and accepted by the survey team on 06/25/26 at 2:30 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure reasonable precautions were exercised against any condition that could threaten the health and safety of a resident was discussed with Staff 2 and Staff 3 on 06/25/26 at 10:31 am. They acknowledged the findings.

1. Food items will be modified for residents who receive a pureed diet when the resident is prepared to eat (not pre-pureed). Food items will be blended to an appropriate pudding-like consistency per Brookdale Diet Manual. Cream of wheat will be the first cereal option for residents on a puree diet who request hot cereal. The Regional Director of Dining Services, along with the Executive Director and Registered Nurse, will re-educate community associates, including managers and kitchen staff, on how to prepare foods consistent with a puree diet, including physical examples of what consistency/texture will look like. For the next 30 days, a manager or designee will be assigned to observe the foods served to residents who are on a pureed diet. For snacks/hydration, the manager on duty will verify to approve consistency of snack/drink served to residents on puree diet prior to being served. For the next 30 days, the snack schedule with modifications or substitutions for a pureed diet will be reviewed daily with DSM. The next two week’s assigned manager meal schedule will be provided to survey team on 6/26/26 by 12 pm. Associates, including managers and kitchen staff, will receive an in-service provided by ED and RN on puree diet, including physical examples of what consistency/texture should look like. 2. Beginning June 26th, 2026, the manager on duty schedule was revised to include the requirement to observe meals in order to confirm residents who need a modified diet receive the diet prepared in accordance with the community policy. 3. A designated manager will be assigned for each meal to verify that the food items served adhere to the resident’s pureed diet order This verification includes snacks/hydration as manager on duty will confirm that the snacks offered are consistent with the Brookdale Diet Manual. This procedure will be re-evaluated after forty-five days. 4. The Executive Director, Associate Executive Director, and the Dining Services Manager are responsible to verify that the corrections have been implemented and are ongoing. For the next 45 days, the Dining Service Manager, Executive Director and Associate Executive Director will review the community’s corrective action plan weekly with the District Director of Operations or Regional Director of Dining Services for compliance and any adjustments needed.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. 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 based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: Observations made from 06/22/26 through 06/25/26 showed the MCC housed 27 residents and consisted of two wings – the east side and west side, with a great room in the middle. An activity calendar was posted in the entry area of the memory care with scheduled activities for each day of the week. The activities noted for 06/23/26 included the following: * 9:30 am – B-Fit (Great Room); * 10:30 am – Morning Meeting (Great Room); * 1:30 pm – Lifelong Learning (Great Room); * 2:00 pm – Axe Throw (Great Room); * 2:00 pm – Resident Council (Great Room); and * 3:30 pm – BINGO (Great Room). The activities for 06/24/26 included the following: * 9:30 am – B-Fit (Great Room); * 10:30 am – Morning Meeting (Great Room); * 11:00 am – Spiritual Club (Great Room); * 1:30 pm – Weekly Outing (Bus Trip); and * 2:00 pm – Chair Yoga (Great Room). Observations made on 06/23/26 and 06/24/26 confirmed nine of the ten activities listed above did not take place. Interviews with staff during the survey identified the following: * An activities person was assigned to the memory care unit who worked Sunday through Thursday and another staff who did activities on Fridays in the memory care unit; * Activities were conducted “depending on how people are feeling”; * The activity calendar was followed “sometimes”; and * “When there are no activities, they just put a movie on.” During an interview on 06/23/26 at 8:41 am, Resident 2 reported s/he was tired of the “same old stuff” regarding watching television as an activity. During an interview on 06/24/26 at 10:55 am, an unsampled resident was sitting alone in the great room. The resident stated, “It’s an awful feeling, a bad feeling, to be in this big room all alone…no one is here, it’s lonely.” The television remained on in the great room throughout the period of the survey, with between one to eight residents watching it at any given time. Other residents were observed wandering the hallways, self-propelling in their wheelchairs, or sleeping in chairs or on couches in the common areas. Residents who were in their apartments were not approached for activity invitations during observations. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 2 (ED Brookdale Bend MCC) and Staff 3 (Health and Wellness Director, RN) on 06/25/26 at 2:02 pm. They acknowledged the findings.

