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 all required postings were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times. Findings include, but are not limited to: During the environmental tour of the facility on 09/08/26, the facility lacked the following required postings: * Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections; and * LGBTQIA2S+ Nondiscrimination Notice. On 09/08/26 at approximately 3:00 pm, Staff 1 (ED/Regional Director of Operations) stated he was unaware of the need to post the required postings. The need to ensure all required postings were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times was reviewed with Staff 1, Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 12:30 pm. They acknowledged the findings.

1. All missing postings are now in place in a routinely accessible and conspicuous location for residents and visitors Executive Director and Program Manager have reviewed the list of required postings to assure understanding. 2. Routine walk throughs of the memory care will be conducted to verify presence of all required postings for ongoing compliance. 3. Weekly 4. Program Director with Executive Director oversight

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 were provided a homelike environment and treated with dignity related to dining services. Findings include, but are not limited to the following: During the survey, conducted 09/08/26 through 09/10/26, the MCC was home to 34 residents. The MCC shared a kitchen with the attached assisted living community. The shared kitchen prepared and delivered meals to the MCC in bulk, and the unit CGs and MTs served out the meals from the unit kitchenette. Throughout the survey, multiple meal observations were made, and the following was identified: Staff were observed serving meals on large, plastic, high-rimmed bases, a component designed for a thermal meal delivery system, instead of using regular dining plates for main menu items. In an interview conducted on 09/08/26 at 12:30 pm with Staff 1 (ED/Regional Director of Operations) and Staff 5 (Culinary Director), both stated they were unaware the plastic bases being used were not acceptable dining plates. Staff 1 stated a previous dining director had ordered and implemented the bases to offer all residents a plate with a high lipped dish. The need to ensure residents were provided a homelike environment, treated with dignity related to dining services, and offered regular dining plates during meals was discussed with Staff 1 on 09/09/26 at approximately 4:00 pm. He acknowledged the findings.

1. All high lipped dishes have been removed and replaced with normal dishware for use during all meals. Re-education has been provided to MC and dining staff to assure understanding of normal dishware use and when it would be appropriate for use of an alternative assisted device for meal times. 2. Routine meal observations will be made to assure proper dishware is in use during meal times. 3. Once daily for 30 days then at least 3/week 4. Program Manager, Dining Manager with Executive Director oversight.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests and physical, mental, and psychosocial needs, and failed to create opportunities for active participation in the community at large. Findings include, but are not limited to: During the survey, the facility memory care was home to 34 residents. Random resident observations made on 09/08/26 through 09/10/26, review of the 09/2026 activity calendar, and interviews with staff revealed the following: The 09/2026 activity calendar provided to the survey team and posted in the facility indicated the following activities would occur on 09/08/26 between 1:30 and 3:00 pm: * Remember When Discussion; * Afternoon Refreshments and Hydration; and * Favorite Games. On 09/09/26 the activity calendar indicated the following activities would occur between 9:00 am and 3:00 pm: * Air Balloon Tennis; * Morning Connections; * Topics and Trivia Time; * Garden and Nature; * Cocktail Hour; and * Reminiscing Game. On 09/10/26 the activity calendar indicated the following activities would occur between 9:00 am and 1:00 pm: * Gentle Chair Yoga; * Morning Connections; * Scenic Drive; and * Music and Memories. Activities observed during survey occurred on 09/09/26 at approximately 11:00 am when five residents were engaged in a ballon toss activity led by a care staff, and at approximately 1:30 pm when a puzzle was provided to one resident in the dining room. Up to four residents at one time were observed during survey sitting in front of the TV, some sleeping. Three or four residents were observed sitting in the dining room at any given time, either sleeping, looking around, or drinking coffee, although the majority of residents returned to their rooms between meals. During an interview with Staff 8 (CG) on 09/09/26 at 10:00 am, the activity calendar was reviewed. Staff 8 reported there had been no activities person on the unit for about a week. Staff 8 stated that “if caregivers have time, they do it, but very slim chance they have time for that” and verified recently activities rarely occurred as scheduled. Staff 1 (ED/Regional Director of Operations) was interviewed on 09/10/26 at 11:25 am. He stated the activities director for the memory care unit was on vacation and no one had been assigned to run scheduled activities until the activities director returned. He acknowledged the lack of activities that occurred from 09/08/26 through 09/10/26. Failure to provide a daily activity program of social and recreational activities based on individual and group interests and physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1, Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 12:30 pm. Staff acknowledged the findings.

