OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors and available for inspection. Findings include, but are not limited to: A tour of the facility, conducted on 06/29/26 at 11:55 am, identified the facility failed to post in a conspicuous location the following required postings: * Name of the administrator or designee in charge (by shift); and * Ombudsman poster. The need to ensure all required postings were displayed in an accessible and conspicuous location for the public was discussed with Staff 1 (ED) on 06/29/26 at 1:00 pm. Staff 1 acknowledged the postings were not displayed as required.

1. What actions will be taken to correct the rule violation for each example/resident? The Executive Director reviewed the facility’s required public postings. The Ombudsman poster was posted in a routinely accessible and conspicuous location for residents and visitors. The facility also implemented a process to ensure the name of the Administrator or designee in charge is posted by shift whenever the Administrator is not present. All required postings were reviewed to ensure they were current, complete, and displayed in an accessible and conspicuous location. 2. How will the system be corrected so this violation will not happen again? The Executive Director or designee will routinely review the facility’s required postings to ensure they remain current, legible, accessible, and conspicuously displayed. The designee-in-charge posting will be updated as needed to accurately identify the person responsible when the Administrator is not present. Required postings will also be reviewed whenever there is a change in leadership, staffing assignments, or updated regulatory materials. 3. How often will the area needing correction be evaluated? Required postings will be reviewed weekly for four weeks, then monthly for three months, and quarterly thereafter. Any missing, outdated, or inaccurate posting identified will be corrected immediately. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee will be responsible for ensuring the corrections are completed and monitoring ongoing compliance.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents’ right to receive services in a manner that protected their privacy and dignity for 2 of 2 sampled residents (#s 4 and 10) whose ADL care was observed. Findings include, but are not limited to: 1. Resident 4 moved into the memory care community in 05/2026 with diagnoses including dementia and diabetes. The resident was identified during the acuity interview on 06/29/26 as requiring heavy care related to behaviors due to being blind and hard of hearing. During the survey, the following was observed: a. Staff 10 (CG), Staff 12 (CG), and Staff 14 (CG) were observed on 6/30/26 at 12:10 pm providing incontinence care to Resident 4. Staff 10 and Staff 12 assisted with transferring from bed and held him/her up using a gait belt while Staff 14 provided the incontinence care. Staff 14 pulled the pants down and removed the soiled brief from the resident. The resident’s lower body was completely undressed. The resident resided in a semi-private room. The resident’s bed was to the right of the room and was in clear view of anyone passing by in the hallway. During the provision of personal care, the resident’s front door was left open. There was no privacy curtain or other privacy device in place to protect the resident's privacy during the provision of care. b. Staff 13 (CG) and Staff 17 (CG) were observed on 07/01/26 at 10:39 am providing incontinence care to Resident 4. During the care, Resident 4 was making vulgar comments to staff and attempting to strike and bite both staff. Staff 13 assisted to hold resident’s arms while Staff 17 provided the incontinence care. When both staff completed the care, Staff 17 made a comment to the resident, “You are clean now, crappy pants.” The facility failed to ensure the resident was treated with dignity and respect. On 07/02/26 at 1:39 pm, the above observations and the need to ensure the resident received services in a manner that protected privacy and dignity was shared with Staff 1 (ED). She acknowledged the findings. 2. Resident 10 moved into the memory care community in 06/2026 with diagnoses including dementia with behavioral disturbance and was observed during survey to require assistance with eating. During the survey, on 06/30/26, the following was observed: Staff 12 (CG) and Staff 14(CG) were observed between 12:25 pm and 1:00 pm assisting residents in the dining room. Staff 12 was assisting Resident 10 with meal intake. Staff 12 intermittently left the area without communicating the disruption of service to the resident. Staff 12 was away for approximately three to five minutes then returned to continue assisting Resident 10 with the meal. The facility failed to ensure dignity during the meal observation. On 07/02/26 at 1:39 pm, the above observation and the need to ensure the residents were treated with dignity and respect was shared with Staff 1 (ED). She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Staff involved in the cited observations will be re-educated regarding resident rights, including maintaining privacy during personal care, communicating respectfully with residents at all times, and ensuring continuity of assistance during meals. Staff will be directed to close resident room doors and use available privacy measures during personal care. Staff assisting a resident with eating will ensure the resident’s needs are communicated and another staff member assumes assistance before leaving the resident. 2. How will the system be corrected so this violation will not happen again? All direct-care staff will receive education regarding resident rights, dignity, privacy, respectful communication, and continuity of care. Expectations will be reinforced during staff meetings and orientation for newly hired direct-care staff. Leadership will conduct direct observations of personal care and meal assistance to verify that resident privacy and dignity are maintained and that residents requiring assistance are not left without appropriate communication or continued support. 3. How often will the area needing correction be evaluated? Direct observations will be completed weekly for four weeks, then monthly for three months, and quarterly thereafter. Any concerns identified will be addressed immediately through coaching, re-education, and additional monitoring as needed. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee will be responsible for ensuring corrective actions are completed and ongoing compliance is monitored.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were free from verbal, mental, or physical abuse and provide a safe and homelike environment for 2 of 2 sampled residents (#s 1 and 2) who were roommates. Resident 2 experienced ongoing physical and verbal abuse and expressed ongoing fear related to living with Resident 1. Findings include, but are not limited to: Resident 2 moved into the MCC in 04/2025 with diagnoses including dementia and benign prostatic hyperplasia (urinary retention). Resident 1 was admitted to the MCC in 06/2026 with diagnoses including Alzheimer’s disease and schizophrenia. Resident 2’s 05/08/26 service plan and Interim Service Plans (ISPs) related to altercations with the resident’s roommate were reviewed, as well as progress notes dated 06/23/26 through 07/15/26. Resident 1’s clinical record, dated 06/23/26 through 07/15/26, was also reviewed. The following was identified: Resident 2 and Resident 1 shared a room beginning on 06/23/26. A 06/24/26 incident report documented, “[Resident 2] entered [his/her] shared room and used the bathroom. When [Resident 2] exited the bathroom, [Resident 1] observed him/ her, balled [his/ her] fists, walked toward [him/her] and yelled, ‘Get out of here, you’re trespassing!’ A caregiver who was assisting [Resident 2] immediately redirected [him/her] away while another caregiver redirected [Resident 1], preventing physical contact.” Following the incident, staff documented Resident 1’s behaviors continued to escalate, necessitating calls to emergency medical services and law enforcement before Resident 1 could be safely transported to the hospital. Resident 1 remained under observation at the hospital until 07/02/26, when s/he returned to the facility and back to the room shared with Resident 2. A 07/03/26 ISP documented Resident 1’s return from the hospital with diagnoses including “anxiety and agitation.” Staff were instructed to “monitor for anxiety,” and “continue to monitor interactions w/ other residents.” There were no resident-specific instructions or interventions for staff on how to maintain Resident 2’s safety and sense of a homelike environment while s/he continued to share a room with Resident 1. On 07/05/26, an incident report documented, “[Staff 17 (CG)] entered [the room] and observed [Resident 1] standing near the foot of the bed. [Resident 1] suddenly struck [Resident 2] in the face with [his/her] fist, causing [Resident 2] to fall to the floor. [Resident 1] then continued attempting to strike [Resident 2]. . . . [Resident 2] stated that [Resident 1] had assaulted [him/her] and expressed that [s/he] was going to kill [Resident 1] if they remained in the same room.” Resident 1 and Resident 2 were sent to the emergency department to have their injuries evaluated and treated, and both returned to the facility early the next day, to their shared room. Resident 2 sustained a facial injury with a nosebleed, injury to the back of the head/neck area, left elbow skin tears, and bruising to his/her hands. On 07/06/26, an ISP for Resident 2 was created by Staff 3 (Health and Wellness Director/ RN), detailing the incident and subsequent injuries and instructed staff to “maintain separation from [Resident 1] at all times.” She also documented, “[Resident 2] reports fear of roommate and concern that another assault could occur. Resident declined to sleep in [his/her] room following the incident and remained in common area overnight.” There was no further documented evidence the facility placed the residents in separate rooms or determined interventions to ensure Resident 2 felt safe in his/her living space and was provided a homelike environment. Staff documented on 07/08/26 the following incident in the residents’ shared room: “[B]ehavior observed: resting in chair, got up walked over to [Resident 2] raised hands with a fist balled, caregiver stepped in between [Resident 1] and [Resident 2].” No interventions were established to address the continued aggression of Resident 1 toward Resident 2. Resident 1 and Resident 2 continued to share a room and Resident 2 continued to avoid being in his/her room while Resident 1 was there, because s/he did not feel safe. In a 07/07/26 progress note, staff documented, “[R]esident spent most of the time in the Activity Room watching TV. [S/he] only went to bed just before 4:10 am.” In a 07/08/26 progress note, staff documented, “[R]esident only went to bed about 2:45 am.” On 07/14/26, staff documented, “[Resident 2] was asleep in [his/her] room and when [Resident 1] saw [Resident 2], [s/he] got upset and wanted [him/her] out of the room despite telling [Resident 1] that [s/he] was sharing a room with [Resident 2]. [Resident 1] was still adamant about [Resident 2] out of the room. . . . in order to ensure the safety of [Resident 2], care staff helped [him/her] to the Activity Room. [Resident 2] remained in the Activity Room since 3:00 am till end of shift.” At approximately 7:00 am that same morning, Resident 2 was transported to the emergency department due to complaints of chest pain and shortness of breath. The resident returned to the facility later that day with a new diagnosis of atrial fibrillation and no new orders. Staff 14 (CG) was interviewed on 07/14/26 at 9:07 am and stated Resident 2 was a “homebody” who enjoyed sitting or napping in his/her recliner and looking out the window. She stated Resident 2 had insomnia and was most comfortable in bed when having difficulty sleeping. She added that since the altercation on 07/05/26, Resident 2 did not want to sleep in the room because s/he was afraid of Resident 1 and had instead been coming out to the common area to sleep. Staff 18 (CG), on 07/14/26 at 10:43 am, reported Resident 2 had repeatedly voiced fear and anger at having to live with Resident 1. Resident 2 had been observed falling asleep in the common area until 2:00 am or 3:00 am due to concerns over being in the shared room with Resident 1. She stated Resident 2’s normal routine prior to the altercation on 07/05/26 had been to go to his/her room about an hour after dinner and rest or sleep until about 6:00 am or 7:00 am. On 07/15/26 at 9:28 am, Staff 1 (MCC Administrator) stated she was not aware Resident 2 was still not sleeping in his/her room. She was also not aware of the incident on 07/08/26 or the details regarding Resident 2’s transport to the hospital on 07/14/26 with chest pains following another verbal altercation with Resident 1 in their shared room. Resident 2 experienced ongoing physical and verbal altercations in his/her home and expressed ongoing fear. The facility failed to ensure Resident 2 was free from verbal, mental, or physical abuse and was provided a safe and homelike environment, placing the resident’s health and safety at risk. The need to provide a safe and homelike environment and ensure residents were free from verbal, mental, or physical abuse was reviewed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/15/26 and 07/16/26. They were providing one-to-one supervision for Resident 1 until an alternative placement could be secured, and instructed staff on additional resident-specific interventions for Resident 2 to provide him/her with privacy in common areas while sleeping, as well as a tablet for entertainment.