1. A new Activity Director was hired on June 30th, 2026. The Activity Director has re-established daily activity routine. 2. Activivty Director will receive ongoing supervision and oversight to confirm that life enrichment activities are occurring in accordance with community policy and CBC standards. 3. Beginning August 1, 2026, and for the next ninety days, the AED, ED, HWD or designee will observe resident activities a minimum of four days per week to verify that the calendar is being followed. The monthly activity calendar will be reviewed by the Executive Director or designee before submitting to printer. 4. Activity Director, Executive Director, Associate Executive Director, or designee.

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 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained all required elements for 1 of 1 sampled resident (#3) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 3 moved into the facility in 05/2026 with diagnoses including Alzheimer’s disease and anxiety disorder. Resident 3’s 06/2026 move-in evaluation was reviewed. The document failed to address the following required elements: * Mental health including history of treatment and non-pharmaceutical interventions; and * Pain including non-pharmaceutical interventions and expression of pain. The need to ensure the initial evaluation contained information addressing all required elements was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director/RN) and Staff 4 (Health and Wellness Coordinator/LPN) on 06/23/26 at 9:15 am. They acknowledged the findings.

1. Resident 3 was assessed for mental health and pain needs on June 25th, 2026. 2. The clinical team will review the initial evaluation for current residents to confirm that their evaluations address the necessary areas. The District Director of Clinical Services will re-educate the clinical team on the requirements for the initial evaluation, including pain and mental health. 3. Beginning August 1st and for the next 30 days, the District Director of Clinical Services will review the initial evaluation for new residents to confirm that the areas of pain and mental health are addressed. 4. Executive Director, Associate Executive Director, Health and Wellness Director.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 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 residents’ service plans were reflective of residents’ current care needs and preferences, provided clear direction to staff regarding the delivery of services, and/or service plans were implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 09/2025 with diagnoses including Alzheimer’s disease and dysphagia (difficulty swallowing). The resident’s 03/26/26 to 06/22/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations were made. The service plan, dated 06/11/26, was not reflective of the resident’s current care needs, lacked clear direction to staff regarding the delivery of services, or was not implemented in the following areas: * Ambulation assistance including use of gait belt and support on the left side; * Intimate relationship with another resident; * Fine motor skills ability; * Frequency of safety checks; * Cell phone assistance including charging daily; and * Aspiration precautions. Observations during the survey on 06/24/26 and 06/25/26 identified Resident 2 would ambulate with a walker in the facility and staff provided assistance on his/her right or left side. No gait belt was used, and Resident 2 was unable to consistently grasp the walker handle with his/her left hand. On 06/24/26 at 1:40 pm, Witness 2 (HH OT) confirmed Resident 2 lacked fine motor skills at this time following the recent stroke. During an interview on 06/23/26 at 12:30 pm, Staff 19 (Care Partner) confirmed Resident 2 was no longer involved in an intimate relationship, and she provided safety checks at least every hour and every 15 minutes if alone in the great room. The need to ensure service plans provided clear direction regarding the delivery of services, were reflective of the resident’s needs and were implemented was discussed with Staff 2 (ED Brookdale Bend MCC) and Staff 3 (Health and Wellness Director/RN) on 06/25/26 at 2:30 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 01/2026 with diagnoses including Alzheimer’s disease. The resident’s clinical record, including the 05/13/26 service plan, was reviewed, interviews with staff were conducted, and observations were made. The service plan was not reflective of the resident’s current care needs, lacked clear direction regarding the delivery of services, or was not implemented in the following areas: * Offering snacks and hydration to the resident between meals; and * Preference for resident door being propped open. Observations made of the resident and interviews with staff confirmed the resident was confined to bed and fully dependent upon staff for all ADL care needs including nutrition and hydration. Observations made on 06/23/26 through 06/25/26 showed staff did not provide Resident 1 with snacks or hydration outside of the breakfast and lunch meals that were observed. In an interview on 06/24/26 at 2:55 pm, Witness 1 (Power of Attorney) confirmed it was his/her preference to have the resident’s door propped open. The need to ensure service plans were reflective of residents’ needs and preferences, provided clear direction regarding the delivery of services and were implemented was reviewed with Staff 2 (ED Brookdale Bend MCC), and Staff 3 (Health Wellness Director/RN) on 06/25/26 at 2:05 pm. They acknowledged the findings.