1. A calendar of designated persons is in place to guiide who will be responsible for hosting which activity for all to follow until the routine activity person returns. 2. Routine observations of activities will be provided to assure adherence to the scheduled activities. 3. Daily 4. Program Director & Activity Director with Executive Director oversight

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation Temporary rule language in effect until 02/05/2027 (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 2) whose move-in and 30-day evaluations were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 07/2026 with diagnoses including dementia. a. The move-in evaluation was reviewed and lacked the following required elements: * Customary routine with sleeping; * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions; * Physical health status, including a list of current diagnoses, a list of medications and PRN use, visits to health practitioners, ER, hospital, or nursing facilities in the past year, and vital signs if indicated by diagnosis, health problems, or medications; * Mental health issues, including presence of depression, thought disorders, or behavioral or mood problems, history of treatment, and effective non-drug interventions; * Personality, including how the person copes with change or challenging situations; * Ability to use the call system; * Pain, including non-pharmaceutical interventions; * Skin condition; * List of treatments; * Indicators of nursing needs, including potential for delegated nursing tasks; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placement; * Smoking – ability to smoke safely; and * Alcohol and drug use, not prescribed by a physician. b. There was no documented evidence the facility completed a review of the evaluation and made appropriate updates within the first 30 days. The need to ensure move-in evaluations addressed all required elements and were updated with the appropriate changes within the first 30 days was discussed with Staff 1 (ED/ Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings.

1. Res #2's needs have been evaluated and active service plan reviewed to assure accuracy. An audit of the most recent move-ins over the last 30 days has been conducted to verify compliance. 2. The community has reviewed their pre move in & 30 day evaluation tools to assure all required elements are present for use. Re-education has been provided to those responsible for completing pre move in and 30 day evals regarding timely completion and completeness for all required elements. Routine record reviews of new move ins will be conducted to assure a pre move in eval has been completed and is present in the residents chart. Routine oversight of the completion of ongoing evaluations including the 30 day eval will be provided. 3. Reviews for pre move in eval will be done within 48 hrs of physical move in. Reviews will be done daily for upcoming/due ongoing evaluations to maintian compliance. 4. Program Director with Executive Director oversight