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 a physical injury of unknown cause to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to immediately notify the local Department office of any incident of suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse, investigate all reports of abuse or suspected abuse, and document the investigation as required for 2 of 2 sampled residents (#s 1 and 4) who experienced resident-to-resident altercations and/or an injury of unknown cause. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 06/2026 with diagnoses including Alzheimer’s disease and schizophrenia. The resident’s clinical record from 06/23/26 through 07/13/26 was reviewed, and the following was identified: a. A 06/23/26 facility investigation description documented, “[Resident 1] approached a group of residents in the living room watching TV,” and after a brief exchange of words, “balled [his/her] fists and struck [Resident 3]. [Resident 3] then returned punches.” On 07/14/26 at 9:45 am, Staff 1 (MCC Administrator) confirmed she had not reported the incident to the local Department office because she did not recall Resident 3 getting hit. She acknowledged the description of Resident 3 being “struck” by Resident 1 and provided documented evidence of the report to the local department office on 07/14/26 at 10:34 am. b. A progress note dated 07/08/26 documented, “Behavior observed: resting in chair, got up walked over to [Resident 2] raised hands with a fist balled, caregiver stepped in between [Resident 1] and [Resident2].” On 07/15/26 at 9:28 am, Staff 1 stated she was not aware of the 07/08/26 incident and had not completed an investigation of the incident, nor had she reported it to the local Department office. The surveyor requested Staff 1 report the incident to the local Department office. Confirmation of the report was received on 07/16/26 at 9:10 am. The need to ensure any incident of abuse or suspected abuse was promptly investigated and immediately reported to the local Department office if abuse could not be ruled out was reviewed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings. 2. Resident 4 moved into the MCC facility in 04/2026 with diagnoses including dementia. Observations made during the survey identified Resident 4 as primarily nonverbal. The resident’s 05/01/26 through 07/13/26 clinical record was reviewed. The following was identified: a. The following resident-to-resident altercations were identified: * On 06/13/26 at 4:50 pm, staff documented Resident 4 had “swatted” an unsampled resident’s shoulder. There was no documented evidence the 06/13/26 altercation was immediately reported to the local Department office as required. At the request of survey, the facility reported the above incident and provided verification of reporting on 07/16/26 at 11:30 am. * On 06/15/26 Staff 1 (MCC Administrator) documented Resident 4 had “gotten into another incident with a different resident.” During an interview on 07/16/26 at 10:20 am, Staff 1 did not recall the situation of the incident and what other resident was involved. She confirmed the incident had not been reported to the local Department office as required, and there was no documented evidence the facility promptly investigated the incident, including documenting the time, date, place, and individuals present; a description of the event as reported; the response of staff at the time of the event; follow-up action; and the Administrator’s review. b. Staff documented on 05/19/26 Resident 4 had a skin tear “on [his/her] right forearm” and “still looks raw.” An incident investigation was requested during the survey. On 07/16/26 at 10:20 am, Staff 1 reported no incident investigation had been completed regarding the injury. The injury to Resident 4's forearm represented an incident which should have been reported to the local Department office 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 07/15/26 at 1:37 pm. The need to ensure incidents of suspected abuse were immediately reported to the local Department office and all reports of suspected abuse and injuries of unknown cause were promptly investigated and reported to the local Department office if abuse could not be ruled out was discussed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings.