1. The service plans and assessments for Residents #1 and #2 were updated to reflect their current needs. For Resident #1 there were updates to ambulation assistance, intimate relationships, fine motor capabilities, safety checks, phone assistance, and aspiration precautions. Resident #2's updates included their current needs for snacks and the locking of their apartment door. 2. Clinical associates were re-educated by the Associate Executive Director on July 30th, 2026 regarding the need to ask residents for their preferences on snacks and locking their doors upon move-in and at each re-assessment. Clinical associates will also be re-educated on the community's service assessment and service plan policies. 3. For the next thirty days, the Health and Wellness Director or designee will review two service plans and two service assessments each week to confirm that the plan and assessment are consistent with current care needs and provide clear directions to associates on the delivery of care and services. 4. Health and Wellness Director, Executive Director, and Associate Executive Director

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence care for 1 of 2 sampled residents (# 1) whose care was observed and for multiple sampled and unsampled residents during meal service in the MCC. Findings include, but are not limited to: 1. Resident 1 moved into the facility 01/2026 with diagnoses including Alzheimer’s disease. Observations were made and interviews with staff were conducted, revealing that the resident was bed-bound and dependent upon staff for all ADL needs, including the assistance of one staff member for all nutrition and hydration needs and two staff members for all other ADL care needs. a. On 06/23/26 at 12:53 pm, Staff 15 (MT/Care Partner) and Staff 19 (Care Partner) provided ADL incontinence care for Resident 1. Staff 15 and Staff 19 donned gloves before providing incontinence care. Staff 15 and Staff 19 rolled Resident 1 on his/her right side to remove the soiled brief. Staff 19 proceeded to provide perineal care, removing fecal matter. Staff 19 leaned over and in the process her hair dangled into the clean wipes lying on the bed next to Resident 1. Following perineal care, Staff 19 placed the barrier cream on Resident 1 while wearing the same pair of gloves. During the observation, the staff failed to change gloves between dirty and clean tasks. b. During the following meal observations Staff 23 (MT/Care Partner) and Staff 27 (Care Partner) did not wear a protective barrier to prevent the potential for cross contamination during meal assistance: * 06/23/26 at 11:55 am; * 06/24/26 at 8:25 am; and * 06/25/26 at 9:10 am. The need to ensure infection prevention and control practices were followed during meal service and while providing incontinence care was discussed with Staff 2 (ED Brookdale Bend MCC) and Staff 3 (Health and Wellness Director/RN) on 06/25/26 at 2:05 pm. They acknowledged the findings. 2. An observation was made on 06/25/26 at 8:12 am of Staff 21 (Care Partner) cutting a banana using ungloved hands during breakfast service. Staff 21 held the banana with her ungloved hand while slicing it, then picked it up and placed it on top of oatmeal for a resident. No hand hygiene was observed during the process. The need to ensure infection prevention and control practices were followed during meal service was discussed with Staff 2 (ED Brookdale Bend MCC) and Staff 3 (Health and Wellness Director/RN) on 06/25/26 at 2:05 pm. They acknowledged the findings. 3. During an environmental tour of the MCC on 06/22/26 to 06/25/26 the following was identified: * The facility had towel warmer machines in the East and West wing kitchenettes that were intended to be used for resident handwashing prior to meal service. * On 06/22/26 at 12:00 pm and 06/25/26 at 11:20 am both towel warmer machines were not in use, cold to the touch and there were no towels observed. During an interview on 06/24/26 at 5:05 pm, Witness 3 (Family Member) reported concerns regarding an unsampled resident was independent with toileting and eating. Witness 3 stated the unsampled resident didn’t remember to wash his/her hands after going to the bathroom and often had soiled nails. Witness 3 further reported the concern had been brought forward to management several times and was told the facility had a hot towel service prior to meals. The need to ensure infection control protocols were implemented during resident meal service was discussed with Staff 2 (ED Brookdale Bend MCC) and Staff 3 (Health and Wellness Director/RN) on 06/25/26 at 1:30 pm. They acknowledged the findings.