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 refer a resident with a significant change of condition to the RN for 1 of 2 sampled residents (# 3) and failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts, with weekly progress noted until resolution, for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2023 with diagnoses including dementia and arthritis. The resident’s 06/08/26 to 09/08/26 clinical record was reviewed, and the following was identified: There was no documented evidence resident-specific actions or interventions had been determined, documented, and communicated to staff on all shifts, with weekly progress noted until resolution for the following changes of condition: * 06/11/26, 06/14/26, 07/29/26, 08/07/26 twice, 08/10/26, 08/16/26, 08/27/26, 08/30/26, 08/31/26, and 09/07/26 - injury and non-injury falls. Resident 1 was observed during survey with his/her bed in the low position and a fall mat on the floor beside the bed. When up, the resident was in a wheelchair with full assist from staff. The service plan, dated 09/03/26, indicated the resident had a history of falls and ambulated with a slow shuffling gait, leaning forward. The resident was to have safety checks every 30 minutes and needed one- to two-person transfer assist. Temporary service plans related to falls failed to include actions or interventions. Staff 2 (RN) reported, on 09/09/26 at 1:14 pm, that she was aware the facility was not monitoring progress of all changes of condition through resolution. The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift for short-term changes of condition and that changes were monitored, with weekly progress noted through resolution, was reviewed with Staff 1 (ED/Regional Director of Operations), Staff 2, and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:25 am. Staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2026 with diagnoses including dementia. The resident’s 07/28/26 to 09/09/26 clinical record was reviewed, and the following was identified: There was no documented evidence resident-specific actions or interventions had been determined, documented, and communicated to staff on all shifts and weekly progress noted until resolution for the following changes of condition: * 07/28/26 – A new move-in to the facility; * 07/31/26 – Non-injury fall; * 08/01/26 – Rash under the breast area; * 08/07/26 – A new medication, Hyoscyamine to reduce saliva; * 08/19/26 - Non-injury fall; * 08/19/26 – A new scheduled pain medication, acetaminophen, three times a day; * 08/29/26 - Non-injury fall; * 08/29/26 – Signs and symptoms of frequent urination; and * 09/01/26 – Antibiotic treatment for urinary tract infection. On 09/09/26 at 2:46 pm, Staff 2 (RN) stated there was no clear system in place to resolve short-term change of conditions. The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift for all short-term changes of condition and that changes were monitored, with weekly progress noted through resolution, was reviewed with Staff 1 (ED/ Regional Director of Operations), Staff 2, and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 07/2022 with diagnoses including acute kidney failure and coronary heart disease. The resident’s 06/08/26 to 09/08/26 clinical record was reviewed, and the following was identified: a. There was no documented evidence that resident-specific actions or interventions had been determined, documented, and communicated to staff on all shifts, and weekly progress noted until resolution for the following short-term changes of condition: * 07/06/26 – Return from hospital with orders for a new medication, polyethylene glycol for constipation; * 07/07/26 – New medications: senna and lactulose for constipation and acetaminophen for pain; * 07/07/26 – Skin tear to right groin area; * 07/08/26 – Discontinuation of multiple medications by hospice; and * 07/24/26 – Discontinuation of medications tamsulosin and magnesium by hospice. b. Resident 3 experienced a significant change of condition and was admitted to hospice care. There was no documented evidence the facility had evaluated the resident, referred him/her to the facility nurse, documented the change, and updated the service plan in a timely manner. On 09/09/26 at 4:25 pm, Staff 2 (RN) stated there was no clear system in place to address short-term changes of condition in the unit. She also acknowledged there was no documented evidence the facility evaluated and updated the service plan, nor completed an RN assessment in a timely manner for Resident 3, who had experienced a significant change of condition. The need to ensure the facility determined and documented actions or interventions and communicated them to staff on each shift for short-term changes of condition and monitored the condition with weekly progress noted through resolution and evaluated residents with significant changes of condition, referred them to the facility nurse, documented the changes, and updated the service plan in a timely manner was reviewed with Staff 1 (ED/ Regional Director of Operations), Staff 2, and Staff 4 (Resident Service Coordinator) on 09/10/26 at 12:30 pm. They acknowledged the findings.

1. All sampled residents noted in the survey have been assessed by the RN and service plans reviewed to assure accuracy for current care needs including interventions as applicable for noted trends. A review of remaining residents will be conducted to verify changes of condition noted in the last 30 days have been addressed, monitored and resolved. 2. Re-education will be provided to applicable care staff, Med Techs as well as Program Director and community Nurse on systems designed to promote compliance with timely and consistent change of conditoin and monitoring. Routine oversight of community's systems will be provided via review of resident care related documentation to assure timely awareness, responsiveness and monitoring is taking place as changes are observed. 3. Daily review of community monitoring systems will be maintained 4. Program Director, community Nurse with Executive Director oversight

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 a timely RN assessment was completed 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 facility in 07/2022 with diagnoses including acute kidney failure and coronary heart disease. A review of the resident's clinical record, from 06/08/26 through 09/10/26, identified the following: Resident 3 returned from the hospital on 07/06/26 with diagnoses of constipation and renal mass and was admitted to hospice care on 07/07/26. This constituted a significant change of condition. The RN assessment was not completed until 07/22/26. On 09/09/26 at 4:30 pm, Staff 2 (RN) stated that she was not aware, nor informed by the facility program director in a timely manner, that Resident 3 had experienced a significant change of condition. The need to ensure the RN at minimum completed a timely assessment of all residents with a significant change of condition that documented findings, resident status, and interventions made as a result of the assessment was reviewed with Staff 1 (ED/Regional Director of Operations), Staff 2, and Staff 4 (Resident Services Coordinator) on 09/10/26 at approximately 12:30 pm. They acknowledged the findings.

