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 create an environment in which residents received services in a manner that protected privacy and dignity for 1 of 2 sampled residents (#1). Findings include, but are not limited to: Resident 1 was admitted to the facility in 12/2025, with diagnoses including Alzheimer’s Disease, hypertension, and chronic kidney disease. Observations of Resident 1’s room on 09/29/26 revealed s/he lived in a shared double-occupancy room. The room lacked a divider to ensure Resident 1 and his/her roommate received services in a manner that protected privacy and dignity. During an interview on 09/29/26, Staff 6 (Resident Assistant) reported all double-occupancy rooms lacked dividers unless purchased by families. In another interview on 09/29/26, Staff 5 (Facility Area Director) reported the facility was going to be purchasing full length curtain dividers for double-occupancy rooms to ensure resident privacy and dignity in the future. On 09/29/26 at approximately 11:00am, the need to create an environment in which residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (ED) and Staff 5. They acknowledged the findings.

1. Correction of cited example Privacy dividers will be installed in all occupied double-occupancy resident rooms. Resident 1’s room will receive a full-length privacy divider positioned to protect each resident’s privacy and dignity while personal care and other services are provided. Until permanent installation is complete, staff will use an approved temporary privacy measure during care. All staff who provide resident care will be educated on protecting resident privacy and dignity, including use of privacy dividers, closing doors when appropriate, covering residents during care, and obtaining permission before entering or providing assistance. 2. Systemic correction The Executive Director or designee will inspect every double-occupancy room to verify that an appropriate privacy divider is available and functional. A privacy-divider check will be added to: • Pre-move-in room inspections • Routine environmental rounds • Maintenance work-order procedures • Room-change procedures Staff will be instructed that privacy equipment is a facility responsibility and is not dependent upon purchase by a resident or family. 3. Monitoring The Executive Director or designee will audit all occupied double-occupancy rooms: • Weekly for four weeks • Monthly for three months • Quarterly thereafter as part of environmental rounds Any missing, damaged, or unusable divider will result in immediate interim privacy measures and a maintenance work order. 4. Responsible person The Executive Director is responsible for overall compliance. The Maintenance Director or designee is responsible for installation and repair. Department supervisors are responsible for reinforcing staff practices.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility?s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction regarding the delivery of services for 1 of 2 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 12/2025 with diagnoses including Alzheimer’s disease, hypertension, and cerebral infarction. Review of Resident 1’s 06/28/26 through 09/28/26 clinical record, including the 09/21/26 service plan, and interviews with staff showed the service plan was not reflective or did not provide clear instructions in the following areas: * Ambulatory status; * Behaviors and related interventions; * Activities; and * Fall prevention. The service plan instructed that “[Resident 1] uses [his/her] walker any time [he/she] is walking”. Observations made from 09/28/26 through 10/01/26 showed Resident 1 using a wheelchair for mobility and needing total assistance from staff for transfers and movement. In an interview on 09/30/26 at 11:10 am, Staff 1 (ED) acknowledged Resident 1 was not ambulatory and agreed the other areas listed above were not reflective of the resident’s needs. On 10/01/26 at 10:40 am, the need to ensure service plans were reflective of current care needs and provided clear instructions for staff was discussed with Staff 1. She acknowledged the findings.

1. Correction of cited example Resident 1 will receive a comprehensive evaluation and service-plan review. The service plan will be revised to accurately describe: • Current non-ambulatory or wheelchair mobility status • Transfer assistance and staff required • Repositioning needs • Fall-prevention interventions • Safety-check frequency • Behavioral symptoms, triggers, and individualized interventions • Activity interests, abilities, limitations, and staff assistance • Escort needs for meals and activities Service plan updates will include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.Staff responsible for Resident 1’s care will review the revised plan before their next independent assignment with the resident. 2. Systemic correction The Health Services Director or designee will audit all current resident service plans against the most recent evaluations, progress notes, incident reports, medication records, activity evaluations, nutrition information, and ABST records. Service plans will be reviewed and updated: • Before move-in • Within 30 days after move-in • At least quarterly • Following a significant change of condition • When incidents, observations, or care documentation indicate that instructions are no longer accurate Service plan changes will be dated and initialed, prior history will be maintained, and updated copies will be offered to the resident or representative. 3. Monitoring The Health Services Director will audit: • All service plans initially • Three (approximately 10% of census) resident service plans weekly for four weeks • Three (approximately 10% of census) service plans monthly for three months • Quarterly thereafter through the quality-improvement process Any inaccurate or incomplete plan will be corrected promptly, and affected staff will be notified. 4. Responsible person The Health Services Director is responsible for clinical review and correction. The Executive Director is responsible for oversight and verification.