1. Caregiving staff were re-educated on the community's overall policies related to infection control, peri-care, and the use of gloves. Caregiving staff will also be re-educated on the specific process to complete pericare for Resident #1. Caregiving staff were also re-educated on the policies regarding the handwashing prior to and during meals. 2. Clinical managers will audit infection control through routine observation of ADL assistance and dining assistance. at least five days a week 3. Beginning August 1, 2026 and for the next 90 days, the ED, AED, or HWD will observe each staff member once per month to confirm that community infection control policies regarding ADL care and meal assistance are followed. Each staff member will be evaluated during competency training at time of hire and at least quarterly after that. 4. Health and Wellness Director, Resident Care Coordinator, Executive Director, and Associate Executive Director

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

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience 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 ensure documentation that non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 2 and 3) whose records were reviewed for PRN psychotropic medication. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 05/2026 with diagnoses including Alzheimer's disease and anxiety. The resident’s signed prescriber orders and 06/11/26 through 06/22/26 MAR and progress notes were reviewed, and the following was identified: The resident had orders for: * Lorazepam, 0.5 mg tab, administer one tablet by mouth every 24 hours as needed for anxiety that was started on 06/10/26 and discontinued on 06/12/26; * Lorazepam, 0.5 mg tab, administer one tablet by mouth twice per day as needed for agitation, that was started on 06/16/26; and *The above PRN medications were administered eight times from 06/11/26 through 06/22/26. There was no documented evidence that staff attempted non-pharmacological interventions with ineffective results prior to administering the above PRN medications. The need to ensure documentation that non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications was discussed at 8:52 am on 06/23/26 with Staff 1 (ED), Staff 3 (Health and Wellness Director/RN) and Staff 4 (Health and Wellness Coordinator/LPN). They acknowledged the findings. 2. Resident 2 moved into the facility in 09/2025 with diagnoses including Alzheimer’s disease and dysphagia (difficulty swallowing). The resident’s 06/01/26 through 06/22/26 MARs and signed physician orders were reviewed. The following was identified: * A prescription for Seroquel 25 mg, 1 tab every 24 hours PRN for breakthrough agitation; and * The PRN Seroquel was administered to the resident two times between 06/14/26 and 06/17/26. There was no documented evidence staff attempted non-pharmacological interventions with ineffective results prior to administering the medication. On 06/24/26 at 2:55 pm, Staff 26 (MT/Care Partner) reported staff should have been documenting the non-drug interventions attempted prior to administration of a PRN psychotropic medication in the progress notes. The need to ensure documentation that non-pharmacological interventions were tried with ineffective results prior to administering a PRN psychotropic medication was reviewed with Staff 2 (ED Brookdale Bend MCC) and Staff 3 (Health and Wellness Director/RN) on 06/25/26 at 2:30 pm. They acknowledged the findings.

1. On July 3rd, 2026, the MAR for Residents #2 and #3 were reviewed to confirm that non-pharmocological interventions were present to direct medication technicians before administering PRN psychtropic medications. By July 7th, 2026, the Medication Technicians will be re-educated by the Health and Wellness Director on the requirement to attempt non-pharmacological interventions before administering PRN psychotropic medications. 2. The MAR for residents with orders for the use of PRN psychotropic medications will be reviewed to confirm that non-pharmacologic interventions are included. 3. The Health and Wellness Director or designee will review new orders for psychotropic medications when the order is entered and during quarterly medication reviews. 4. Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator, Executive Director, Associate Executive Director

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

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 observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, ensure ancillary staff including licensed nurses and administrators were not used to meet the minimum caregiver staffing requirements, and failed to ensure staffing was 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. The findings include, but are not limited to: On 06/22/26 at 12:00 pm the undated facility staffing plan was observed in the MCC and noted the following: * Day: 2 Care Partners and 2 MT’s; * Evening: 2 Care Partners and 2 MT’s; and * Overnight: 1 Care Partner and 1 MT. a. During an interview with Staff 1 (ED) on 06/23/26 at 4:30 pm, the proprietary Acuity-Based Staffing Tool (ABST), “Service Alignment,” was reviewed and identified the facility would need 10.77 direct care staff per day. Staff 1 reported the facility rounds up to cover unscheduled needs. Staff 1 reported “we need a total of 11 caregivers. I will immediately add another full-time caregiver tomorrow.” Staff 1 reported the facility monitored the ABST “weekly, as often as we can;” however, he was not able to provide verification of the last time the ABST was reviewed or when the staffing plan had been updated, as required. b. On 06/24/26 at 12:23 pm, Surveyor and Staff 6 (Business Office Manager) reviewed the staffing schedule and verified the schedule and payroll from 06/14/26 day shift to 06/22/26 overnight shift, which identified 25.92 percent of the shifts were understaffed based on the posted staffing plan. During an interview on 06/24/26 at 4:02 pm, Staff 1 reported Staff 29 (Assistant ED) and Staff 4 (Health and Wellness Coordinator/LPN) “cover shifts on the floor all the time.” Staff 1 reported a total of 40 hours from 06/14/26 to 06/21/26 was covered by Staff 29. Staff 1 confirmed he was unable to verify those hours with payroll because Staff 29 was a salaried employee and not always added to the staffing schedule. Surveyor and Staff 1 discussed the use of ancillary staff did not meet the minimum direct care hours generated by the facility’s ABST. c. On 06/25/26 at 2:04 pm, Staff 28 (Care Partner/MT) reported they do not have enough staff, “especially since [Resident 3] moved in almost a month ago.” Staff 28 reported “We [the facility] usually have three or four staff and it’s just not enough to keep residents safe, do our other work and provide care for other residents because we are always with [him/her].” Staff 28 further reported “many of us, I know I have reported this to management, but they don’t respond. They haven’t increased staff since s/he moved in.” Refer to C 362, example 3. The need to ensure the facility consistently had qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, ensure ancillary staff were not used to meet the minimum caregiver staffing requirements and ensure staffing was increased to compensate for the evaluated care and service needs of residents at move-in was discussed with Staff 1 on 06/24/26 at 4:02 pm and with Staff 2 (Brookdale Bend MCC ED) and Staff 3 (Health and Wellness Director/RN) on 06/25/26 at 1:30 pm. They acknowledged the findings.