1. Res #3 has been assessed by the RN and service plan reviewed for accuracy. A review of remaining residents will be conducted to verify completion of timely RN assessments for noted significant changes of condition in the last 30 days. 2. Re-education will be provided to the care staff, Med Techs, Program Director and community nurse of the expectations for timely RN notification of changes and timely RN assessments as changes are noted. Routine review of resident care related documentation will be used to maintain ongoing compliance. 3. Reviews of resident care related documenation will take place daily 4. Program Director, community Nurse with Executive Director oversight

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 implement effective methods of infection control for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to: Observations were made in the facility during survey to determine adherence to universal precautions for infection control. 1. Resident 1 was admitted to the facility in 09/2023 with diagnoses which included dementia. On 09/08/26 at 12:50 pm there was soiled linen consisting of sheets and an incontinence pad observed laying directly on the floor of Resident 1’s room. The need to ensure infection prevention and control practices were followed was discussed with Staff 2 (RN) on 09/09/26 at 01:15 pm. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2026 with diagnoses which included dementia. Observations and interviews with staff during the survey revealed the resident relied on staff for incontinence care needs. On 09/09/26 at 1:00 pm, the surveyor obtained permission and observed Staff 8 (CG) provide ADL care to Resident 2. During the observation, Staff 8 donned gloves and assisted the resident with incontinence care. While wearing the same pair of gloves, Staff 8 wiped the resident's perineal area. It appeared the resident had a bowel movement. Staff 8 then proceeded to touch the resident’s clothing and assist the resident with a transfer to the bed while wearing the same pair of gloves. Staff 8 did not change gloves between clean and dirty tasks. The need to ensure infection prevention and control practices were followed during the care was discussed with Staff 1 (ED/ Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings.

1. In Service training with all staff and support staff will be conducted on Infection Prevention and Control. Training will be provided by RN and Program Director. Staff will have to show competency during the in service. 2. Staff are assigned training in Relias on Infection Prevention and Control. In services will be conducted more frequency to ensure compliance is met. 3. Bi- weekly, Program Director will conduct in service on Infection Prevention and Control. Signed documentation of staff will support compency of procedure. 4. RN and Program Director will be responsible to ensure Infection Prevention and Control procedures are being followed and in compliance. Date of compliance will be 11/9/2026.

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 for each care element 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 that ABST care time accurately reflected resident care needs for 2 of 3 sampled residents (#s 1 and 2) whose ADL care time and service plans were reviewed. Findings include, but are not limited to: During the survey, Residents 1 and 2 were observed, and staff were observed providing care to both residents. Interviews were conducted with staff to determine the care and amount of time needed for Resident 1 and 2 related to the ABST care elements. Review of Resident 1 and 2’s service plans and the facility ABST showed inaccurate minutes recorded for care time in one or more of the following areas: * Supervision, cueing or supporting while eating; * Time spent providing treatments, e.g. skin care, would care, antibiotic treatment; * Time spent monitoring physical condition or symptoms; * Safety monitoring, fall precautions; * Time spent escorting to and from meals or activities; and * Time transferring in or out of the bed or chair. The need to ensure care element minutes entered on the ABST were accurately reflective of the residents’ current care needs was discussed with Staff 1 (ED/Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:20 am. The staff acknowledged the findings.

1. ABST tool was reviewed and updated as needed for Res #1 & #2. A review was conducted for the remaining residents to assure care needs were accurately reflected on the community ABST tool. 2. Re-education was provided to the Program Director regarding routine review of the ABST for new move ins, move outs or those with changes in care needs to assure understanding. Routine reviews of the community ABST will be conducted to maintain ongoing compliance. 3. ABST will be reviewed before a new resident moves in, when updated evals/service plans are created, for noted changes of condition and/or at least weekly. 4. Program Director and RN with Executive Director oversight.

OAR 411-054-0037 (4-7) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete, update, review, and document the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly and corresponding with resident service plan updates, updating as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. (a) The posted staffing plan must incorporate: (A) The total ABST care time in minutes per shift, per day. If a proprietary ABST does not have this functionality, at a minimum the ABST total time must be shown in daily minutes as referenced in paragraph (2) of this rule. (B) The unscheduled care needs of residents. (C) The staffing requirements outlined in OAR 411-054- 0070(1). (D) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (E) The time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (F) The facility’s distinct and segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. Each distinct and segregated area must have a posted staffing plan. (G) The staffing needs required under the Specific Needs Contracts, if applicable. (b) The facility must maintain staffing documentation to show consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (c) The facility must maintain historical posted staffing plans. The posted staffing plan must contain the date(s) it was effective. Records must be kept for a minimum of three years. (6) CONSISTENTLY MEETING NEEDS. The facility must consistently meet the scheduled and unscheduled needs of all residents, 24 hours a day, seven days a week. (7) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under a Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the numbers as indicated in the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was completed before move-in for 1 of 1 sampled resident (# 2) whose ABST data was reviewed for move-in. Findings include, but are not limited to: Resident 1 moved into the MCC in 07/2026 with diagnoses including dementia. The resident’s ABST evaluation information was reviewed and showed it was not completed until 09/07/26, more than a month after move-in. The need to ensure the ABST was completed before move-in was reviewed with Staff 1 (ED/Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:15 am. Staff acknowledged the findings.

1. Before a new move in happens for Compass Rose Memory Care. RN or Program Director will complete a pre move in assessment. Before the new resident moves in, new resident will be entered into ABST. This will allow the staffing plan to be adjusted if needed based on residents needs. Staff will review ABST at 30 days/90 days and any change of conditions. 2. Before a new resident moves in Compass Rose, Program Director and Resident Service Coorditator will review and verify as part of our checklist to ensure resident is in ABST and care needs are reflected. Staffing plan to be reviewed and updated as needed. 3. This will happened before any new resident moves into Compass Rose Memory Care. 4. Program Director and Resident Service Coordintator will be responsible to ensure compliance is met. Compliance date of 11/9/2026.

OAR 411-054-0070 (5, 9-10) Training Within 30 Days of Hire ? Direct Care Staff Temporary rule language in effect until 02/05/2027 (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible for verifying that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person?s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. (b) Exempt from this training requirement are contractors who contract directly with the resident or the resident’s representative, and contractors who do not generally provide services or supports directly to residents, including, but not limited to, contractors for landscaping, pest control, deliveries and building repairs. (c) By December 31, 2024, facilities shall ensure that all contracts entered into with entities described in paragraph (a) of this section shall include language requiring contractors provide Department-approved LGBTQIA2S+ training to their employees within 12 months of entering into the contract with the facility and every two years thereafter. (d) For existing contracts in effect January 1, 2025, facilities shall require the contractor provide Department-approved LGBTQIA2s+ training to employees by December 31, 2025, and every two years thereafter. (e) For new contracts created after January 1, 2025, facilities shall require contractors provide the Department-approved LGBTQIA2S+ training to employees within 12 months of entering into the contract with the facility, and every two years thereafter. (f) Facilities must inform contractors that the cost of all LGBTQIA2S+ trainings for contracted employees shall be paid by the contractor. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired direct care staff (#s 10, 14, 16, and 17) completed first aid and abdominal thrust training within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 3 (Business Office Director) on 09/09/26 and showed the following: * There was no documented evidence Staff 10 (MT), hired 05/07/26, Staff 14 (MT), hired 05/18/26, Staff 16 (CG), hired 07/09/26, and Staff 17 (CG), hired 07/22/26, had completed first aid and abdominal thrust training within 30 days of hire. The need to ensure staff completed first aid and abdominal thrust training within 30 days of hire was reviewed with Staff 3 on 09/09/26 and with Staff 1 (ED/ Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings.