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 observation, interview, and record review, it was determined the facility failed to determine resident-specific interventions and to monitor the resident consistent with evaluated needs and service plan following short-term changes of condition for 1 of 1 sampled resident (# 1) who experienced multiple falls. Findings include, but are not limited to: Resident 1 was admitted to the memory care community in 12/2025 with diagnoses including Alzheimer’s disease, hypertension, and chronic kidney disease. In the acuity interview on 09/28/26 at approximately 9:45 am, Resident 1 was identified as experiencing multiple falls, including two falls with fractures, in the last 90 days. Review of Resident 1’s 06/28/26 through 09/28/26 clinical record revealed the following: In a progress note on 09/25/26, Staff 3 (Health Services Director) documented the resident had experienced 20 falls since 01/20/26, both injury and non-injury. At the time of the injury fall on 08/21/26, the resident’s service plan included the following interventions: * Remind resident to use his/her walker any time s/he was walking; * Remind resident to ask for assistance with ambulation and toileting; and * Resident needed assistance with repositioning on bed. The resident was admitted to the hospital on 08/21/26 following a fall and diagnosed with a right femur fracture. S/he was then admitted to a skilled rehabilitation center on 08/28/26. On 09/21/26, the resident was readmitted to the memory care community. Upon admission, Resident 1 was evaluated for a significant change of condition due to new ambulatory status, cognitive decline, and increased care needs. After returning to the facility, Resident 1 experienced two additional falls, on 09/22/26 (non-injury) and 09/25/26 (bruise on left palm). Following these two falls, temporary service plans were created, with the following interventions identified: * “Frequent checks on resident for safety and toileting”; and * “Frequent monitoring.” There was no documented evidence that resident-specific fall interventions were developed and existing fall interventions were evaluated for effectiveness. In an interview on 09/29/26, Staff 10 (Resident Assistant) stated “[Resident 1] really can’t walk anymore. We transfer him with one person, but he’s in the wheelchair for all mobility. We do regular safety checks, and he usually won’t use his call light”. On 09/28/26 at 1:15 pm, Resident 1 was observed seated on a couch in common area. One staff member assisted the resident with a stand-pivot transfer into a wheelchair. Resident 1 required total assistance with mobility and the transfer from wheelchair onto bed. On 10/01/26 at 10:40 am, the need to determine resident-specific interventions following falls and to monitor the resident consistent with evaluated needs and service plan was discussed with Staff 1 (ED). She acknowledged the findings.

1. Correction of cited example Resident 1’s fall history, current functional status, transfer needs, toileting needs, injury history, and contributing risk factors will be reviewed by the facility nurse. Resident-specific interventions will be developed and added to the service plan. Instructions will identify: • Safety-check frequency • Toileting schedule or assistance • Transfer method and number of staff required • Wheelchair and positioning needs • Call-light limitations and alternative monitoring • Environmental precautions • Individual behavioral or activity approaches • Circumstances requiring nurse or provider notification The effectiveness of existing interventions will be evaluated following every fall, and the resident’s responsible party and provider will be notified as required. 2. Systemic correction The facility will maintain a resident monitoring and reporting process 24 hours a day, seven days a week. Staff on every shift will document and report changes in a resident’s physical, mental, or functional condition and will have access to a designated manager on call, who can determine whether additional evaluation, intervention, provider notification, or emergency response is needed. Resident-specific instructions and temporary service plans will be communicated in writing to staff on each shift. Following a fall or other change of condition, the Health Services Director will review whether current interventions were followed and effective, revise them when needed, and ensure the service plan is updated as appropriate. The facility’s change-of-condition and fall-response process will be reviewed and revised as needed to require: • Timely nurse review • Classification as a short-term or significant change • Resident-specific temporary interventions • Written communication to staff on every shift • Weekly progress notes for short-term changes until resolved • Service-plan revision when indicated • ABST revision when a significant change affects care time • Post-incident evaluation of whether interventions were implemented and effective Licensed and direct-care staff will be educated on the revised process. 3. Monitoring The Health Services Director or designee will review: • Every fall and newly identified change of condition by the next business day • Open short-term change-of-condition progress notes weekly until they are resolved • All incident and change-of-condition documentation weekly until they are resolved Deficiencies will be corrected immediately and addressed through coaching or additional training. 4. Responsible person The Health Services Director is responsible for clinical implementation and monitoring. The Executive Director is responsible for administrative oversight.

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 residents' MARs were accurate regarding reasons for use and/or any resident-specific parameters and instructions for PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2026 with diagnoses including hypertension. The resident’s 09/01/26 through 09/28/26 MAR and current physician orders were reviewed, and the following was identified: a. The following medications lacked reasons for use on the MAR: * Acetaminophen 1000mg three times a day; and * Lorazepam 1mg twice daily. b. The following PRN pain medications lacked parameters for order of administration: *Fever: - Acetaminophen 650mg tablet every 6 hours as needed; and - Acetaminophen 650mg suppository every 4 hours as needed. *Pain: - Acetaminophen PM 500-25mg as needed every 4 hours; and - Hydromorphone 2mg/ml every hour as need every hour as needed. *Constipation: - Bisacodyl 10mg once a day as needed; and - Senna 17.2mg at bedtime as needed. On 10/02/26 at approximately 11:15 am, the need to ensure all medications had reasons for use and clear parameters was discussed with Staff 1 (ED). She acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2025 with diagnoses including Alzheimer’s disease, hypertension, and chronic kidney disease. Review of Resident 1’s MAR, dated 09/01/26 through 09/28/26, identified the following: * The MAR lacked reasons for use for tizanidine 4 mg and ramelteon 8 mg; and * The MAR listed two PRN medications for constipation, bisacodyl 5 mg tablets and polyethylene glycol 3350 powder. There were no parameters for the sequential order of administration of these medications; On 10/01/26 at 10:40 am, the need to ensure an accurate MAR was kept which provided resident-specific parameters and medication reasons for use was discussed with Staff 1 (ED). She acknowledged the findings.

1. Correction of cited examples The Health Services Director or licensed nurse will review the orders and MARs for Residents 1 and 2. The facility will obtain clarified, legally valid prescriber orders where needed and ensure that the MARs identify: • Reason for use for every scheduled and PRN medication • Resident-specific PRN indications • Administration sequence when multiple medications are ordered for the same symptom • Required time intervals • Maximum dosage or frequency, when applicable • When staff must contact the nurse or prescriber Staff will not independently determine medication sequencing when the prescriber’s directions are unclear. 2. Systemic correction A 100% audit of current resident medication orders and MARs will be completed. The audit will compare each MAR with the current signed prescriber order and verify that every entry includes the required directions and reason for use. The medication-order entry and verification procedure will be reviewed and revised as needed so that a licensed nurse reviews new or changed orders before or promptly after they are entered into the MAR. Unclear orders will be clarified with the prescriber before administration whenever necessary for safe implementation. Medication staff will receive education on complete MAR requirements and on escalating incomplete or ambiguous orders. 3. Monitoring The Health Services Director or designee will audit: • A sample of at least three (approximately 10% of census) MARs weekly for four weeks • A sample of at least three (approximately 10% of census) MARs monthly for three months • Quartely thereafter through the quality improvement process Errors or omissions will be corrected promptly and reviewed with the involved staff member. 4. Responsible person The Health Services Director is responsible for MAR accuracy, order clarification, staff education, and auditing. The Executive Director will review audit completion and unresolved concerns.

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 the ABST accurately captured care time and care elements staff were providing to residents for 1 of 2 sampled residents (#1) whose ABST was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 12/2025 with diagnoses including Alzheimer’s disease, hypertension, and chronic kidney disease. The resident’s ABST data was reviewed on 09/30/26. Resident 1's care time and care elements were not reflective in the following areas: * Safety checks/fall prevention; * Monitoring behavioral conditions or symptoms; * Assisting with leisure activities; * Ensuring non-drug interventions for behaviors; * Ambulation, escorting to and from meals or activities; and * Repositioning in bed or chair. The ABST showed “0 minutes” of staff time for each of these elements. Review of Resident 1’s clinical record, interviews with staff, and observations during the survey revealed the following: * Regular safety checks were being performed for resident 1; * Resident 1 occasionally displayed symptoms of feeling anxious, frustrated, or overwhelmed. * Behavioral non-drug interventions included: giving resident time to process, initiating a group or one-on-one activity, or allowing the resident alone time; * The resident required escort by wheelchair to all meals and activities; and * Resident 1 required assistance with repositioning in bed. On 10/01/26 at 10:40 am, the need to ensure the ABST accurately captured care time and care elements staff were providing to residents was discussed with Staff 1 (ED). She acknowledged the findings.

1. Correction of cited example Resident 1’s ABST will be recalculated using the current evaluation and service plan. Resident-specific time will be entered for all applicable care elements. 2. Systemic correction The facility will compare every resident’s ABST with the current service plan and evaluation. Discrepancies will be corrected. A reconciliation process will require the service plan and ABST to be reviewed together: • At admission • During the 30-day review • Quarterly • Following a significant change • Whenever care needs or service-plan instructions change Staff responsible for ABST entries will be trained to include both scheduled and unscheduled resident needs. 3. Monitoring The Executive Director and Health Services Director will jointly audit: • All current resident ABST records initially • Three (approximately 10% of census) resident records weekly for four weeks • Three (approximately 10% of census) resident records monthly for three months • Quarterly thereafter The audit will compare evaluation findings, service-plan instructions, observed care, and ABST minutes. 4. Responsible person The Health Services Director is responsible for ensuring that clinical care needs are accurately identified. The Executive Director is responsible for ABST completion, staffing-plan integration, and ongoing monitoring.

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) evaluation was updated timely, following a significant change of condition for 1 of 2 sampled residents (#1) who experienced a significant change. Findings include, but are not limited to: The facility’s ABST was reviewed on 09/30/26. The following was identified: Review of Resident 1’s clinical record revealed the resident was evaluated for a significant change of condition, including a service plan update, on 09/21/26, following a fall with a femur fracture. There was no documented evidence Resident 1’s ABST was updated timely, following the significant change of condition. In an interview on 09/30/26 at 11:05 am, Staff 1 (ED) acknowledged the ABST update had not been completed for Resident 1. The update was completed that day, on 09/30/26. On 10/01/26 at 10:40 am, the need to ensure residents’ ABST evaluations were updated following a significant change of condition was discussed with Staff 1 (ED). She acknowledged the findings.

1. Correction of cited example Resident 1’s ABST will be updated to reflect the significant-change evaluation, service plan, and current level of assistance and will be checked to verify that all affected care elements and time requirements are included. 2. Systemic correction The significant-change process will include a required ABST review and a documented completion date. The posted staffing plan will be reviewed whenever the ABST is updated due to quarterly evaluations or change of condition evaluations. A tracking mechanism will identify residents requiring an ABST update due to: • Admission • Significant change of condition • Quarterly review • Service-plan revision affecting care time • Return from hospitalization or rehabilitation with changed needs The Health Services Director will notify the Executive Director or ABST designee when a significant change is identified. Completion of the service plan and ABST will be tracked together. 3. Monitoring The Executive Director or designee will review the tracking log: • Weekly for four weeks • Monthly for three months • Quarterly thereafter Each audit will verify that the evaluation, service plan, ABST, and staffing plan were updated within the required process. 4. Responsible person The Health Services Director is responsible for initiating notice of clinical changes. The Executive Director is responsible for ensuring timely ABST completion and staffing-plan revision.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was?determined?the facility?failed to?ensure the environment was kept in clean and good repair. Findings include, but are not limited to: Observations of the MCC facility were made from 09/28/26 through 10/01/26. The following was identified: a. Cottage B: * Two brown recliners in common area were worn and not in good repair; * Multiple doors and/or door frames were observed with damage, scratches, dings, and marks; and * Flooring in multiple areas had scratches and deep gouge marks in the surfaces. b. Cottage C: * Multiple doors and/or door frames were observed with damage, scratches, dings, and marks; and * Flooring in multiple areas had scratches and deep gouge marks in the surfaces. On 09/30/26 at approximately 11:15am, the areas in need of cleaning and repair were discussed with Staff 1 (ED) and Staff 5. They acknowledged the findings. 2. Cottage A was toured on 09/28/26 at 11:05 am. The following areas needed cleaning or repair: * Scratches, marks, and gouges were observed on wood doors or frames of the kitchen entrance, utility room, laundry room, exit door to courtyard, and resident rooms 6, 7, and 8; * Paint chips and damage to the plaster walls in the dining room, piano room, and in multiple areas in hallway; * Wooden handrails in the hallway showed paint chips and scrapes in multiple areas; * Deep scratches were observed on wood furniture legs in several common areas; * Scrapes and damage to wood cabinet fronts in TV area; and * Deep black scratches and grooves in several areas of panel floor. On 10/01/26 at 10:40 am, the need to keep all interior surfaces and all equipment necessary for the health, safety, and comfort of residents clean and in good repair was discussed with Staff 1. She acknowledged the findings.