1. The clinical staff schedule has been updated to include 11 associates each day. Every week, ABST will be reviewed prior to the new schedule being posted. No salaried staff will be utilized to fill gaps in the staffing scheudle. 2. Beginning August 1st and for the next three months, the Executive Director will review the clinical staff schedule to confirm that the number of employees on shift are in compliance with the community's ABST. The ED, AED and HWD will be re-educated on the requirement to include only direct care staff in the ABST hours. The ED will review ABST hours weekly to (1) confirm that ancillary staff are not included and (2) hours are adjusted if resident needs changed in the last week. 3. The Executive Director will review the caregiving staff schedule weekly before it is posted to confirm compliance with the hours reported in ABST. This review will confirm that ancillary staff are not included and hours are adjusted if resident needs changed in the last week. 4. Executive Director, Associate Executive Director, Resident Care Coordinator, and Health and Wellness Director.

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:

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 proprietary Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements staff were providing to residents for 3 of 3 sampled residents (#s 1, 2 and 3) whose ABST evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 01/2026 with diagnoses including Alzheimer’s disease. Observations of Resident 1, interviews with staff, and review of the 05/13/26 service plan and ABST were completed. The following was identified: Observations and interviews with staff during the period of the survey confirmed Resident 1 was confined to bed and required two-person staff assistance for ADL care, including repositioning, transfers, incontinence care, and dressing. Resident 1 was also dependent upon one staff member for all nutrition and hydration needs. Resident 1’s ABST failed to accurately capture care time in the following care areas: * Supervising, cueing or supporting while eating; and * Bowel and bladder management. On 06/25/26 at 2:05 pm, the need to ensure resident ABST evaluations accurately captured care time and care elements that staff were providing to each resident was reviewed with Staff 2 (ED Brookdale Bend MCC) and Staff 3 (Health and Wellness Director/RN). They acknowledged the findings. 2. Resident 2 moved into the facility in 09/2025 with diagnoses including Alzheimer’s disease and dysphagia. Observations of Resident 2, interviews with staff, and review of Resident 2’s 06/11/26 service plan and ABST were completed. The following was identified: Observations on 06/24/26 at 7:45 am identified two staff provided dressing assistance for Resident 2 on the toilet. During an interview on 06/23/26 at 2:39 pm, Staff 25 (MT/Care Partner) indicated Resident 2 was weaker in the evening and would sometimes require two-person transfer assist. Staff interviews conducted on 06/23/26 and 06/24/26 also confirmed they performed safety checks every one to two hours but if alone in the great room they checked on him/her every 15 to 20 minutes. Resident 2’s ABST failed to accurately capture care time in the following care areas: * Dressing and undressing; * “Multiple Staff Required to Assist with Transferring”; * Ensuring non-drug behavior interventions; and * Safety checks. On 06/25/26 at 2:30 pm, the need to ensure resident ABST evaluations accurately captured care time and care elements that staff were providing to each resident was reviewed with Staff 2 (ED Brookdale Bend MCC) and Staff 3 (Health and Wellness Director/RN). They acknowledged the findings. 3. Resident 3 moved into the MCC in 05/2026 with diagnoses including Alzheimer's disease and anxiety. Observations of Resident 3, interviews with staff, and review of Resident 3’s ABST were completed during the survey. The following was identified: On 06/22/26 at 1:32 pm, Staff 15 (Care Partner/MT) reported “it’s been rough related to behaviors and near resident altercations, staff are getting hit so the residents don’t get injured. We can’t get our other work done because we are always with [Resident 3].” On 06/24/26 at 5:05 pm, an unsampled resident’s family reported concerns regarding Resident 3 moving into the MCC and being intrusive during family visits and disruptive to other residents. Progress notes dated 05/30/26 through 06/22/26 identified Resident 3 had behavioral symptoms during the day, evening and overnight shifts on 14 occasions. During an interview on 06/25/26 at 2:04 pm, Staff 28 (Care Partner/MT) reported aggressive behaviors, inability to complete other tasks and resident care, and taking four to five hours of an eight-hour shift to redirect, deescalate and try to prevent altercations with other residents. Although Resident 3’s ABST evaluation showed a total of 48 minutes per day for monitoring physical changes in behaviors and cueing and redirecting for cognitive impairments or dementia; the documented evidence and staff and family interviews demonstrated 48 minutes per day was not enough care time to support Resident 3’s care needs related to monitoring physical changes in behaviors and cueing and redirecting for cognitive impairments or dementia. The need to ensure resident ABST evaluations captured resident specific care time for care elements was discussed with Staff 2 (Brookdale Bend MCC ED) and Staff 3 (Health and Wellness Director/RN) on 06/25/26 at 1:30 pm. They acknowledged the findings.