1. Ab Thrust training has been completed for S#1, S#2, S#3, S#4 and S#5 on 10/9/2026. Business Office Director will ensure all proper training is completed before new hire is on the floor. All Oregon Care Partner training and Relias Training, to include Ab thrust training will be completed within 30 days of hire. 2. Business Office Director will manager all certificates of completion and have a tracking system to ensure all training is completed within the 30 days. 3. Weekly, Business Office Director will review training with the Executive Director and monitor training with new hires. Before new hire is on the floor on there own, Business Office Director will ensure that all required training is complete along with competency checklist for each staff member. 4. Business Office Director and Dept. Manager will work together to ensure compliance is met. Compliance date will be 11/9/2026.

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 ensure fire and life safety instruction to staff was provided on alternate months of fire drills. Findings include, but are not limited to: Fire drills and fire and life safety training records for the previous six months were requested. Review of the documentation provided identified the following: * There was no documented evidence fire and life safety instruction to staff was provided on alternate months of fire drills. The requirements regarding fire and life safety instruction for staff were reviewed with Staff 1 (ED/ Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings.

1. Bomb Threat in service/training was conducted for all MC staff on 10/5/2026. Next Fire Safety in service will be on 11/5/2026. Re-education provided to Maintenance Director and Program Director on Fire Drills/Alternating trainings to assure understanding. 2. Maintenance Director who is Compass Rose Safety Officer will conduct training with all employees in Compass Rose monthly and alternate months on Fire Drills and Life Safety. Training will be keep in a binder for review each month for compliance. Monthly training will include alternating months of Fire Drill, life safety topics to be in compliance. All staff will complete this training monthly. 3. This will be conducted monthly will employees in compass rose. All documenation of fire drill and life safety will be available for review. 4. Maintenance Director and Program Director with Executive Director oversight.

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 all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: On 09/08/26 at 12:30 pm, the interior of the facility was toured, and the following observations were made: * Seven armchairs and/or recliners in the TV living room area were observed to be in poor repair, with stained armrests and worn and/or torn upholstery; * The coffee bar table had scuffed, chipped, and cracked paint; * There was scraped paint on the wall under the Ombudsman poster, on the divider wall between the dining room and the common living area, and on the corner wall near Room 138; * Baseboards throughout the facility were dirty, and near rooms 101 and 110 they were scuffed and chipped; and * Wooden handrails throughout the facility had worn finishing with bare wood exposed, leaving an uncleanable surface. The need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED/Regional Director of Operations) and Staff 6 (Maintenance Director) on 09/10/26 at 10:30 am during a walkthrough of the facility. They acknowledged the findings.

1. Maintenance Director and Executive Director have replaced with brand new chairs, those that were in poor repair. Mainteance Director will repair or replace coffee bar table and repair any scrapes, chips or damage to baseboards or any area in compass rose. Wood Hand rails will be re surfaced for a smooth touch. 2. Re-education will be provided to the direct care staff on how and when to complete a work order for needed replacement/repairs to assure understanding. Routine walk throughs of the community will be conducted to assure timely completion of known repairs and timely reporting of new repair needs. 3. Daily & Weekly for walk throughs and weekly review of open maintenance orders with Executive Director for ongoing compliance. 4. Program Director & Maintenance Director with Executive Director oversight.

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 and interview, it was determined the facility failed to ensure privacy and dignity in each resident’s own unit related to locks on bathroom doors, privacy screens, and individual private space for residents who lived in shared units. Findings include, but are not limited to: a. The facility had nine double-occupancy rooms, with two residents residing in each room during the survey. During an observation on 09/10/26, it was observed that the shared bathrooms had no locking mechanism on the door to ensure resident privacy. The observations were reviewed with Staff 1 (ED/ Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings. b. During the survey, it was observed that three rooms, Rooms 107, 112, and 133, had double occupancy and did not have curtains, screens, or dividers to provide privacy when one of the residents was receiving incontinence care or personal care. The observations were reviewed and discussed with Staff 1 (ED/Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am, including the need to provide privacy during the personal care. They acknowledged the findings. c. The facility had five designated one-bedroom apartments which they used as double occupancy rooms. The living area of the apartment was identified as “Room A,” and the bedroom of the unit was identified as “Room B.” The rooms shared a main entrance and there was a door inside “Room A” that provided access to “Room B.” The shared bathroom was accessed by a door in “Room B.” The resident residing in “Room B” had to pass through “Room A” to enter his/her apartment. The resident residing in “Room A” had to pass through “Room B” to use the shared bathroom. Using the one-bedroom units as double-occupancy units prevented each resident from having privacy within their own unit. The observations were reviewed and discussed with Staff 1 (ED/Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am, including the need to provide privacy when a one-bedroom unit was used for double occupancy. They acknowledged the findings.