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, were readily available to staff, and were updated with significant changes of condition for 2 of 5 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the memory care community in 12/2021 with diagnoses including mixed dementia. Observations were made of the resident's care on 06/29/26 and 06/30/26, interviews with facility staff were conducted, and the 05/31/26 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: * Bathing, including the PRN need for additional CG assistance, behaviors associated with bathing, and sharing a bathroom; * Grooming tasks; * Dressing; * Toileting and incontinence assistance; * Customary routines related to sleeping and eating; * Frequency of safety checks; * Use of a PRN psychotropic; and * Entering other residents' units uninvited. In an interview on 06/30/26 at 2:03 pm, Staff 10 (CG) reported it was difficult to shower Resident 2 relating to his/her behaviors, which included scratching, biting, and pulling staff’s hair. She often needed additional staff to assist with the bathing task because of the behaviors. Staff 10 reported hands-on assistance with all the resident’s grooming tasks but did verify that Resident 2 would brush his/her own teeth “sometimes.” Staff 10 verified during the evening shift the resident needed hands-on assistance for dressing and toileting. This was not reflective in Resident 2’s service plan. In an interview on 07/01/26 at 10:39 am, Staff 16 (CG) and Staff 21 (CG) verified the ADL assistance that Staff 10 reported on 06/30/26. They added that Resident 2 slept until lunch and, per shift reports, was usually up all night. Staff 16 and Staff 21 stated the night shift offered him/her snacks and beverages while the resident was awake. Due to Resident 2 sleeping during the day shift, Staff 16 and Staff 21 reported checking on the resident at least hourly relating to behaviors. Resident 2 would go into other residents’ units, which had resulted in resident-to-resident altercations. This was not reflective in the resident’s service plan. Resident 2’s service plan noted the use of a PRN psychotropic for “behavior/anxiety/agitation.” The MAR, dated 06/01/26 through 06/29/26, and physician’s orders were reviewed, and there was no PRN psychotropic medication available for the resident to use. 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) on 07/02/26 at 12:13 pm. She acknowledged the findings. 2. Resident 3 moved into the memory care community in 08/2025 with diagnoses including unspecified dementia, Parkinson’s disease, and schizoaffective disorder, bipolar type. The resident’s 03/29/26 to 06/29/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations were made. a. The service plan, dated 04/13/26, was not reflective of the resident’s current care needs and lacked clear direction to staff regarding the delivery of services in the following areas: * Use of half side rail and the precautions associated with the device; and * The resident was hard of hearing and preferred to be spoken to through his/her left ear. During the resident interview on 06/29/26 at 12:38 pm, a half side rail was noted in the raised position on the bed. The resident stated s/he used it for bed mobility and transfers. b. The resident’s current service plan, dated 04/13/26, was not readily available to staff. The service plan in the binder available to staff was dated 12/24/25. c. The resident was identified to have experienced a severe weight loss over the period of three months, from 02/02/26 to 05/03/26. There was no documented evidence the service plan was reviewed and updated once the significant change of condition was identified on 06/02/26. In an interview with Staff 1 (ED) on 07/01/26 at 2:20 pm, she stated she had not updated the service plan with the significant change of condition. The need to ensure service plans were reflective of residents’ needs, provided clear instruction to staff, were readily available to staff, and were updated with significant changes of condition was reviewed with Staff 1 on 07/02/26 at 11:30 am. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? The service plans for Residents 2 and 3 will be reviewed and updated to accurately reflect their current assessed needs, preferences, routines, behaviors, required assistance, safety interventions, and current medication-related information. Resident 2’s service plan will be updated to provide clear direction regarding bathing, grooming, dressing, toileting and incontinence care, customary sleep and eating routines, safety checks, behaviors including entering other residents’ rooms, and current medication information. Resident 3’s service plan will be updated to address use and safety precautions related to the half side rail and the resident’s hearing and communication preference. The current service plans will be made readily available to staff. 2. How will the system be corrected so this violation will not happen again? Resident service plans will be reviewed following evaluations, significant changes of condition, and identified changes in care needs to ensure they accurately reflect current needs and provide clear direction regarding what services are to be provided and how they are to be delivered. When a service plan is updated, the current version will be made available to direct-care staff and outdated copies will be removed from active staff-access areas. Care information, staff observations, current orders, and identified changes in resident needs will be compared with the service plan and updated as needed. 3. How often will the area needing correction be evaluated? Service plans will be audited weekly for four weeks, then monthly for three months, and quarterly thereafter to verify they reflect current resident needs, provide clear direction to staff, and that the most current version is readily available. Any discrepancies identified will be corrected promptly. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee will be responsible for ensuring the corrections are completed and ongoing compliance is monitored.

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, monitor the resident consistent with the resident’s evaluated needs, and document weekly progress until the condition was resolved for 2 of 2 sampled residents (#s 1 and 4) with changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the MCC facility in 04/2026 with diagnoses including dementia. The resident's 05/01/26 through 07/13/26 clinical record was reviewed. a. For the following changes of condition, the facility failed to communicate to staff what action or intervention was needed for a resident following a change of condition: * On 06/04/26 an RN assessment for a “progressive decline” was completed and identified the intervention to “offer food/fluids frequently…” There was no documented evidence the facility communicated the intervention to staff on each shift. * On 06/22/26 Resident 4 had a fall out of bed. The incident form identified an intervention which included to “reposition resident higher in bed and toward the center during bedtime care and with each overnight safety check as needed…” There was no documented evidence the intervention was communicated to staff on each shift. * On 06/28/26 Resident 4 was found on the floor “grasping the armrest of a nearby dining chair…” The investigation report identified an intervention instructing staff to cue the resident when the resident was attempting to sit in a chair and “encourage the resident to fully position [himself/herself] in front of the chair before sitting down” with “hands-on” assist as needed. There was no documented evidence the fall intervention was communicated to staff on each shift. b. For the following changes of condition, the facility failed to document the status of the condition at least weekly until resolved or failed to document whether the condition was resolved: * 05/01/26 – New move-in; * 05/02/26 – Refusal of multiple medications; * 05/08/26 – Skin tear on the top of his/her left hand; * 05/19/26 – Skin tear on right forearm; * 05/22/26 – New medication risperidone (for agitation) 1 mg/mL nightly; * 05/26/26 – Skin tear on left middle finger; * 06/05/26 – Witnessed fall; * 06/08/26 – Protein shakes three times a day; * 06/13/26 – Resident-to-resident altercation; * 06/15/26 – Resident-to-resident altercation; * 06/15/26 – Increase risperidone 1 mg/mL to twice a day; * 06/18/26 – Discontinue atorvastatin (for high cholesterol) and metformin (for diabetes); * 06/22/26 – Unwitnessed fall; * 06/22/26 – Redness on left shoulder; * 06/28/26 – Found on floor, with emergency room visit; * 06/29/26 – Progress notes indicated “bruising found on the left hip and left inner thigh”; * 07/01/26 – New medication potassium chloride (for low potassium); and * 07/02/26 – Discontinue medication memantine (for cognitive decline). During an interview on 07/16/26 at 10:20 am, Staff 1 (MCC Administrator) stated Staff 3 (Health and Wellness Director/RN) monitored and resolved significant changes of condition and skin issues, while Staff 1 resolved all other changes of condition. The need to ensure interventions for short-term changes of condition had been determined, documented, and communicated to staff on all shifts, and the resident was monitored, with progress noted weekly through resolution, was reviewed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings. No further documentation was provided. 2. Resident 1 moved into the MCC in 06/2026 with diagnoses including Alzheimer’s disease and schizophrenia. The resident’s 06/23/26 through 07/13/26 clinical record was reviewed. For the following changes of condition, there was no documented evidence of weekly progress monitored to resolution: * 06/23/26 - New move-in; * 06/24/26 - Skin tear to left elbow; * 07/03/26 - Discontinuation of lisinopril; and * 07/03/26 - Addition of the following medications: sennoside, tamsulosin, amlodipine, brexpiprazole, apixaban, losartan, quetiapine, melatonin, lorazepam, finasteride, and divalproex. In an interview with Staff 1 (MCC Administrator) on 07/16/26 at 10:20 am, she stated Staff 3 (Health and Wellness Director/ RN) would discontinue monitoring of skin issues, but it was Staff 1’s responsibility to discontinue alerts for all other short-term changes of condition. The need to ensure short-term changes of condition were monitored with weekly progress until the condition resolved was reviewed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 1 of 1 sampled resident (# 3) who experienced a significant change of condition. Findings include, but are not limited to: Resident 3 moved into the memory care community in 08/2025 with diagnoses including unspecified dementia, Parkinson’s disease, and schizoaffective disorder, bipolar type. The resident’s 03/29/26 through 06/29/26 clinical record and 12/2026 through 06/2026 weight records were reviewed, and staff were interviewed. The following weights were recorded by the facility: 12/24/25: 158.2 pounds; 02/02/26: 164.8 pounds; 03/18/26: 157.4 pounds; 05/03/26: 143.4 pounds; and 06/24/26: 137.4 pounds. Resident 3 experienced an unexplained weight loss of 13.53% of his/her body weight in three months (from 02/02/26 to 05/03/26). This severe weight loss constituted a significant change of condition that required an RN assessment. In a progress note dated 06/02/26, the LPN identified the weight loss, established interventions, and notified the ED and the RN of the weight change. There was no documented evidence the facility RN conducted an assessment until 06/10/26, 38 days after the weight loss was first recorded, and eight days after the LPN notified her of the weight loss. Resident 3 was interviewed on 06/29/26 at 12:38 pm and stated, “The food here is great.” S/he reported being aware s/he had lost quite a bit of weight but felt it was due to decreased appetite following a recent hospitalization. Resident 3 revealed a cabinet next to the bed full of snacks brought to him/her by his/her spouse and reported being able to eat whenever and whatever s/he chose. Resident 3 was reweighed during the survey and had regained one pound of the 21.4 pound weight loss, weighing 138.4 pounds. The need to ensure significant changes of condition were assessed timely by the facility RN and documented findings was discussed with Staff 1 (ED) on 07/02/26 at 11:30 am. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? The facility RN completed a review of Resident 3’s significant weight loss, and the change-of-condition documentation was completed. The Executive Director and facility RN reviewed the sequence of events and determined that the concern was identified and addressed; however, the RN review and documentation were not completed timely. The consulting RN independently reviewed the applicable change-of-condition guidance document. As part of the corrective action, the consulting RN will review the document with the Executive Director and designated clinical leadership to reinforce expectations for timely identification, reporting, assessment, documentation, and follow-up of changes of condition. 2. How will the system be corrected so this violation will not happen again? Staff will promptly report significant or unexplained weight changes and other changes of condition to the facility LN or designee. The facility LN or designee will ensure the appropriate licensed-nurse review, provider notification, interventions, documentation, and service-plan updates are completed timely. An RN will be involved when an RN assessment, review, or clinical decision is required. The consulting RN will provide education using the change-of-condition guidance document to reinforce a consistent process within the facility. Leadership will review weight records and change-of-condition documentation to verify timely follow-through. 3. How often will the area needing correction be evaluated? Weight reports and change-of-condition documentation will be reviewed weekly for four weeks, then monthly for three months, and quarterly thereafter. Any delay in RN review, documentation, notification, or follow-up will be addressed immediately. 4. Who will be responsible to see that the corrections are completed/monitored? The facility RN and Executive Director or designee will be responsible for completing and monitoring the corrective actions.