1. Correction of cited examples The facility will create and complete a written repair schedule addressing the survey findings in Cottages A, B, and C, including: • Worn recliners • Damaged or marked doors and door frames • Scratched or deeply gouged flooring • Damaged plaster and painted walls • Chipped or scraped handrails • Damaged furniture legs • Damaged cabinet fronts Items that cannot immediately be permanently repaired will be evaluated for safety and removed from service when necessary. 2. Systemic correction A comprehensive environmental inspection will be completed in all cottages and common areas. Identified concerns will be entered into the maintenance work-order system with: • Location • Description • Priority level • Interim safety action • Responsible person or vendor • Target completion date • Actual completion date Staff will be educated on promptly reporting damaged furniture, flooring, doors, walls, handrails, and other resident-use surfaces. 3. Monitoring The Maintenance Director or designee will conduct weekly environmental rounds. The Executive Director will review outstanding work orders: • Weekly until all survey items are completed • Monthly for three months • Quarterly thereafter through the quality-improvement process Completed repairs will be visually verified and documented. 4. Responsible person The Maintenance Director or designee is responsible for repairs, work orders, and environmental rounds. The Executive Director is responsible for prioritization, resource approval, and verification.

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

1. Correction of cited example The corrective actions described under C 200 will be completed for Resident 1 and all other residents occupying double-occupancy rooms. Privacy dividers will be provided and used during personal care and other services. 2. Systemic correction The facility will integrate privacy and dignity protections into room inspections, staff education, care observations, and resident-rights oversight. Privacy equipment will be supplied and maintained by the facility. 3. Monitoring Monitoring will follow the same audit schedule identified under C 200. Results will be documented and reviewed by the Executive Director. 4. Responsible person The Executive Director is responsible for compliance. The Maintenance Director or designee and department supervisors are responsible for implementation within their assigned areas.

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 C200, C362, C363, and C513.

1. Correction of cited examples Corrective actions for the underlying findings under C 200, C 362, C 363, and C 513 will be completed for the cited residents and environmental examples. 2. Systemic correction The Executive Director will establish a memory-care compliance review that verifies: • Privacy protections in double-occupancy rooms • Alignment of service plans and ABST records • Timely ABST updates following significant changes • Staffing-plan revision when required • A clean and well-maintained memory-care environment 3. Monitoring The Executive Director will review completion of the underlying corrective-action audits: • Weekly until all corrections are completed • Monthly for three months • Quarterly thereafter 4. Responsible person The Executive Director is responsible for overall memory-care licensing compliance. The Health Services Director and Maintenance Director are responsible for their assigned corrective actions.