1a. All shared bathroom locks have been switched so the lock is accessible to lock from the inside of the bathroom. This was completed as of 10/1/2026. 1b. Maintenance Director has placed a bulk order of privacy curtains. This will be for all shared room and or rooms that require it. Install date of 11/2/2026. 1c. All Jack n Jill bathroom locks have been switched so the lock is accessible from the inside of the bathroom. Completed on 11/2/2026. 2. A bulk order of privacy curtains have been placed. Maintenance Director will install. Each resident will then have privacy when being provided care or if they just want privacy from roomate. 3. Once privacy curtains are installed, Maintenance Dept. will montior the condition through time. If needed to be replaced or cleaned, Maintenance Director will do so. 4. Program Director and Maintenance Director will monitor the condition of privacy curtains. Replace and or clean as needed. Compliance date of 11/9/2026.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: Review of records for Residents 1, 2, and 3 showed no documented evidence the residents had been provided with a key to their rooms. During the survey, from 09/08/26 through 09/10/26, observation and interviews with staff and Residents 2 and 3 confirmed residents did not have keys to their units. The need to ensure all residents were provided keys to their units was discussed with Staff 1 (ED/ Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings.

1. Apartment keys have been placed in each resident apartment. It will be documenated on resident service plan that they received a key. Re-education was provided to Program Director on provision of keys to residents to assure understanding. 2. Before any new resident move ins, residents will be offered a key to there apartment. Resident and or Representative will sign off that they received a key or location the key will be in apartment. Record will be kept is resident file. This will be completed before a new resident moves in at agreement signing with Executive Director. 3. Monthly, Program Director will audit all apartments to ensure key is still in the agreed upon place and replace key if needed. 4. Program Director and Resident Serivce Director with Executive Director oversight.

OAR 411-054-0025 (5)(f)(g) 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: (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. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to ensure the required postings, Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections, and the LGBTQIA2S+ Nondiscrimination Notice were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times. Findings include, but are not limited to: Refer to C152.

Refer to C152.

OAR 411-057-0140(1&6) Administration Responsibilities Temporary rule language in effect until 12/27/2026 (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, safety and comfort. This includes the supervision, training, and overall conduct of the staff. (6) The licensee must ensure that each administrator assigned responsibility for an endorsed memory care community: (a) Has completed and maintains compliance with the administrator qualification, licensure, and continuing education requirements applicable to the facility’s license type, including but not limited to: (A) OAR 411-054-0065 for assisted living facilities and residential care facilities; or (B) OAR chapter 853, division 30 for nursing facilities; and (b) Completes and documents Department-approved training specific to memory care operations, dementia-related risk factors, and the physical design, environment, and safety requirements of this division. (c) Nothing in this subsection alters, replaces or expands administrator licensure, authorization, or examination requirements established under other applicable statutes or administrative rules. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 09/08/26 through 09/10/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in the report.

Refer to the deficiencies in the report

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 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, C242, C295, C362, C363, C372, C420, and C513.