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 maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 3 sampled residents (# 4) who relied on staff for incontinence cares and multiple unsampled residents during meal service. Findings include, but are not limited to: 1. Resident 4 moved into the memory care community in 05/2026 with diagnoses including dementia and diabetes. The resident was identified during the acuity interview on 06/29/26 as requiring heavy care related to behaviors due to being blind and hard of hearing. During multiple ADL observations on 06/30/26 through 07/02/26, the following was noted: a. Staff 10 (CG), Staff 12 (CG), and Staff 14 (CG) were observed on 06/30/26 at 12:10 pm providing incontinence care to Resident 4. Staff 10 and Staff 12 assisted with transferring from bed and held him/her up using gait belt while Staff 14 provided the incontinence care. All the three staff members donned gloves, and no hand hygiene was observed prior to donning gloves. Staff 14, who had touched the dirty brief and provided peri care, did not change gloves from dirty to clean tasks. All the three staff members removed the gloves; no hand hygiene was observed after glove removal. b. Staff 10 and Staff 14 proceeded towards the dining room and started serving the lunch meal to the residents. Neither staff performed hand hygiene prior to serving the lunch meal. Neither staff member used protective clothing while assisting the residents with the lunch meal. Two sampled residents and one non-sampled resident required meal assistance from staff. c. Staff 13 (CG) and Staff 17 (CG) were observed on 07/01/26 at 10:39 am providing incontinence care to Resident 4. Both staff applied gloves without performing hand hygiene. During the care, Resident 4 was making vulgar comments to staff and attempting to strike and bite both staff. Staff 13 assisted to hold resident’s arms while Staff 17 provided the incontinence care. Resident 4 was incontinent of bowel and bladder. Staff 17 placed the soiled brief on the foot of the bed, and while assisting the resident to roll, the soiled brief fell to the floor. When they completed care, Staff 17 picked up the soiled brief from the floor and placed it in trash bag, and with the same dirty gloves on, proceeded to get a clean blanket from the closet, realized it was small and placed it back. She opened the door with the dirty gloves still on, took another blanket from the recliner, which was in the living room, returned and covered the resident, then turned off the light switch, left the room and removed the gloves. She then performed hand hygiene in the kitchenette sink. Staff 13 removed gloves, no hand hygiene was observed, then put on new gloves and proceeded down the hall to assist another resident. The observation and the need to implement universal precautions when completing ADL care and providing meal assistance was shared with Staff 1 (ED) on 07/02/26 at 1:39pm. She acknowledged the findings. 2. During the survey, on 07/01/26 at 1:44 pm, the following was observed: * Staff 13 (CG), Staff 17 (CG), and Staff 20 (CG) provided transfer assistance for Resident 10 from a recliner to a wheelchair and escorted the resident down the hall to his/her apartment; * Staff 13, 17, and 20 donned gloves prior to escorting the resident into the apartment; * At 1:50 pm, Staff 17 exited the apartment, removed gloves, and verified the resident was receiving ADL care from all three staff and that the resident had been soiled; * Staff 13 exited the resident apartment, removed gloves, and proceeded to the kitchen area to heat up a plate of food and prepare a beverage for Resident 10. Staff 13 verified she had not washed her hands after assisting with ADL care and preparing food for the resident. The need to ensure staff consistently used universal precautions when completing ADL care and providing meal assistance was shared with Staff 1 (ED) during the exit interview on 07/02/26 at approximately 3:15 pm. No additional information was provided.

1. What actions will be taken to correct the rule violation for each example/resident? An all-staff training on infection prevention and control was completed. During the training, all direct-care staff were educated on proper glove use and wearing aprons as protective barriers during meal service and while providing feeding assistance to residents. The training also included hand hygiene before donning and after removing gloves, changing gloves between residents and between dirty and clean tasks, proper disposal of soiled items, avoiding contact with clean supplies or environmental surfaces while wearing contaminated gloves, and performing hand hygiene before food preparation or meal assistance. Completion of the training was documented on the all-staff training roster. Staff involved in the cited observations also received individual re-education regarding the infection-control practices identified during the survey. 2. How will the system be corrected so this violation will not happen again? Infection-prevention expectations, including proper glove use and wearing aprons during meal service and feeding assistance, will be reinforced during new-hire orientation, staff meetings, and as concerns are identified. Hand-hygiene supplies, gloves, and aprons will remain available in resident-care and food-service areas. Leadership will complete direct observations during personal care, incontinence care, transfers, food preparation, meal service, and feeding assistance to verify gloves and aprons are used as required. Any concern identified will be corrected immediately, and the involved staff member will receive additional re-education and observation. 3. How often will the area needing correction be evaluated? Direct observations of infection-prevention practices will be completed on varied shifts weekly for four weeks, monthly for three months, and quarterly thereafter. Any concern identified will be addressed immediately and monitored more frequently until consistent compliance is demonstrated. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director, who also serves as the facility’s Infection Control Specialist, or designee will be responsible for ensuring corrective actions are completed and ongoing compliance is monitored.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (# 2) who had documented medication refusals. Findings include, but are not limited to: Resident 2 moved into the memory care community in 12/2021 with diagnoses including mixed dementia, depression, and hypertension. The resident's 06/01/26 through 06/29/26 MAR, prescriber orders, and clinical records were reviewed. Resident 2 refused to consent to the following orders: * 06/02/26 - refused quetiapine (used to regulate mood); * 06/08/26 - refused Eliquis (used as a blood thinner), mirtazapine (used to regulate mood) and quetiapine; * 06/15/26 - refused metoprolol (used to regulate blood pressure); and * 06/22/26 - refused quetiapine. There was a signed order for staff to notify the prescriber “each day” the resident refused medications. On 06/30/26 at 3:13 pm, Staff 1 (ED) confirmed the prescriber had not been contacted for the above refusals. The need to notify the practitioner when a resident refused to consent to an order was discussed with Staff 1 on 07/02/26 at 12:13 pm. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Resident 2’s medication refusals, medication orders, MAR, and related documentation were reviewed. Medication staff were re-educated regarding the resident’s right to refuse medication, accurate documentation of each missed or refused medication, required PCP notification, and placement of the resident on alert for follow-up monitoring. An order was entered in the MAR directing medication staff on each shift to notify the PCP at the end of the shift of any missed or refused medications and to place the resident on alert. 2. How will the system be corrected so this violation will not happen again? Orders are being added to each resident’s MAR to identify that resident’s PCP-specific notification preferences for missed or refused medications. Medication staff will review every resident’s MAR at the end of each shift for missed or refused medications and follow the resident-specific order. Staff will accurately document the missed or refused dose, notify the PCP according to the instructions and timeframes in the resident’s MAR, document the notification and any instructions received, place the resident on alert for monitoring and follow-up, and communicate the information during shift report. Orders will also be reviewed upon admission and when a resident’s PCP or PCP notification preferences change. Medication documentation will be reviewed to ensure the resident-specific order was followed and all required notification, alert placement, documentation, and follow-up were completed. 3. How often will the area needing correction be evaluated? Missed and refused medication documentation will be reviewed daily for four weeks, weekly for two months, and monthly for three months thereafter. Any missing PCP notification, alert placement, documentation, or follow-up will be corrected promptly, and the involved staff member will receive additional re-education. 4. Who will be responsible to see that the corrections are completed/monitored? The Wellness Director or designee and Executive Director will be responsible for ensuring the corrective actions are completed and ongoing compliance is monitored.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were kept accurate and included resident-specific parameters for PRN medications for 3 of 4 sampled residents (#s 1, 3, and 4) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the memory care community in 08/2025 with diagnoses including unspecified dementia, Parkinson’s disease, and schizoaffective disorder, bipolar type. The resident’s clinical record, including the 06/01/26 through 06/29/26 MAR and physician’s orders were reviewed. The following was identified: The following medications lacked a reason for use: * Carbidopa-Levodopa; and * Olanzapine. The need to ensure MARs were kept accurate was reviewed with Staff 1 (ED) on 07/02/26 at 11:30 am. She acknowledged the findings. 2. Resident 4 moved into the memory care community in 05/2026 with diagnoses including dementia and diabetes. The resident’s clinical record, including the 06/01/26 through 06/29/26 MAR and physician’s orders were reviewed. The following was identified: The following medications lacked a reason for use: * Aspirin; * Psyllium fiber oral powder; * Lisinopril; * Multivitamin; * Rosuvastatin; and * Sertraline. The need to ensure MARs were kept accurate was reviewed with Staff 1 (ED) on 07/02/26 at 1:39 pm. She acknowledged the findings. 3. Resident 1 was admitted to the facility in 05/2024 and had diagnoses which included dementia. Review of the resident’s 06/2026 MAR and PCP orders dated 03/26/26 revealed the following: The resident had the following PRN medications ordered for symptoms including agitation and restlessness: * Quietapine Fumarate 25 mg PRN (used seven times); * Lorazepam 0.5mg tablet PRN (used four times); and * Haloperidol LAC 2mg/ML CONC PRN (used four times). The MAR lacked clear parameters for when to use the PRN medications, a clear sequence, and instructions for use. During an interview on 07/01/26 at 11:00 am, Staff 15 (MT) stated MTs often called hospice for instructions, and MTs also initiated the use of PRNs based on symptoms. The need to ensure the MAR contained resident-specific parameters and instructions for PRN medications was discussed with Staff 3 (Director of Health Services) at 12:30 pm, who acknowledged the lack of clearly documented parameters and instructions for when to give which medication. The requirement to document resident-specific parameters and instructions for staff was discussed with Staff 1 (ED) at 1 pm on 07/01/26. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? The medication orders and MARs for Residents 1, 3, and 4 were reviewed. Resident 1’s existing directions instructed medication staff to contact hospice before each use of the cited PRN medications and to administer the medication only when directed by hospice. Under the direction and guidance of the survey team, the facility RN entered clear resident-specific parameters and sequencing instructions into the MAR while retaining the requirement to contact hospice before administration. Reasons for use were added to the identified MAR entries for Residents 3 and 4. Medication staff were re-educated regarding the updated MAR instructions. 2. How will the system be corrected so this violation will not happen again? The facility LN or designee will review new and changed medication orders before or upon entry into the MAR to ensure the medication name, dosage, route, administration time, reason for use, and medication-specific instructions are complete and accurate. PRN medication entries, including hospice medications, will include resident-specific indications, parameters, sequencing instructions when multiple medications address similar symptoms, and any requirement to contact hospice, the prescriber, or a licensed nurse before administration. Incomplete or unclear instructions will be clarified before the medication is administered. An RN will be consulted when an RN assessment, review, or clinical decision is required. 3. How often will the area needing correction be evaluated? The facility LN or designee will review MARs and medication orders weekly for four weeks, monthly for three months, and quarterly thereafter. New and changed medication orders will also be reviewed when received. Any missing reason for use, parameter, sequencing instruction, or other discrepancy will be corrected promptly, with staff re-education provided as indicated. 4. Who will be responsible to see that the corrections are completed/monitored? The facility LN or designee and Executive Director will be responsible for ensuring the corrections are completed and ongoing compliance is monitored. The RN will be involved when clinically indicated or required by regulation.