1. The service assessment for Residents #1, #2, and #3 were reviewed to confirm that the assessment captured the assistance needed and provided the necessary time to provide the care, in the service areas identified in the statement of deficiency. Service planned ABST minutes were verified for accuracy through observation by AED and HWD. 2. The Health and Wellness Director and clinical staff will be re-educated by the district nurse on the assessment process and the need to identify service needs accurately. Observation of care tasks will again be reviewed to capture care hours as part of the ABST times generated from service plans. 3. The Brookdale ABST tool (composed of service assessment and service plan processes) is not a new process. The ABST tool has been in place for years and was approved by the State of Oregon several years ago. As such, the clinical staff were re-educated on these processes in order to complete the assessment and service plan in accordance with the approved ABST Tool. The ED, AED, HWD or designee will review the community's ABST Tool results weekly to verify that the time and care identified is in accordance with community's policies. 4. Executive Director, Associate Executive Director, Resident Care Coordinator, Health and Wellness Coordinator, and Health and Wellness Director.

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:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records, dated 12/2025 through 06/2026, were reviewed and identified the following: a. Unannounced fire drills were not conducted and recorded every other month at different times of the day, evening, and night shifts. b. Written fire drill records lacked one or more of the following components: * Date and time of day; * Location of simulated fire origin; * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * Staff members on duty and participating; and * Number of occupants evacuated. The need to ensure fire drills were conducted according to the Oregon Fire Code, with all required components documented, was discussed with Staff 1 (ED) and Staff 7 (Maintenance Manager) on 06/23/26 at 12:04 pm and 11:46 am, respectively. They acknowledged the findings.

1. There were no residents impacted by the alleged violations. Fire drills were conducted on the three shifts by 6/27/26. 2. Separate section of fire drill binder for AL and MC created as well as separate tasks in electronic maintenance queue. Fire drills will be executed on the three shifts quarterly. The Fire Drill Report will be updated to include, at a minimum, the following elements: Date and time of day; Location of simulated fire origin; The escape route used; Problems encountered and comments relating to residents who resisted or failed to participate in the drills; Evacuation time-period needed; Staff members on duty and participating; and Number of occupants evacuated. 3. The fire drill binder will be reviewed monthly by the ED to verify that fire drills have been completed in accordance with community policy and Oregon rules. 4. Maintenance Manager, Exectuive Director, Associate Executive Director.

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

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to: During the relicensure survey, conducted 06/22/26 through 06/25/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity of the citations. 1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area: * OAR 411-054-0025 (4) - C160 Reasonable Precautions The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. 2. Refer to deficiencies in the report.

Refer to: C160

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. 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 C160, C242, C295, C360, C362, and C420.

Refer to C160, C242, C295, C360, C362, and C420

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: C252, C260, and C330.

Refer to: C252, C260, and C330.

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: