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 immediately notify the local Department office or the local AAA (Area Agency on Aging) of any incident of abuse or suspected abuse, report a physical injury of unknown cause to the local Department office or the local AAA unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse, for 2 of 3 sampled residents (#s 1 and 4) with resident-to-resident altercations, incidents of suspected abuse or injuries of unknown cause. Findings include, but are not limited to: 1. Resident 1 was admitted to the residential care facility in 11/2024 with diagnoses including fracture of left femur, type 2 diabetes mellitus and metabolic encephalopathy. Resident 1’s clinical record was reviewed on 08/31/26 and the following was identified: A 07/16/26 facility incident report documented, “It was reported to this MT on 07/16/26 that resident’s hair was matted and not taken care of. Resident indicated [s/he] has not been showered in a week, hair not brushed or taken care of since last shower.” The above statements represented possible neglect of care for which the facility was required to report to the local Department office or AAA as an incident of suspected abuse. There was no documented evidence the resident’s statements were reported to the local Department office or AAA. The facility did not investigate the report and take measures necessary to prevent the reoccurrence of abuse/neglect. In an interview on 09/01/26 at 1:50 pm, Staff 1 (ED) confirmed the facility had not reported the statements to the local Department office and could not provide documented evidence the facility investigated the incident to determine whether actions were needed to ensure the resident was receiving proper care. The need to ensure incidents of suspected abuse were immediately reported to the local Department office or AAA and investigated to ensure neglect or abuse did not recur was reviewed with Staff 1, Staff 2 (LPN) and Staff 3 (RCC) on 09/03/26 at 11:05 am. They acknowledged the findings. On 09/03/26 at 8:55 am, Staff 1 provided documented evidence the facility had reported the incident to the local office earlier that day. 2. Resident 4 was admitted to the memory care community in 02/2026 with diagnoses including dementia. The resident’s progress notes, dated 05/30/26 through 08/31/26, incident reports, dated 07/16/26 through 08/21/26, and temporary service plans, dated 05/20/26 through 08/30/26, were reviewed, and the following was identified: * 05/20/26 – Staff were notified of “discoloration of outer portion of upper left arm” and were directed to monitor for “pain, discomfort, darkening or discoloration.” * 05/27/26 – Staff were notified of “[Resident 4] involved with verbal altercation [with] roommate resulting in physical contact by other resident.” * 06/25/26 – Staff documented when they heard Resident 4 yelling and went to investigate, they observed an unsampled resident sitting on the floor in Resident 4’s apartment. Resident 4 told staff the unsampled resident was “stealing clothes.” * 08/30/26 – Staff documented “Resident received a shower on 08/29/26. Staff observed abrasions and skin discoloration on both biceps, one on right side upper bicep and two on left side upper bicep.” On 09/02/26 at 2:59 pm, Staff 1 (ED) confirmed there was no documented evidence the injuries of unknown cause had been investigated to rule out abuse. She also confirmed the injuries of unknown cause and the resident-to-resident altercations had not been reported to the local Department office. The facility was asked to report the incidents to the local Department office on 09/02/26. Confirmation of the report was received on 09/03/26 at 10:12 am. The need for the facility to immediately notify the local Department office of any incident of abuse or suspected abuse, and report physical injuries of unknown cause to the local Department office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse was discussed with Staff 1, Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 10:12 am. They acknowledged the findings.

For Residents 1and 4: 1. In a staff meeting before 11/2/26, the leadership team and staff are to be instructed by the ED and or HSD on the importance of reporting any allegations of abuse to the ED, HSD, any other member of the leadership team, or reporting directly to the APS office. 2. The HSD and or ED will review and investigate the matter and make a report to all applicable agencies, when there has been an incident report or other type of notification of alleged abuse. 3. This is for all matters of resident - to - resident altercations, injuries of unknown cause, or other forms of abuse within the 24-hour window. These incidents will be reviewed in the Emar and investigated 4 out of 5 days a week. 4. Staff in-service will be provided on Abuse/Neglect and Exploitation at next all staff meeting. The date for this will be 11/02/26 compliance date.

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 resident’s current health status and care needs, were readily available to staff, provided clear direction regarding the delivery of services and/or were completed quarterly for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose records were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the memory care community in 05/2025 with diagnoses including Alzheimer’s disease. Review of Resident 5’s clinical record revealed the most recent service plan was dated 06/30/26. However, the service plan available to staff for Resident 5 was dated 03/12/26. On 09/02/26 at 10:10 am, the need to ensure current service plans were available to staff was discussed with Staff 1 (ED). She acknowledged the findings. 2. Resident 1 was admitted to the residential care facility in 11/2024 with diagnoses including fracture of left femur, type 2 diabetes mellitus and metabolic encephalopathy. Resident 1’s current service plan, dated 07/09/26, was reviewed, observations were obtained and interviews with the resident and care staff were conducted. The following was identified: During an observation of personal care on 08/31/26 at 1:13 pm, Staff 10 (CG) was observed to offer, and then apply, talc powder for the resident. Staff 10 placed a pillow under the resident’s knees when the resident was in bed after providing care. Staff 10 also rinsed a washcloth and handed it to the resident to keep on his/her over bed table. There were several cases of protein shakes in the resident’s room. The resident received continuous oxygen delivered via nasal cannula from an oxygen concentrator machine. There were bilateral side rails on the resident’s bed. In an interview on 09/01/26 at 1:10 pm, Staff 10 explained the resident asks a family member to purchase the talc powder and protein shakes for him/her. In a follow-up interview on 09/02/26 at 10:25 am, Staff 10 explained the resident requested staff apply the talc powder because the resident liked the fragrance and it helped keep his/her skin dry. Staff 10 explained staff offered the resident protein shakes when the resident didn’t eat large portions of a meal. She explained the resident liked to have a warm washcloth handy to place on his/her forehead or over his/her eyes when in bed. Staff 10 stated she did not know who provided routine care and monitoring of the oxygen concentrator. Staff 10 also stated Resident 1 always liked to have a straw in his/her beverages. In an interview on 09/01/26 at 2:34 pm, Resident 1 acknowledged asking staff for the talc powder and protein shakes. Resident 1 acknowledged s/he liked having the pillow placed under his/her knees. Resident 1 stated s/he had extra vinyl tubing for the concentrator and that s/he periodically asked a caregiver to change the tubing for him/her. Resident 1 did not know if anyone provided routine maintenance or monitoring of the concentrator machine. Resident 1’s current service plan lacked information or instructions for staff in the following areas: * Oxygen equipment care; * Placing pillows under the resident’s knees; * Providing a straw with each beverage; * Providing a warm washcloth; * The use and monitoring of the side rails; * Instructions for providing protein shakes; and * Instructions for applying the talc powder. The need to ensure service plans were reflective of the residents’ needs and provided clear direction regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 11:05 am. They acknowledged the information lacking from Resident 1’s service plan. 3. Resident 3 was admitted to the?memory care community in 12/2023 with diagnoses including?dementia. Resident 3’s service plan, dated 08/13/26, and temporary service plans, dated?08/13/26 through 08/26/26, were?reviewed, observations were made, and interviews with staff were conducted. On 09/01/26 the resident was observed to have a quarter-length side-rail on his/her bed in the up position, covered with a foam pad. Multiple direct care staff reported in interviews throughout the survey that the resident required incontinence care in bed due to weakness and inability to stand. ? The service plan was not reflective of the resident’s care needs and?lacked clear instructions to staff in the following areas:? * Toileting and incontinence care; and * The use of padding on side rails. The need to ensure the service plan was reflective of the resident’s current status and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (RCC) on 09/03/26 at 10:30 am. They acknowledged the findings.?? 4. Resident 2 to admitted to the memory care community in 10/2025 with diagnoses including severe dementia. The resident’s clinical record, including the 06/10/26 service plan, was reviewed. Observations were made and interviews with the staff were conducted. The service plan was not reflective of Resident 2’s current needs and lacked clear caregiving instruction in the following areas: * Assistance needed with oral care; * Preference to nap in a recliner; * Dressing assistance; * Toileting assistance including laminated signage for visual reminders; * Ability to shave; * Fall interventions; and * Hospice involvement including what services were provided and contact information. On 09/02/26 at 10:40 am, Staff 9 (CG) reported the resident was not independent with oral care or shaving but could dress him/herself independently. She confirmed that Resident 2 used the restroom when appropriately with verbal reminders. The need to ensure service plans were reflective of the residents’ needs and provided clear direction regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 9:50 am. They acknowledged the findings. 5. Resident 4 was admitted to the memory care community in 02/2026 with diagnoses including dementia. The resident’s clinical record, including the 04/28/26 service plan, was reviewed. Observations were made and interviews with the staff were conducted. The following was identified: a. The service plan was not reflective of Resident 4’s current needs and lacked clear caregiving instruction in the following areas: * Current activity preferences; * Hospice involvement including what service were provided and contact information; * Preference of peanut butter and jelly sandwiches; * When to offer finger foods versus regular meals served on plates with utensils; * The use of a nightlight; and * What triggered the resident’s behaviors. On 08/31/26 and 09/01/26, Resident 4 was observed watching a Michael Jackson concert, singing along and moving to the music. On 09/02/26 at 11:59 am, Staff 9 (CG) confirmed the resident preferred peanut butter and jelly sandwiches. She went on to verify when Resident 4 required finger foods and when s/he would eat a meal with utensils, served on a plate. Staff 9 reported the resident no longer had a nightlight in his/her apartment. b. Resident 4’s service plan had not been updated quarterly. The need to ensure service plans were reflective of the residents’ needs and provided clear direction regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 10:12 am. They acknowledged the findings.

For Residents 1, 2, 3, 4, 5: 1. The RCC, HSD and ED will review all current service plans and TSPs, Discuss needs with staff, residents, and family members to update services plans accurately reflect care needs. This process will occur at 30 days after move in, then quarterly there after. These will be availble in the Care plan and TSP binders that are kept in the laundry rooms for all the staff to review and sign. 2. When the ED, HSD, RCC receive the consultant visit documents from the RN, any notes/recommendations/observations will be reviewed. Any suggestions will be discussed with care staff and will result with the creation of TSPs to be placed in the TSP binders, these will indicate who shall provide the services, when they are to be done and how often, and implemented into the services plans at the next review. The staff will have access to the binders that are located in the laundry rooms of the cottages. There will be a copy of the care plan electronically or through regular mail given to the resident and or POA/Legal guardian for review. 3. These will be reviewed weekly, during the morning clinical meetings. The updates for the five identified residents will be completed by the compliance date. 4. HSD, RCC, or ED will be responsible to go through the service plan binders to ensure that only the most current service plans are in place, for the staff to review and sign.Compliance date of 11/02/2026.

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 ensure residents who experienced significant changes of condition were evaluated and referred to the nurse, the change was documented, and the service plan was updated as needed, and failed to ensure residents who experienced short term changes of condition had actions or interventions determined, documented, and communicated to staff on each shift and the changes were monitored with weekly progress noted through resolution for 3 of 5 sampled residents (#s 2, 3 and 4) who experienced changes of condition. Resident 3 experienced ongoing severe weight loss. Findings include, but are not limited to: 1. Resident 3 was admitted to the memory care community in 12/2023 with diagnoses including dementia. a. A review of the resident’s clinical record, including weights from 01/01/26 through 09/01/26, interviews with staff and a witness, and observations of the resident were completed from 08/31/26 through 09/03/26. The current service plan dated 08/05/26 documented resident “requires care staff for full assistance to eat.” Resident 3’s weight records identified the following: * 04/01/26 – 135.5 pounds; * 05/11/26 – 132.0 pounds; * 06/02/26 – 118.5 pounds; * 07/01/26 – 109.5 pounds; * 08/01/26 – 107.0 pounds; and * 09/01/26 – 104.0 pounds during survey. Resident 3 experienced a 13.5-pound weight loss between 05/11/26 and 06/02/26, or 11.85% of his/her body weight in 22 days, a severe weight loss which constituted a significant change of condition. There was no documented evidence the facility evaluated the weight loss, referred the condition to the RN, or that the service plan was updated. On 06/25/26, an assessment from the resident’s primary care provider noted the 13.5-pound weight loss and implemented daily nutritional shakes. The health shakes were documented as provided on the MAR, but there was no monitoring of the intervention for effectiveness. On 07/01/26 the resident experienced an additional 9.0-pound weight loss, or 10.95% of his/her body weight in 30 days, which constituted another severe weight loss. There was no documented evidence the facility evaluated the weight loss or referred to the RN. Observations during the survey identified the resident had a pureed diet texture and was dependent on caregivers for meal assistance. S/he ate 75% - 100% of meals and snacks when s/he was awake, as observed between 08/31/26 and 09/02/26. The facility failed to evaluate the resident’s weight loss, determine interventions, and monitor Resident 3 according to his/her needs, and s/he continued to lose weight. b. There was no documented evidence the following short-term changes of condition were monitored at least weekly through resolution: * 06/11/26 - Three skin tears on left elbow; * 07/09/26 - Red discoloration and tenderness above the right ear on scalp; * 07/16/26 - Bruise on left hip; and * 07/28/26 - Skin tears and bruise on right foot. On 09/03/26 at 10:30 pm, these findings were discussed with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (RCC). They acknowledged the findings. 2. Resident 2 was admitted to the memory care community in 10/2025 with diagnoses including severe dementia. The resident's clinical record and charting notes, dated 05/25/26 through 08/30/26, were reviewed and the following was identified: a. There was no documented evidence the facility determined what action or intervention was needed for the resident, communicated the determined action or intervention to staff on each shift, and monitored the condition through resolution for the following changes of condition: * 04/30/26 - Inappropriately touching another resident; * 07/18/26 - Resident to resident altercation; and * 07/24/26 - Fall. b. There was no documented evidence the facility monitored the following changes of condition through resolution: * 08/01/26 - Fall; * 08/02/26 - New medication; * 08/04/26 - Hospice admission and behaviors; * 08/10/26 - Increase in citalopram (an antidepressant); and * 08/22/26 - Missed dose of citalopram. On 09/01/26 at 12:48 pm, Staff 1 (ED) confirmed there was no documented evidence the facility determined what action or intervention was needed for Resident 2’s changes of condition, communicated the determined action or intervention to staff on each shift, and monitored the conditions through resolution relating to the incidents with other residents and the fall. In the same interview, Staff 1 also confirmed there was no documented evidence the facility monitored the resident’s additional fall, medication matters, hospice admission and behaviors through resolution. The need to ensure the facility monitored changes of condition through resolution with actions or interventions determined, documented, and communicated to staff on each shift was discussed with Staff 1, Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 9:50 am. They acknowledged the findings. 3. Resident 4 was admitted to the memory care community in 02/2026 with diagnoses including dementia. The resident’s clinical record and charting notes, dated 05/30/26 through 08/31/26, were reviewed and the following was identified: There was no documented evidence the facility monitored the following changes of condition through resolution: * 05/31/26 – Room change; * 06/23/26 – Bruising to thumb; * 06/25/26 – Possible resident-to-resident altercation; * 06/28/26 – Fall; * 07/18/26 – Resident-to-resident altercation; * 08/17/26 – Start of routine cephalexin (prophylactic antibiotic); * 08/21/26 – Missing evening medications; and * 08/27/26 – Increase in quetiapine (used for behaviors). On 09/02/26 at 2:59 pm, Staff 1 (ED) confirmed there was no documented evidence the facility monitored the resident’s room change, bruising, resident to resident altercations, fall, and medication matters through resolution. The need to ensure the facility monitored changes of condition through resolution with actions or interventions determined, documented, and communicated to staff on each shift was discussed with Staff 1, Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 10:12 am. They acknowledged the findings.