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 2 of 5 sampled residents (#s 1 and 2) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the memory care community in 12/2021 with diagnoses including mixed dementia. Observations of the resident, interviews with staff, review of the 05/31/26 service plan, and review of Resident 2’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Dressing and undressing; * Bowel and bladder management; * Bathing; * Non-drug interventions for behaviors; and * Safety checks. 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) on 07/02/26 at 12:13 pm. She acknowledged the findings. 2. Resident 1 was admitted to the facility in 05/2024 and had diagnoses which included dementia. Interviews with staff and observations from 06/29/26 through 07/02/26, review of the evaluation and 06/03/26 service plan, and the corresponding resident ABST data identified the following care time and care elements were not accurate: * Two staff to transfer in or out of bed or chair; * Time spent assisting with leisure activities; and * Time spent monitoring behavioral conditions or symptoms. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 3 (Director of Health Services) at 12:30 pm and with Staff 1 (ED) at 1:00 pm on 07/01/26. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? The Executive Director reviewed the evaluations, service plans, and ABST entries for Residents 1 and 2. The ABST entries were updated to accurately reflect the care elements and resident-specific time required to provide their current services. Resident 2’s ABST was corrected to address dressing and undressing, bowel and bladder care, bathing, behavioral interventions, and safety checks. Resident 1’s ABST was corrected to address two-person transfers, assistance with leisure activities, and monitoring of behavioral conditions or symptoms. The staffing plan was reviewed following the corrections to ensure it reflected the residents’ current care needs. 2. How will the system be corrected so this violation will not happen again? The Executive Director will compare each resident’s current evaluation and service plan with the ABST to ensure all care elements and resident-specific care times are accurately reflected. The ABST will be updated following quarterly evaluations, significant changes of condition, service plan changes, or when staff identify a change in the amount or type of assistance being provided. Licensed nursing staff and direct-care staff will communicate changes in resident needs to the Executive Director so the ABST and staffing plan can be reviewed and updated as necessary. 3. How often will the area needing correction be evaluated? The Executive Director will review ABST entries weekly for four weeks, monthly for three months, and quarterly thereafter. The ABST will also be reviewed following significant changes of condition or changes to resident evaluations and service plans. Any discrepancy identified will be corrected promptly, and the staffing plan will be adjusted when indicated. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee will be responsible for completing, updating, and monitoring the ABST and ensuring the staffing plan reflects current resident care needs.

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 conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Six months of fire and life safety records, from 01/2026 through 06/2026, were reviewed with Staff 4 (Regional Maintenance Director) on 06/30/2026 at 10:45 am. The fire drill documentation failed to address the following: * Escape routes used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. During an interview on 06/23/26 at 10:45 am, Staff 4 acknowledged the missing details related to the fire drills and stated, “If they weren’t documented, they didn’t happen.” The need to ensure fire drills were conducted in accordance with the OFC was discussed with Staff 1 (ED) on 07/01/26 at 3:15 pm. Staff 1 acknowledged the findings.

1. What actions will be taken to correct the rule violation? The Maintenance Director reviewed the requirements for conducting and documenting fire drills. The facility’s fire-drill documentation was updated to include all required information, including the escape route used, problems encountered, resident participation or resistance, number of occupants evacuated, evacuation time, and evidence that alternate routes are used. A fire drill will be completed and documented using the updated process to confirm that all required information is captured. 2. How will the system be corrected so this violation will not happen again? The Maintenance Director or designee will conduct unannounced fire drills at the required frequency and at varied times across day, evening, and night shifts. Different fire origins and escape routes will be used to ensure staff practice alternate evacuation routes. Following each drill, the Maintenance Director or designee will complete the fire-drill record in its entirety. The Executive Director will review each completed record to verify that the drill and all required details were documented. Any missing information will be corrected promptly. 3. How often will the area needing correction be evaluated? The Executive Director will review each fire-drill record after the drill is completed. Fire-drill schedules and records will also be reviewed monthly for six months and quarterly thereafter to verify drills are completed timely, occur on varied shifts, use alternate routes, and contain all required documentation. 4. Who will be responsible to see that the corrections are completed/monitored? The Maintenance Director or designee will be responsible for conducting and documenting the fire drills. The Executive Director or designee will be responsible for reviewing the records and monitoring ongoing compliance.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure each resident was re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: Six months of fire and life safety records from 01/2026 through 06/2026 were reviewed with Staff 4 (Regional Maintenance Director) on 06/30/2026 at 10:45 am. No documentation was found related to fire and life safety topics being provided annually to residents. Staff 4 stated the facility conducted full evacuation exercises each year, but he was not aware of instructions provided to residents in general safety procedures related to fire safety topics during these evacuations. On 06/29/26 at 1:22 pm, an unsampled resident stated s/he did not recall being provided with fire and life safety training since moving into the facility. In an interview with Staff 1 (ED) on 06/29/26 at 1:22 pm, no evidence was provided to indicate the facility had a system in place to reinstruct residents on fire and life safety topics on an annual basis. The need to re-instruct residents at least annually on fire and life safety topics was discussed with Staff 1 on 07/02/26 at 3:15 pm. Staff 1 acknowledged the findings.

1. What actions will be taken to correct the rule violation? All current residents will receive instruction regarding general fire and life-safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting areas, regardless of cognitive ability. Each resident’s service plan will be reviewed and updated to document the date the resident most recently received the instruction. 2. How will the system be corrected so this violation will not happen again? All new residents will receive fire and life-safety instruction within 24 hours of move-in, regardless of cognitive ability. The instruction will be presented in a manner appropriate to the resident’s communication and cognitive needs. The date the instruction was provided will be documented in the resident’s service plan. All residents will receive the instruction at least annually thereafter, and the service plan will be updated with the most recent instruction date. 3. How often will the area needing correction be evaluated? New resident service plans will be reviewed after move-in to verify that fire and life-safety instruction was provided within 24 hours and documented. Resident service plans will be reviewed monthly for six months and quarterly thereafter to verify that the most recent instruction date is documented and annual instruction remains current. Any missing or overdue instruction will be completed and documented promptly. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee will be responsible for ensuring all residents receive fire and life-safety instruction within the required timeframes and that the date is documented in each resident’s service plan.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exterior pathways were smooth and maintained in good repair, free of gardening equipment and debris, and drop-offs were less than an inch. Findings include, but are not limited to: The exterior courtyard between The Maple (200 hall) and The Dogwood (300 hall) was observed on 06/29/26 at 12:26 pm. There were multiple cracks and separations between concrete slabs of more than two inches wide and deep which created uneven surfaces in several areas of the walkway. A discarded garden hose was observed to be stretched across the walkway and draped into a raised planter in the center of the courtyard. A large landscape rock (approximately 10” x 8”) was observed on the walkway near the south exit gate. A drop-off which exceeded one inch in depth was observed along the walkway adjacent to The Dogwood. Two clear plastic trash bags of garden debris were observed to be discarded under a chair in the center of the walkway and outside the Dogwood (300 hall) exit doorway. These items created multiple tripping hazards and an unmaintained environment in the courtyard. On 6/29/26 at 1:07 pm, the courtyard was toured with Staff 1 (ED). Staff 1 acknowledged the cracks in the pavement, discarded hose, landscape rock, trash bags, and drop offs. Staff 1 stated these items needed to be addressed for resident safety and maintenance.

1. What actions were taken to correct the rule violation? The garden hose, landscape rock, yard debris, and other items obstructing the courtyard pathways were removed. The damaged sections of the courtyard walkway, including cracks, separations, uneven surfaces, and the drop-off adjacent to the Dogwood hallway, were repaired to provide a smooth and safe walking surface. The courtyard and exterior pathways were inspected following completion of the work to verify that the identified hazards were corrected and the areas were safe for resident use. 2. How will the system be corrected so this violation will not happen again? The Maintenance Director or designee will inspect exterior walkways, courtyards, entrances, exits, and outdoor resident-use areas at least once daily for debris, hoses, landscaping materials, yard waste, and other items that may obstruct a pathway. Items obstructing a pathway will be removed immediately. The same areas will also be inspected for cracks, uneven surfaces, drop-offs, and other structural or surface hazards according to the monitoring schedule below. Structural or surface concerns that cannot be corrected immediately will be reported to the Executive Director, the affected area will be secured or restricted, and repair arrangements will be initiated. 3. How often will the area needing correction be evaluated? Outdoor resident-use areas will be inspected daily on an ongoing basis for obstacles, hoses, debris, and other pathway obstructions. Structural and surface conditions will be inspected daily until all identified repairs are completed, weekly for four weeks following completion, monthly for three months, and quarterly thereafter. Any hazard identified will be addressed immediately or the affected area will be restricted until it is repaired. 4. Who will be responsible to see that the corrections are completed/monitored? The Maintenance Director or designee will be responsible for completing the inspections and coordinating repairs. The Executive Director or designee will monitor completion of the corrective actions and ongoing compliance.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the facility was free from unpleasant odors. Findings include, but are not limited to: On 06/29/26 at 12:20 pm, a strong and unpleasant odor of urine was noted in the shared area of The Maple (200 hall) and was stronger adjacent to rooms 206 and 207. The odor remained noticeable and pervasive during multiple observations from 06/29/26 through 07/02/26. On 06/29/26 at 1:15 pm the areas were toured with Staff 1 (ED) who acknowledged the odor. Staff 1 stated the resident in 206a was incontinent of bladder and s/he spent time in his/her room and in the shared areas of The Maple (200 hall) throughout the day. Staff 1 stated CGs provided incontinence assistance to contain the odor and air fresheners were used to cover the odor. and She acknowledged the odor was still noticeable. The need to ensure the facility was free from odors was discussed with Staff 1 on 07/01/26 at 3:15 pm. Staff 1 acknowledged the findings.

1. What actions will be taken to correct the rule violation? Rooms 206 and 207 and the surrounding shared areas of the Maple hallway will be thoroughly cleaned and deodorized. Flooring, furniture, mattresses, bedding, laundry, waste containers, and other potentially affected surfaces will be inspected, cleaned, and replaced when cleaning is not sufficient to eliminate the odor. Resident 206A’s incontinence-care needs and current service plan will be reviewed by the facility LN or designee and updated as indicated. Care staff will be re-educated regarding timely incontinence assistance, prompt removal of soiled briefs and laundry, and immediate reporting of persistent odors. 2. How will the system be corrected so this violation will not happen again? Care staff will provide incontinence assistance according to each resident’s service plan and promptly remove soiled briefs, clothing, bedding, trash, and laundry from resident and common areas. Staff identifying an unpleasant odor will immediately investigate the source, complete or request necessary cleaning and resident care, and notify the department supervisor when the odor is not resolved. Air fresheners will not be used as a substitute for identifying and correcting the source of an odor. The facility LN or designee will review resident care needs when recurrent odors may be related to a change in continence, health status, or required assistance. 3. How often will the area needing correction be evaluated? The Maple hallway and Rooms 206 and 207 will be evaluated on each shift for four weeks, weekly for three months, and quarterly thereafter. Other resident and common areas will be observed during routine leadership rounds. Any unpleasant odor identified will be investigated and corrected promptly, with additional monitoring continued until the odor is resolved. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee will be responsible for monitoring ongoing compliance. The facility LN or designee will oversee resident-related care interventions, and the Housekeeping Supervisor or designee will oversee environmental cleaning and odor elimination.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exited the facility. Findings include, but are not limited to: On 06/29/26 at 12:12 pm, exit doors leading from The Cottonwood (100 hall), The Maple (200 hall), The Dogwood (300 hall), and The Pine (400 hall) to the outdoor courtyards were observed and tested. The exit doors did not have alarms or other acceptable systems to alert staff when residents exited the facility. On 06/29/26 at 12:15 pm, Staff 15 (CG) stated the exit door alarms were only turned on at night and during inclement weather. Staff 15 also stated the door alarm from The Maple (200 hall) to the courtyard was “broken.” On 06/29/26 at 12:16 pm, Staff 6 (RCC) acknowledged the door alarms were turned off and stated they should be turned on at all times. Staff 6 also stated the door alarm from The Maple (200 hall) to the courtyard needed a new battery. On 06/29/26 at 1:15 pm, Staff 1 (ED) observed the exit doors, noted the alarms were activated, and stated they should always be on to alert staff when residents exited their neighborhoods or returned from the courtyards.

1. What actions will be taken to correct the rule violation? All courtyard exit-door alarms were activated and tested to verify they alerted staff when the doors were opened. The Maple courtyard exit-door alarm was checked and restored to proper operation. Staff were re-educated that all courtyard exit-door alarms must remain activated at all times and that any malfunction must be reported immediately. 2. How will the system be corrected so this violation will not happen again? Designated staff will verify at the beginning of each shift that the courtyard exit-door alarms for the Cottonwood, Maple, Dogwood, and Pine neighborhoods are powered, activated, and functioning. If an alarm does not function properly, staff will immediately notify the Maintenance Director and Executive Director. The affected door will be secured or directly monitored until the alarm is restored to proper operation. Repairs and battery replacements will be completed promptly. 3. How often will the area needing correction be evaluated? Courtyard exit-door alarms will be verified at the beginning of each shift. The Maintenance Director or designee will also test each alarm weekly for four weeks, monthly for three months, and quarterly thereafter. Any malfunction will be addressed immediately. 4. Who will be responsible to see that the corrections are completed/monitored? The Maintenance Director or designee will be responsible for testing, maintaining, and repairing the exit-door alarms. The Executive Director or designee will be responsible for monitoring ongoing compliance.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to create an environment in which residents were treated with dignity and respect and received services in a manner that protected privacy. Findings include, but are not limited to: Refer to C200.

1. What actions will be taken to correct the rule violation for each example/resident? Staff involved in the cited observations will be re-educated regarding residents’ rights to privacy, dignity, and respectful treatment. Staff will ensure resident room doors are closed and available privacy measures are used during personal care. Staff will communicate respectfully with residents at all times and will not use demeaning, inappropriate, or disrespectful language. When a resident requires assistance with eating, staff will ensure another staff member assumes the assistance before leaving the resident or will communicate the temporary interruption to the resident and return promptly. 2. How will the system be corrected so this violation will not happen again? All direct-care staff will receive education regarding resident rights, privacy during personal care, dignity, respectful communication, and continuity of assistance. These expectations will also be included in new-hire orientation. Leadership will conduct direct observations during personal care and meal assistance to verify that privacy measures are used, residents are treated respectfully, and required assistance is provided without inappropriate interruption. Any concern identified will be corrected immediately through coaching, re-education, and additional observation. 3. How often will the area needing correction be evaluated? Direct observations will be completed on varied shifts weekly for four weeks, monthly for three months, and quarterly thereafter. Any concern involving privacy, dignity, respectful communication, or continuity of care will be addressed immediately and monitored more frequently until consistent compliance is demonstrated. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee will be responsible for ensuring corrective actions are completed and ongoing compliance is monitored.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure each individual had privacy in his or her own unit for multiple sampled and unsampled residents who shared bathrooms. Findings include, but are not limited to: The facility was comprised of four neighborhoods. The Cottonwood (units 101-107), The Maple(units 201-207), The Dogwood (units 301-307), and The Pine (units 401-407). Each neighborhood consisted of seven apartments, all of which were constructed to house two residents with a shared bathroom. During the environmental tour on 06/29/26 at 9:30 am, multiple apartments were observed to have privacy curtains in the doorway of the bathrooms versus some type of lockable door. In an interview on 06/29/26 at 9:33 am, Staff 1 (ED) verified all the apartments in the facility were constructed to be shared units. In addition, all units had privacy curtains in the bathroom doorway, and there were no lockable doors used for bathroom doors. The need to ensure an individual’s right to privacy in his or her own unit when the apartment was double occupied was discussed at 9:35 am on 06/29/26 with Staff 1 and Staff 2 (Regional Operations Director). They acknowledged the findings.

1. What actions will be taken to correct the rule violation? The facility is working with its policy analyst to determine whether the shared-bathroom configuration qualifies for an OPA exception. Each affected Memory Care unit is one shared resident room with one bathroom used by both residents; the bathroom opening currently has a privacy curtain instead of a door. While a decision is pending, staff will knock and announce before entering, prevent the other resident from entering an occupied bathroom, and redirect as needed. The facility will obtain pricing and schedule installation of one compliant locking door at the bathroom opening in each affected shared room. The door will provide privacy during use and permit emergency staff access. Installation will be completed by 08/31/26 unless the OPA first grants a written exception. Privacy screens or curtains will be obtained and used during bedside personal care for residents who cannot be assisted in the bathroom. Staff will position the screen or curtain before care and ensure the resident is not visible from the hallway, doorway, roommate’s area, or other common areas. 2. How will the system be corrected so this violation will not happen again? Resident service plans will identify whether personal care is provided in the bathroom or at bedside and the required privacy measures. Screens or curtains will remain available for bedside care, and staff will close the room door and fully shield the resident before care. Unless the OPA first grants a written exception, one compliant locking door will be installed at the bathroom opening in each affected shared Memory Care room by 08/31/26. The Maintenance Director or designee will verify that each door can be secured during use to prevent the other resident from entering and permits emergency staff access. If the OPA grants the exception, the facility will retain the written determination and follow any required alternative privacy measures. 3. How often will the area needing correction be evaluated? Leadership will observe privacy practices weekly for four weeks, monthly for three months, and quarterly thereafter. Screens and curtains will be checked for availability and correct use. The Maintenance Director or designee will review installation progress weekly until the doors are installed or the written OPA exception is received. Installed doors and locks will be tested weekly for four weeks, monthly for three months, and quarterly thereafter. Any concern will be corrected immediately. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee will coordinate with the policy analyst and OPA, ensure service plans include clear privacy directions, and monitor compliance. The Maintenance Director or designee will obtain, install, test, and maintain the required doors and locking hardware unless the OPA grants the written exception.

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 C152, C200, C420, C422, C510, C513, and C555.

1. What actions will be taken to correct the rule violation? The dining chairs identified in the courtyard will be removed and returned to the indoor dining area. All furniture in resident-accessible outdoor areas will be reviewed to ensure it is designed for outdoor use and is of sufficient weight and stability to prevent resident injury or aid in elopement. Any furniture that does not meet these requirements will be removed or replaced. 2. How will the system be corrected so this violation will not happen again? Staff will be instructed that indoor dining chairs and other lightweight furniture may not be moved into resident-accessible courtyards. Outdoor furniture will be evaluated before placement to ensure it is stable, appropriately designed, and of sufficient weight for use in a secured memory-care setting. During routine rounds, staff will return any unauthorized furniture to its appropriate location and immediately report unsafe outdoor furniture to the Maintenance Director or Executive Director. 3. How often will the area needing correction be evaluated? Resident-accessible courtyards and outdoor furniture will be inspected weekly for four weeks, monthly for three months, and quarterly thereafter. Staff will also observe the courtyards during routine daily rounds. Any unauthorized, damaged, unstable, or lightweight furniture identified will be removed immediately. 4. Who will be responsible to see that the corrections are completed/monitored? The Maintenance Director or designee will be responsible for inspecting and maintaining outdoor furniture. The Executive Director or designee will be responsible for monitoring ongoing compliance.

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, C280, C295, C305, C310, and C362.

1. What actions will be taken to correct the rule violation for each example/resident? The facility completed or initiated the corrective actions identified under C260, C280, C295, C305, C310, and C362. Resident service plans and ABST entries were reviewed and updated to accurately reflect current resident needs and services. The cited change-of-condition review and documentation were completed, and the process for timely licensed-nurse follow-up was reinforced. An all-staff infection-prevention and control training was completed, and involved staff received additional re-education. An order was entered in the MAR for each shift to notify the PCP at the end of the shift of missed or refused medications and to place the resident on alert. Reasons for medication use and resident-specific PRN parameters and sequencing instructions were added or clarified as identified during the survey. 2. How will the system be corrected so this violation will not happen again? The Executive Director and facility LN or designee will ensure health-care services are provided in accordance with facility licensing requirements. Resident evaluations, service plans, medication orders, MAR documentation, change-of-condition follow-up, infection-control practices, and ABST entries will be reviewed and updated when resident needs or orders change. The facility LN or designee will review clinical and medication-related documentation, with RN involvement when an RN assessment, review, or clinical decision is required. The Executive Director, who serves as the Infection Control Specialist, will monitor infection-control practices. The Executive Director will complete and update the ABST based on current evaluations, service plans, and resident-specific care needs. 3. How often will the area needing correction be evaluated? Compliance with the health-care systems addressed under the referenced citations will be reviewed weekly for four weeks, monthly for three months, and quarterly thereafter. Medication refusals, significant changes of condition, new or changed medication orders, service plan changes, and changes in resident acuity will also be reviewed as they occur. Any discrepancy will be corrected promptly, with additional staff re-education and monitoring as indicated. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director or designee and the facility LN or designee will be responsible for ensuring the corrections are completed and ongoing compliance is monitored. The Executive Director will oversee the ABST and infection-control systems. An RN will be involved when clinically indicated or required.

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 outdoor furniture was of sufficient weight, stability, and design to prevent resident injury or aid in elopement. Findings include, but are not limited to: The secured courtyard of the memory care community was toured on 06/29/26 at 12:26 pm. Multiple dining chairs were observed in the courtyard between The Maple (200 hall) and The Dogwood (300 hall), to which residents had free access. The furniture was easily movable and not of sufficient weight to prevent injury or elopement. On 06/29/26 at 1:07 pm the outdoor courtyard was toured with Staff 1 (ED). Staff 1 noted the presence of the dining chairs and stated residents brought them to the courtyard from the dining room. The need to maintain outdoor furniture of sufficient weight was discussed with Staff 1, and she acknowledged the findings.

1. What actions will be taken to correct the rule violation? The indoor dining chairs identified in the secured courtyard were removed and returned to the dining area. All furniture located in the resident-accessible courtyards was reviewed to ensure it was appropriate for outdoor use and of sufficient weight, stability, and design to prevent resident injury or aid in elopement. Any furniture that did not meet these requirements was removed from the resident-accessible area. 2. How will the system be corrected so this violation will not happen again? Staff will not move indoor dining chairs, lightweight furniture, or other unauthorized items into resident-accessible courtyards. Outdoor furniture will be reviewed before placement to ensure it is stable, appropriate for the secured memory-care environment, and of sufficient weight to prevent injury or use as an aid in elopement. During routine rounds, staff will remove and report any unauthorized, damaged, unstable, or lightweight furniture found in a courtyard. Maintenance concerns will be reported to the Maintenance Director or Executive Director for correction. 3. How often will the area needing correction be evaluated? Resident-accessible courtyards and outdoor furniture will be inspected weekly for four weeks, monthly for three months, and quarterly thereafter. Staff will also observe courtyard conditions during routine daily rounds. Any unsafe or unauthorized furniture will be removed immediately. 4. Who will be responsible to see that the corrections are completed/monitored? The Maintenance Director or designee will be responsible for inspecting and maintaining courtyard furniture. The Executive Director or designee will be responsible for monitoring completion and ongoing compliance.