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 3 of 3 newly hired staff (#s 7, 8 and 9) completed all required pre-service dementia training topics prior to beginning job duties. Findings include, but are not limited to: Staff 7 (Medication Assistant) was hired 04/22/26, Staff 8 (Resident Assistant) was hired 06/02/26, and Staff 9 (Resident Assistant) was hired 06/23/26. There was no documented evidence Staff 7, 8, and 9 had completed the following required pre-service dementia topics: * Environmental factors that are important to a resident's well-being; and * Family support and the role family may have in the care of the resident. On 09/30/26 at approximately 1:30 pm, the need to ensure staff completed all required training prior to beginning job duties with Discussed with Staff 4 (Business Office Manager). She acknowledged the findings.

Z 155: Memory Care Staff Training 1. Correction of cited examples Staff members 7, 8, and 9 will complete documented training addressing: • Environmental factors important to the well-being of residents with dementia • Family support and the role families may have in resident care Each employee’s understanding and competency will be evaluated and documented by a qualified trainer. The employees’ remaining orientation, preservice dementia training, job-specific training, and competency records will also be reviewed. Any additional missing element will be completed. 2. Systemic correction A 100% audit of memory-care employee training files will be completed. The new-hire process will be revised to include a preservice dementia-training checklist. Staff will not independently provide personal care or other resident services until all required preservice topics and competencies are documented as complete. The Business Office Manager and department supervisor will independently verify completion before the employee is released from direct supervision. 3. Monitoring The Business Office Manager will review: • Every new memory-care employee’s file before independent assignment • Current employee files weekly for four weeks • A sample of approximately 10% of employee files quarterly thereafter through the quality improvement process Missing training documentation will result in immediate removal from independent duty when required until training and competency validation are completed. 4. Responsible person The Business Office Manager is responsible for training-file tracking. Department supervisors are responsible for competency verification. The Executive Director is responsible for final 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 observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, and C310.

1. Correction of cited examples The facility will complete all resident-specific corrective actions under C 260, C 270, and C 310, including correction of Resident 1’s service plan and fall interventions and correction of Residents 1 and 2’s medication records. 2. Systemic correction The memory-care clinical oversight process will require coordinated review of: • Evaluations • Service plans • Changes of condition • Falls and incident interventions • MARs and prescriber orders • ABST care elements and time The Health Services Director will ensure that health care services in the memory-care community follow the facility licensing requirements. 3. Monitoring The Health Services Director will review the audit results per the schedules identified under C 260, C 270, and C 310. Unresolved issues will be reported to the Executive Director. 4. Responsible person The Health Services Director is responsible for clinical compliance. The Executive Director is responsible for administrative oversight.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 2 of 2 sampled residents (#s 1 and 2) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Residents 1 and 2’s current service plans were reviewed during the survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. On 10/01/26, the need to develop a nutrition and hydration plan based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED. She acknowledged the findings.

Z 163: Nutrition and Hydration 1. Correction of cited examples Residents 1 and 2 will receive a review of their individual nutrition and hydration status, needs, and preferences. Their service plans will be updated with clear staff instructions, including, as applicable: • Food and beverage preferences • Dietary restrictions and prescribed diets • Allergies or intolerances • Preferred meal routines and locations • Assistance, prompting, cueing, or supervision • Adaptive equipment • Plate, utensil, and table contrast needs • Fluid preferences and hydration supports • Risks affecting intake • Monitoring and reporting instructions • Circumstances requiring nurse or provider notification The residents or their representatives will be offered participation in the review and an updated copy of the service plan. 2. Systemic correction A nutrition and hydration assessment will be completed or reviewed for every memory-care resident. Each assessment will be compared with the resident’s current service plan. The admission, quarterly, and significant-change processes will include verification that nutrition and hydration information is current, individualized, and translated into clear staff instructions. Dietary staff, care staff, and health-services staff will be educated on communicating changes in appetite, intake, weight, swallowing, food preferences, and hydration needs. 3. Monitoring The Health Services Director or designee will audit: • All current resident service plans initially • Three (approximately 10% of census) plans weekly for four weeks • Three (approximately 10% of census) plans monthly for three months • Quarterly thereafter The audit will verify consistency among the nutrition assessment, dietary records, observed needs, and service-plan instructions. 4. Responsible person The Health Services Director is responsible for clinical assessment and service-plan content. The Dining Services Director is responsible for communicating and implementing dietary preferences and needs. The Executive Director is responsible for oversight.