Refer to C152, C200, C242, C295, C362, C 363, C372, C420 and C513

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 10, 14, 16, and 17) completed all required pre-service training, 3 of 4 sampled staff (#s 10, 15, and 17) had written job descriptions, and 4 of 4 sampled newly hired staff (#s 10, 14, 16, and 17) completed pre-service dementia training and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: The facility’s training records were reviewed on 09/09/26 with Staff 3 (Business Office Director) and showed the following: a. Staff 10 (MT) was hired 05/07/26, Staff 14 (MT) was hired 05/18/26, Staff 16 (CG) was hired 07/09/26, and Staff 17 (CG) was hired 07/22/26. There was no documented evidence the staff had completed the pre-service training in one or more of the following required topics: * Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; and * Use of supportive devices with restraining qualities in memory care communities. Additionally, there was no documented evidence Staff 17 had completed the following pre-service orientation topic areas prior to performing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fires safety and emergency procedures; * Infectious Disease Prevention; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. There was no documented evidence that Staff 10 and 17 or Staff 15 (Lifestyle Assistant), hired 06/05/26, had reviewed their written position descriptions with their job responsibilities. c. There was no documented evidence Staff 10, 14, 16, and 17 had demonstrated competency in one or more of the following required topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The facility’s need to ensure all training was completed and staff demonstrated competency within the required timeframes was discussed with Staff 1 (ED/ Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings.

1. Alzheimers Disease and Related Disorders the envirnoment was completed for S#1, S#2, S#3,S#4 and S#5 on 10/10/2026. For Alzheimers Disease and Related Disorders, ethical and family issues was completed by S#1, S#2, S#3, S#4 and S#5 on 10/10/2026. An audit of remaining staff was conducted to verify completion of required trainings. Re-education was provided to Program Director and Business Office Manager on training requirements and timing to assure understanding. 2. Routine reviews of employee training documents will be maintained to assure ongoing compliance. 3. Upon completion of the general orientation process and at least twice monthly thereafter Business Office Manager and Program Director with Executive Director oversight

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 interview and record review, it was?determined?the facility?failed to?provide health care services?in accordance with?the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: ? Refer to C252, C270, and C280.

Refer to C252, C270, C280 and C363

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical, cognitive and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to develop an individualized activity plan for each resident based on their activity evaluation for 3 of 3 sampled residents (#s 1, 2, and 3) residing in the Memory Care Community. Findings include, but are not limited to: Resident 1, 2, and 3’s evaluations and service plans were reviewed during the survey. The evaluations and service plans offered some information about the residents' interests, but the facility had not fully evaluated one or more of the following: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities. The need to ensure all residents had individualized activity plans developed based on their activity evaluation was discussed with Staff 1 (ED/ Regional Director of Operations), Staff 2 (RN), and Staff 4 (Resident Service Coordinator) on 09/10/26 at 11:07 am. They acknowledged the findings.

1. Activity plans have been reviewed and adjusted as needed for sampled residents 1,2 & 3. A review of remaining residents activity plans has been conducted to assure accuracy. Re-education has been provided to Program Director and Activity personnel on requirements to assure understanding. 2. Routine reviews of each residents individual activity plans will be conducted to assure ongoing compliance. 3. Upon move in and in line with routine evaluations/service plan updates or with significant changes in their functional status that impacts activity participation. Program Director, Activity personnel with Executive Director oversight

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, the facility failed to ensure the fence surrounding the perimeter of the outdoor recreation area was no less than six feet in height and constructed to reduce the risk of resident elopement. Findings include but are not limited to: On 09/08/26 at 12:30 pm, the outdoor recreation area of the facility was toured and noted to have a section of the perimeter fencing, behind a built-up landscaped area with strawberry plants, that measured 65 inches instead of the required 72 inches. This posed a risk for potential resident elopement. The need to ensure the perimeter fencing surrounding the outdoor recreational area was no less than six feet in height was discussed with Staff 1 (ED/Regional Director of Operations) and Staff 6 (Maintenance Director) on 09/10/26 at 10:10 am during the walkthrough of the facility. They acknowledged the findings.

1. Landscaper's have removed the area with the strawberries, have flatten out the land so the required measurement of 72 inches are met. 2. Upon physical plant inspection, we will add this to our inspection visual checklist and make at all times the clearance from ground to top of fence measures 72 inches. 3. Monthly, we will conduct a visual inspection and measure the ground to top of the fence as part of our physical plant check off list. 4. Mainteance Director will ensure complaince at all times. Compliance date of 11/9/2026.