For Residents 2, 3, 4: 1. The RN consultant and HSD will evaluate and document all necessary changes and interventions. They will put TSPs in place for these residents. All changes in conditions will be reported to the RN consultant within 48 hours, to review and followup, provide recommendations in relation to the residents current care needs. 2. The HSD or designee will track all resident changes of condition on a weekly basis to ensure that the RN assessment is completed and that all required updates are made to resident records and care documentation. When the RN Consultant identifies a change of condition or makes recommendations to the RCC, HSD, or Executive Director, they will ensure timely follow-up and implementation of those recommendations. A Temporary Service Plan (TSP), will be placed in the TSP binder and communicated to staff. The TSP will remain active until the resident's next service plan update, at which time the interventions will be incorporated into the resident's permanent service plan as appropriate. Med Techs and Caregivers will document the progress and outcomes of all active treatments in the resident's chart notes until the treatment is completed. The resident's Primary Care Provider (PCP) will be notified of treatment results, and any additional orders received will be implemented and documented accordingly. To ensure ongoing compliance, the HSD or designee will audit change-of-condition documentation, RN assessments, TSPs, treatment charting, and PCP notifications weekly for 30 days and monthly thereafter as part of the facility's quality assurance process. 3. The HSD, RCC, or the ED will review the chart notes daily and monitor resident response to their treatment. PCP will be notified of treatment results. 4. The HSD, RCC, and or the ED will be responsible for monitoring and implementing changes, following company policy and state guidelines. Compliance date of 11/02/2026.

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 completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes of conditions related to weight loss. Findings include, but are not limited to: 1. Resident 3 was admitted to the memory care community in 12/2023 with diagnoses including dementia. The resident's monthly weights were reviewed, observations were made, and interviews with staff were conducted during the survey. The resident's recent weights were recorded as follows: * 04/01/26 – 135.5 pounds; * 05/11/26 – 132.0 pounds; * 06/02/26 – 118.5 pounds; * 07/01/26 – 109.5 pounds; * 08/01/26 – 107.0 pounds; and * 09/01/26 – 104.0 pounds during survey. From 05/11/26 to 06/02/26, the resident lost 13.5 pounds or 11.85% of his/her body weight in 22 days, which constituted a severe weight loss that required an RN assessment. From 06/02/26 to 07/01/26, the resident lost 9.0 pounds or 10.95% of his/her body weight in 30 days, which constituted another severe weight loss. Both instances of severe weight loss constituted a significant change of condition for which an RN assessment was required. There was no documented evidence that the facility RN had completed a significant change of condition assessment. In an interview on 09/01/26 at12:55 pm Witness 1 (RN Consultant) acknowledged that an RN assessment had not been completed for these significant changes of condition. The facility failed to ensure an RN assessment was completed for Resident 3’s severe weight loss, and s/he continued to lose weight. The need to ensure an RN completed an assessment for a significant change of condition was discussed with Witness 1 on 09/01/26 at 1:10 pm and with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (RCC) on 09/03/26 at 10:30 am. They acknowledged the findings. Refer to C 270, example 1a. 2. Resident 2 was admitted to the memory care community in 10/2025 with diagnoses including severe dementia. The resident's clinical record, including observation notes, dated 05/25/26 through 08/30/26, and weight records were reviewed. Interviews with facility staff were conducted and the following was identified: In 06/2026 the facility documented Resident 2’s weight as 141.7 pounds and in 07/2026 as 134.5 pounds. This constituted a 7.2 pound, or 5.08%, significant weight loss in one month. On 08/31/26 at approximately 10:00 am, Staff 1 (ED) reported they used an RN Consultant who was on-site once a week, on Tuesdays. On 09/01/26 at 1:35 pm, Witness 1 (RN Consultant) reported the facility obtained monthly weights “between the first and the fifth.” She verified receiving Resident 2’s weight information on 07/14/26 and requested staff to re-weigh the resident. The weight provided to her was 138.5 pounds, which was not a significant weight loss. She confirmed there was no RN assessment for the weight loss in 07/2026. The need to ensure an RN completed a timely assessment of residents’ significant changes of condition which documented findings, resident status and interventions made as a result of the assessment, was discussed with Staff 1, Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 9:50 am. They acknowledged the findings.

For residents 2 and 3: 1. Resident 2 and 3. The HSD/RN will work together to monitor resident weights, meet to discuss any changes in resident weights weekly. The residents will be offered alternitive meal choices form their prefered food selections, if they do not like meal that is planned is offered. Snacks will be offered to the residents from their lists of likes. The staff are to offer smaller meals more often, encourage the residents to drink more fluids. Resident 3 has an order for Ensure shakes to be offered once a day, we will ask the PCP for a prescription for her to have house stock healthshakes two times a day. For resident two, we will ask the PCP for a prescription for them to have house stock healthshakes 2xs daily for extra calories. 2. On 9/21/2026, the scales throughout the community, were callibrated by Michelli Weighing and Measurement, to ensure that the weights that are being used for the records, are accurate and will be consistant when used. The RCC, HSD and ED will oversee the consulting RN's weight tracker to ensure that they receive the weights timely, any concerns can be caught early. The HSD, RCC, and/or the ED will follow up weekly, to ensure all interventions are implemented and followed by the staff through TSPs and updated service plans, for each resident with any documented COC. RCC/HSD/ED will register and complete the COC courses offered through Nurse Learn, sign up to be completed by 11/2/2026, and the COC course to be completed by 11/2/2026. 3. The above mentioned corrections will be monitored and reveiwed weekly by the HSD, RCC, and/or ED. 4. The Consulting RN will document and communicate all identified significant changes of condition to the HSD, RCC, and ED. The HSD or designee will maintain a tracking system for all significant changes of condition, including required assessments, physician notifications, service plan updates, and follow-up actions. The HSD, RCC, and ED will review the tracking system and Consultant RN notes weekly to verify completion of all required actions. Weekly audits will be conducted by the HSD or designee, and any identified deficiencies will be addressed immediately with additional follow-up and staff education as needed. Compliance date 11/02/2026.

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 1 sampled resident (#1), related to the provision of personal care. Findings include, but are not limited to: Resident 1 was admitted to the residential care facility in 11/2024 with diagnoses including fracture of left femur, type 2 diabetes mellitus and metabolic encephalopathy. During the acuity interview on 08/31/26 at 10:00 am, Staff 1 (ED) and Staff 2 (Health Services Director) reported Resident 1 spent most of the time in bed where s/he received personal care. On 08/31/26 at 1:13 pm, the surveyor obtained Resident 1’s permission to observe personal care to determine adherence to universal precautions for infection control. During the observation, Staff 10 (CG) provided incontinence care while Resident 1 was in bed. Staff 10 donned gloves, removed the resident’s soiled brief and wiped the resident’s bottom. Then, without changing the soiled gloves, the staff applied a clean brief, positioned a pillow under the resident’s legs and covered the resident with a blanket. Staff 10 also took a washcloth, ran it under warm water and provided it to the resident without changing the soiled gloves. The caregiver did not follow basic universal precautions for infection control by neglecting to change her gloves between dirty and clean tasks. The need to ensure staff adhered to infection prevention and control protocols during the provision of personal care was reviewed with Staff 1, Staff 2 and Staff 3 (RCC) on 09/03/26 at 11:05 am. They acknowledged the staff did not follow proper infection control practices.

Resident 1: 1. Staff will be retrained on the proper procedure for assisting a bed bound resident with proper peri-care. This will include proper hygiene protocols, making sure the residents needs are met, the care staff are to inform the MT of resident preference with pericare. TSP will be created and the Service plan updated to reflect personal preference of the resident. 2. Care staff will be re-trained by demonstration on providing proper peri-care techniques during a special training session, taught by a Hospice nurse that will be completed by 11/2/2026. 3. The in-service training will be completed by Hospice once, but ongoing review and training will be completed via competency review by the HSD or RCC, monthly. Any newly hired staff will be trained during orientation. 4. HSD, RCC and/or ED will be responsible for making sure all training is completed, care staff will sign competency and understanding of care task. Signed documents will remain in staff personnel file. Compliance date of 11/02/2026.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 2 of 5 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:? 1. Resident 3 was admitted to the memory care community in 12/2023?with diagnoses including?dementia. The resident had a physician’s order dated 07/24/26 for a puréed diet texture. * On 08/16/26 the MAR recorded the resident received a snack of cottage cheese and mandarin oranges. * On 09/01/26 Staff 11 reported assisting the resident with breakfast: “It wasn’t puree. It was soft scrambled eggs with cheese and hashbrowns.” The need to ensure all physician orders were carried out as prescribed was discussed with Staff 1, Staff 2 (Health Services Director), and Staff 3 (RCC) on 09/03/26 at 10:30 am. They acknowledged the findings. 2. Resident 1 was admitted to the residential care facility in 11/2024 with diagnoses including fracture of left femur, type 2 diabetes mellitus and metabolic encephalopathy. During an observation of personal care on 08/31/26 at 1:13 pm, Staff 10 (CG) was observed to offer, and then apply, talc powder for the resident. The talc powder was an over-the-counter product. There were several cases of protein shakes in the resident’s room. The resident received continuous oxygen delivered via nasal cannula from an oxygen concentrator machine. In an interview on 09/02/26 at 10:25 am, Staff 10 explained the resident requested staff apply the talc powder. She also explained staff offered the resident protein shakes when the resident didn’t eat large portions of a meal. Review of Resident 1’s most recent signed physician orders summary, dated 04/30/26, lacked orders for the oxygen, talc powder and protein shakes. The need to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer was reviewed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 11:05 am. They acknowledged the lack of orders.

For residents 1 and 3: 1. Diet plans for residents will be monitored and updated as needed each week for any changes noted from the PCP or other recognized practitioner. Any diet changes will result in an evaluation from the RN consultant, a TSP will be placed in the TSP binder, and the new orders will be given to the kitchen staff to ensure that the most current diet is followed per order. In regard to other PCP orders or outside providers, that are not food related, the HSD, RCC, and /or the ED will check the MAR to make sure that all treatments and medications have been added properly, all treatments and medications have the purpose and/or the proper location of where to apply the treatments, along with how often to apply it. 2. The HSD, RCC, and/or ED will ensure all new physician and practitioner orders are entered into the resident record within 24 hours of receipt. Medication orders will be entered into the MAR, treatment orders will be entered into the TAR, and all applicable service plans, TSPs, diet lists, and care instructions will be updated accordingly. Documentation supporting implementation of the order will be maintained in the resident record. During daily clinical review, all new orders received within the previous 24 hours will be audited to verify that: • The order has been transcribed accurately into the MAR/TAR. • The order is present in the resident chart. • Any required service plan, TSP, or dietary updates have been completed. • Staff have been notified and trained as necessary. • Documentation reflects that the order has been implemented and followed. 3. Follow up/ Review will be completed 3 times weekly during each clinical meetings, with each new resident, or orders from PCP or outside providers. 4. The HSD, RCC, and/or ED will complete weekly audits of resident charts for 30 days and monthly audits thereafter for an additional 60 days to ensure all physician orders are present in the resident record, accurately transcribed, and documented as being followed. Compliance date of 11/02/2026.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications, including over-the-counter medications, that were ordered by a legally recognized prescriber and administered by the facility for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose records were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the memory care community in 05/2025, with diagnoses including Alzheimer’s Disease, heart disease, and depression. Review of Resident 5’s MAR, dated 08/01/26 through 08/31/26, revealed the MAR lacked reasons for use for the following medications: * Loratadine 10 mg; * Melatonin 5 mg; and * Trazodone 100 mg. On 09/02/26 at 10:10 am, the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (ED). She acknowledged the findings. 2. Resident 1 was admitted to the residential care facility in 11/2024 with diagnoses including fracture of left femur, type 2 diabetes mellitus and metabolic encephalopathy. Resident 1 had signed physician orders directing the facility to obtain the resident’s blood pressure and weight daily. Review of Resident 1’s 08/01/26 through 08/31/26 MAR/TAR indicated the following: * There were 10 of 31 days where the entry for the daily blood pressure was left blank; and * There were 10 of 31 days where the entry for the daily weight was left blank. On 09/01/26 at 2:05 pm, the MAR was reviewed with Staff 2 (Health Services Director). She acknowledged the blank entries. The need to ensure the facility maintained an accurate MAR was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (RCC) on 09/03/26 at 11:05 am. They acknowledged the findings. 3. Resident 3 was admitted to the memory care community in 12/2023 with diagnoses including dementia. The resident’s MAR dated 08/01/26 through 08/31/26, and corresponding physician’s orders were reviewed. The following was identified: a. The following medications lacked a reason for use: * Quetiapine fumerate 25 mg tab – give one tablet by mouth twice daily; * Morphine sulfate 20 mg/1 ml solution – give .25 ml (5 mg) by mouth every hour as needed; and * Polyethylene glycol 3350 powder – dissolve one powder pack in 8 oz liquid once a day as needed. b. The resident had orders for the following PRN psychotropic medications: * Haloperidol lactate 2mg/ml concentrate 15 – give 0.25 ml (0.5 mg) by mouth every 4 hours as needed for agitation, delirium, nausea; and * Lorazepam 2 mg/ml oral concentrate – give 0.25 ml (0.5 mg) by mouth every 2 hours as needed for anxiety, shortness of breath, restlessness. The medications lacked resident-specific parameters as to how the resident demonstrated agitation, anxiety, and restlessness. c. The resident had orders for Skintegrity wound cleanser – use to cleanse abrasion/minor skin tear as directed. The MAR lacked resident-specific parameters as to where this treatment should be applied. The need to ensure an accurate MAR was kept of all medications and treatments administered by the facility, including reason for use, and resident-specific parameters for PRN medications and treatments, was reviewed with Staff 1 (ED), Staff 2 (Health Services Directed), and Staff 3 (RCC) on 09/04/26 at 10:30 am. They acknowledged the findings. 4. Resident 2 to admitted to the memory care community in 10/2025 with diagnoses including severe dementia. The resident’s MAR dated 08/01/26 through 08/31/26 and physician’s orders were reviewed. The following was identified: * Citalopram lacked a reason for use. The need to ensure MARs were accurate and included reasons for use for all medications was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 9:50 am. 5. Resident 4 was admitted to the memory care community in 02/2026 with diagnoses including dementia, arthritis and fibromyalgia. The resident’s MAR dated 08/01/26 through 08/31/26, and physician’s orders were reviewed. The following medications lacked the reason for use: * Acetaminophen; * Melatonin; and * Quetiapine. The need to ensure MARs were accurate and included reasons for use for all medications was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 9:50 am.

For residents 1, 2, 3, 4, and 5 I. The HSD, RCC, and Executive Director Re reviewing the medication administration records (eMARs) for Residents 1, 2, 3, 4, and 5. All identified discrepancies are bien corrected, including ensuring that physician orders are accurately entered into the eMAR, diagnoses and medication indications are updated as applicable, and documentation accurately reflects medication administration, refusals, and treatment completion. Any missed documentation will be investigated and addressed. Medication parameters are being reviewed to ensure compliance with physician orders, and any required physician notifications related to medication or treatment refusals completed and documented. Each resident's record Will be audited to verify accuracy and compliance with medication management requirements. 2.The HSD, RCC, and/or ED will review the eMAR 3 times weekly to ensure that the orders are correctly entered into the eMAR, along with the diagnosis for use listed with the medications. RCC/HSD will verify that the med techs are documenting successful administration or refusal, with an explanation of why medication was not administered. RCC/HSD will monitor med techs to ensure that all parameters are being followed for certain treatments and medications as ordered. RCC/HSD will ensure compliance that med techs are notifiying the PCP timely of any refusals of scheduled medications or treatments. This is to be completed by 11/02/2026 3. An audit will be completed by the RCC/HSD or ED 3 times weekly to ensure accuarcy and compliance. 4. The HSD, RCC, and/or ED will be responsible for ensuring all corrections are implemented and monitored in compliance with the plan of correction. Compliance date of 11/2/2026.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident’s service plan and evaluated on a quarterly basis, for 2 of 2 sampled residents (#s 1 and 3) who had side rails on their beds. Findings include, but are not limited to: 1. Resident 1 was admitted to the residential care facility in 11/2024 with diagnoses including fracture of left femur, type 2 diabetes mellitus and metabolic encephalopathy. During an observation on 08/31/26 at 1:13 pm, bilateral quarter-length side rails were observed on Resident 1’s bed. The rails were both in the up position and securely fastened toward the head of the bed. Though the side rails were assessed on 01/14/25, the current quarterly evaluation and service plan, both dated 07/09/26, did not include an evaluation of, or documentation of the use of, the side rails. The need to ensure documentation of the use of supportive devices with restraining qualities was included in the resident’s service plan and evaluated on a quarterly basis was reviewed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 11:05 am. They acknowledged the findings. 2. Resident 3 was admitted to the memory care community in 12/2023 with diagnoses including dementia. Observations of the resident’s room throughout the survey identified a quarter side rail on the exit side of the bed. The side rail was in the up position and wrapped with a covered foam padding. In an interview on 09/03/26 at 9:30 am Staff 15 (CG) reported that the rail was always placed in the up position for resident safety. An assessment was completed by Witness 1 (RN Consultant) on 07/26/26, however the resident’s service plan was not updated to include the use of the side rail. The need to ensure any device with potential restraining qualities was included in the resident service plan, and that the facility had instructed caregivers on the correct use and precautions related to use of the device, was discussed with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (RCC) on 09/03/26 at 10:30 Am. They acknowledged the findings.

For residents 1 and 3 1. The HSD, RCC, and Executive Director will review the use of siderails for Residents 1 and 3. The Consultant RN will complete or verify assessments for the siderails and determine whether the devices meet the definition of a supportive device with restraining qualities. Physician orders will be obtained and/or verified as appropriate, and resident records will be updated to include the required assessment, care plan interventions, and documentation related to the use of the device. The siderails will be inspected to ensure they were proper insatllation, functioning correctly, and being used safely according to the resident's assessed needs. Staff responsible for providing care to Residents 1 and 3 will be re-educated on the proper use and monitoring of the devices to ensure resident safety and compliance with facility policy and regulatory requirements. 2. The HSD, RCC, and/or the ED will go through the community and track all the supportive devices with restraining qualities, review with the Consultant RN to ensure an assessment have been completed and that there is a physician's order for each device. Care Staff will have an inservice on the proper use for each device for residnet safety. The training is to be completed by 11/2/226. Competency checks to ensure staff are understanding and using devices properly. Maintenance will monitor the devices to ensure each device is working properly, are secure and safe for resident use. 3. RCC/HSD and Consultant RN will review devices weekly, and make any necessary changes to the service plan, create a TSP for the staff and educate staff to alert the RN and PCP of any changes. This is to be completed weekly. 4. The HSD, RCC or designee, and/or the ED will be responsible for carrying out corrections and timely communicate all changes to the resident's provider/PCP. Compliance date of 11/02/2026.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured care time and care elements staff were providing to residents for 3 of 5 sampled residents (#s 2, 3 and 4) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the memory care community in 10/2025 with diagnoses including severe dementia. The resident’s clinical record, ABST data, and service plan, dated 06/10/26, were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST reflected zero care minutes in the following areas: * Monitoring behavioral conditions or symptoms; * Non-drug interventions for behaviors; and * Medication administration. Resident 2’s charting notes indicated the resident exhibited behaviors on 08/20/26. The resident’s 08/01/26 through 08/31/26 MAR indicated the facility administered medication once a day and had PRN medications available for administration. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 9:50 am. They acknowledged the findings. 2. Resident 4 was admitted to the memory care community in 02/2026 with diagnoses including dementia. The resident’s ABST data and service plan, dated 04/28/26, were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST reflected zero care minutes in the following areas: * Monitoring behavioral conditions or symptoms; * Non-drug interventions for behaviors; and * Leisure activities. Resident 4’s charting notes indicated the resident exhibited behaviors on 08/21/26. Staff were observed on 08/31/26 and 09/01/26 assisting the resident with watching music videos and a music documentary. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 3 (RCC) on 09/03/26 at 10:12 am. They acknowledged the findings. 3. Resident 3 moved into the memory care community in 12/2023 with diagnoses including dementia. The resident’s ABST was reviewed and the following was identified: * There was no care time assigned in the area of supervising, cueing, or supporting while eating. Throughout the survey, Resident 3 was observed requiring 1:1 staff assistance with meal and snack intake. Multiple staff reported the resident was unable to feed him/herself. The need for the ABST to accurately capture care time that staff provided to the resident was discussed with Staff 1 (ED), Staff 2 (Health Services Director), and Staff 3 (RCC) on 09/03/26 at 10:30 am. They acknowledged the findings.

For residents 2. 3, and 4 1. The HSD, RCC, and Executive Director reviewed the residents' service plans, TSPs, changes of condition, and ABST entries. The ABST is being updated to accurately reflect the residents' current care needs and the caregiver time that is required to provide services identified in their service plans. Any discrepancies identified between the service plans and the ABST will be corrected. The residents' records will be reviewed to ensure that care needs, interventions, and assigned caregiving minutes accurately reflected the services being provided. 2. The HSD, RCC, and/or Executive Director will conduct a 100% audit of all resident ABSTs and compare them to current service plans, TSPs, and documented changes of condition. Any discrepancies identified between resident care needs and assigned caregiving minutes will be corrected. Residents experiencing changes in condition, new interventions, increased assistance needs, or updated service plans will have their ABST reviewed and adjusted as necessary to ensure accuracy. 3. The HSD, RCC, or designee will review and update resident ABSTs whenever a service plan is revised, a TSP is implemented, a significant change of condition occurs, a resident returns from an absence with changed care needs, or there is any identified change affecting caregiving time requirements. In addition, the facility will conduct a weekly review of resident ABSTs to ensure caregiving minutes remain consistent with documented resident care needs. Relevant staff will be educated on the facility's process for maintaining accurate ABST information. 4. .The Executive Director and RCC/HSD will conduct weekly audits of ABST data and compare it to service plans, TSPs, and documented changes of condition for a period of at least 60 days. Any discrepancies found during the audits will be corrected immediately and reviewed with the responsible staff member. Results of the audits will be maintained by the facility and reviewed to ensure ongoing compliance with resident assessment and staffing requirements. Compliance date 11/02/2026.

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 according to the Oregon Fire Code (OFC), keep a complete written record of fire drills, and provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire drill records were reviewed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 09/02/26 at 12:55 pm. The following was identified: a. The facility did not evacuate residents during two of the last three fire drills. Documentation indicated those fire drills were “mock drills.” Staff 1 and Staff 4 acknowledged residents had not participated in those drills. b. The following information was not documented on the monthly fire drill record: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. c. Staff 1 and Staff 4 stated the facility had not been providing fire and life safety instruction to staff on alternate months. No records of instruction were provided. The need to ensure the facility conducted fire drills according to the Oregon Fire Code (OFC), kept a complete written record of fire drills, and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 on 09/03/26 at 11:05 am. She acknowledged the findings.

For the staff and residents 1. The Executive Director reviewed the community's fire drill and life safety records to identify missed or incomplete fire drills, evacuation exercises, and life safety training requirements. The leadership team and staff will have education regarding state requirements for fire drills, resident evacuation procedures, documentation requirements, and alternate-month life safety training. 2. Because all residents have the potential to be affected by deficiencies related to fire drills and emergency preparedness, the Executive Director and Maintenance Director will review the community's fire and life safety program in its entirety. Fire drill schedules, evacuation procedures, staff training records, and documentation practices will be audited to ensure compliance with state requirements. Any identified deficiencies will be corrected immediately, and staff will receive additional training as needed. 3. The facility will implement a fire and life safety. compliance program that includes: • Fire drills conducted at the frequency required by state regulations. • Documentation of all required fire drill elements, including staff response, alarm activation, resident evacuation procedures, and drill outcomes. • Life safety training provided to staff during alternate months when fire drills are not conducted, as required. • Monthly review of fire drill and training schedules by the Executive Director and Maintenance Director to ensure all required activities are completed timely. • Ongoing education for leadership and staff regarding emergency preparedness, evacuation procedures, and fire safety requirements. 4. The Executive Director and Maintenance Director will review fire drill records, evacuation documentation, and life safety training records monthly for a period of at least 60 days and continuing thereafter as part of the facility's quality assurance process. Any missed drills, incomplete documentation, or training deficiencies will be corrected immediately. Compliance results will be maintained by the facility and reviewed to ensure ongoing adherence to state fire and life safety requirements. Compliance date 11/02/2026.

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 an exit door alarm or other acceptable system for security purposes and to alert staff when residents exit the RCF. Findings include, but are not limited to: At the time of the survey, the facility consisted of four separate buildings. Two buildings were unlocked RCFs and two buildings were locked MCCs. A tour of the buildings on 08/31/26 at 11:15 am indicated the following: * There was no exit door alarm or other acceptable system on the two RCF buildings – numbers 910 and 920. * In MCC building number 940, the alarm on one of the two exit doors that led to the secure outdoor patio was not working. * In MCC building number 950, the alarms on both of the two exit doors that led to the secure outdoor patio were not working. The need to ensure the facility provided an exit door alarm or other acceptable system for security purposes and to alert staff when residents exit the buildings was reviewed with Staff 1 (ED) on 09/01/26 at 1:25 pm. She acknowledged the issues with the door alarms.

For the residents and the staff 1. The maintenance director immediately installed new alarms on the doors leading to the courtyard area of the memory care cottages. The maintenance director immediately ordered alert bells for both of the assisted living cottages, while the survey team was still in the community. (Installed upon arrival from Amazon) 2. This was corrected immediately when the survey crew was still in the community. The staff in the cottages are to check the alarms in the MC cottages to make sure they are on and working properly, and report any isues immediately to the maintenance Director or the ED. 3. These are to be checked daily by scheduled staff and weekly and as needed by the maintenace director. 4. The maintenance director, the staff and the community leadership team are all responsible to ensure the alarms are on and working properly. Compliance date 11/02/2026.

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: C 231, C 295, C 362, C 420 and C 555.

Refer to C 231, C 295, C 362, C 420, C 555

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 C 260, C 270, C 280, C 303, C 310 and C340.

Refer to C 260, C 270, C 280, C 303, C 310, and C 340.