Print Inspection: CHOW005663

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 07/21/25 through 07/24/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes and satisfaction was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. Refer to the deficiencies in the report.

C 156- It was determined that we had not ensured an adequated Quality Assurance Program.1 We will do monthly audits of specific departments and a community quality assurance meetin quarterly going forward. This will begin in August. 4. Executive director responsible for monitoring

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by:

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, interview, and record review, it was determined 5 of 8 sampled residents (#’s 1, 4, 5, 7, and 8) and multiple unsampled residents were not treated with dignity and respect in a safe and homelike environment. Findings include, but are not limited to: During the survey conducted 07/21/25 through 07/24/25 multiple sampled and unsampled residents were interviewed. 1. Resident’s 1, 4, 5, 7, and 8 required staff assistance with ADL care, including shower assistance. During interviews with the residents each expressed concerns regarding excessive wait times for assistance, including multiple times showers were not provided. 2. On 07/23/25 and 07/24/25 Resident 1 was observed before breakfast wearing a shirt with dried-on food in multiple places. On 07/24/25 at 12:20 pm the surveyor asked Staff 9 (CG) if they had offered Resident 1 a clean shirt that morning. Staff 9 stated she had not because, “All of [his/her] shirts are probably dirty. [S/he’s] probably just putting on dirty shirts. We have lots of residents like that." The need to ensure residents received services in a manner that promoted dignity and respect in a homelike environment was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations) and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings. Refer to C 360.

C 200- General Rights It was determined that multiple sampled and unsampled residents were not treated with dignity and respect in a safe homelike environment. Resident 1, 4, 5, 7 and 8 voiced concerns with long call light times and showers not provided. Resident 1 was at breakfast wearing a shirt with dried on food in multiple places. 1 Call light times will be monitored by the front desk, wellness director, RCC's and administrator. Shower logs will be monitored daily by RCC's and Wellness Director. Shower refusals will be logged. Residents will be offered a change of clothing if they have soiled or stained clothes on and refusals documented. 4. Front desk, Resident Care Coordinators, Wellness Director and Executive Director to monitor.

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:

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' current care needs, provided clear direction for staff, and were consistently implemented by staff for 5 of 7 sampled residents (#s 1, 2, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including muscle weakness. Observations of the resident, interviews with staff, review of the resident's 04/30/25 service plan, and 04/30/25 through 07/21/25 temporary service plans and progress notes were completed. Staff indicated the resident was able to direct his/her own care. The resident required assistance with transfers and other ADL care. The resident attended most meals in the dining room and utilized a wheelchair for transportation to the meals. The resident’s service plan was not reflective, not consistently implemented, and/or lacked resident-specific direction for staff in the following areas: * Incontinent care, toileting assistance, and supervision; * Shower preferences and assistance; * Self-administration of medications; * 1 versus 2-person assistance for transfers; * Fall and safety interventions; and * Evacuation ability. The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 06/2023 with diagnoses including diabetes. Observations of the resident, interviews with staff, review of the resident's 07/21/25 service plan, and 04/01/25 through 07/21/25 temporary service plans and progress notes were completed. Staff indicated the resident was able to direct his/her own care. The resident required some assistance with transfers and lower extremity dressing and bathing. The resident was alert and oriented and spent most of his/her time in their apartment. The resident had a manual wheelchair, a walker, and an electric scooter for mobility. The resident’s service plan was not reflective, not consistently implemented, and/or lacked resident-specific direction for staff in the following areas: * Toileting assistance; * Resident sleeps in recliner, transfer assistance, and night-time needs related to recliner; * Daytime vs nighttime compression stockings and padded leg wraps; * Shower preferences and assistance; * Self-administration of medications; * Right arm limitations and pain; * Gel cushion use; * Chronic yeast rashes and skin injury to bottom; and * Evacuation ability. The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. The staff acknowledged the findings. 3. Resident 1 moved into the assisted living community in 09/2019 with diagnoses including Parkinson’s disease and late-onset cerebellar ataxia (movement disorder). The resident’s service plan, dated 05/20/25, was reviewed, observations were made, and resident and staff interviews were conducted. The resident's service plan was not reflective of the resident’s needs, did not provide clear direction to staff regarding the delivery of services, and/or was not implemented. Resident 1’s service plan documented the following regarding walking, transfers, and bathing: * “...requires full assistance including physical and verbal assistance with walking needs. Requires hands on assistance with helping stand up, helping use any walking devices, and helping sit down/lay down.” * “[Resident] is independent with transfers and usually transfers in and out of [his/her] power chair without use of any assistive devices.” * “Monitor and provide assistance as needed with bathing/showering...one person assist with set up and transfer on wet surfaces As [sic] needed assist of one for drying and dressing [Resident] is able to direct cares. Stand by assist of one male care partner or two female. [sic]” In an interview on 07/22/25 at 10:15 am Staff 12 (MA) stated the following: * Resident 1 was fully independent with walking and transfers; * “Sometimes we give [him/her] showers but sometimes ....[the resident] will tell us [s/he] just took a shower.”: and * Confirmed s/he did not know what Resident 1’s service plan said in regard to his/her bathing needs. In an interview on 07/23/25 at 2:00 pm, Resident 1 reported s/he was supposed to get showers by staff, and when staff did not show up for a scheduled shower, s/he “managed to” shower him/herself. Resident 1’s service plan also instructed staff to cue resident to change his/her shirt if dirty. On 07/23/25 and 07/24/25 Resident 1 was observed before breakfast wearing a shirt with dried-on food in multiple places. In an interview on 07/24/25 at 12:20 pm Staff 9 (CG) reported, “[S/he is] probably just putting on dirty shirts,” and confirmed she had not cued the resident to change into a clean shirt. On 07/24/25, the need to ensure service plans were reflective of the residents’ needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/25/25. They acknowledged the findings. 4. Resident 6 moved into the assisted living community with diagnoses including congestive heart failure. Observations of the resident, interviews with staff, and review of the service plan, dated 07/15/25, and subsequent temporary service plans (TSP’s) identified the service plan did not provide clear direction to staff, including the frequency care should be provided in the following areas: * Transfers in and out of bed; * Use of wedges to elevate legs in bed; * Edema and open skin concerns; * Dressing assistance, including the use of compression stockings; * Frequency for escorts in wheelchair; * Frequency of showers; * Frequency of housekeeping; and * Frequency of laundry assistance. The need to ensure resident service plans provided clear direction to staff including the frequency of how often care was to be provided was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations) and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings. 5. Resident 2 was admitted to the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease, hypertension, and depression. Interviews with staff and Resident 2 and a review of the resident's current service plan, dated 06/03/25, and temporary service plans were conducted during the survey. Resident 2's service plan was not reflective and did not provide clear direction to staff in the following areas: * Relationship with another resident; * Use of PRN psychotropic medication; * Refusal of care; * Dressing, grooming, bathing, and personal hygiene status; * Frequency of hospice services provided; * Environmental risk factors that impacted the resident’s behavior; * Preference to eat meals in apartment; * Pet living in apartment; and * The resident's ability to care for his/her pet. The need to ensure service plans reflected the resident care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25. They acknowledged the findings.

C 260- Service Plan- Resident 4 was admitted on 4/30/25. Resident service plan was missing information on incontinence care, toileting assitance and supervision. Shower preference and assistance, self administration of medication, one vs two person assist with transfers, fall and safety internventions, and evacuation ability. Resident 5 was admitted to the community on 6/23/23. Resident service plan was missing: Toileting assistance, resident sleeps in a recliner and needs night time assistance related to the recliner, daytime vs nighttime compression stocking and padded wraps, shower preferences and assistance, self medication administration,Right arm limitations and pain, Gel cushion use, Chronic Yeast Rashes and evacuation ability. Resident 1 moved in on 9/2019.Residents service plan was not reflective of walking, transfers and bathing. Resident stated when staff don't show up he showers himself, care plan stated resident needed assistance with walking and transfers, resident is able to do this on his own, Resident to be offered clean clothes and was seen with a shirt with food stains on it. Resident 6 moved in with a diganosis of Congestive heart failure. Service plan was missing Transfers in and out of bed, use of wedge to elevate legs in bed, edema and open skin concers, dressing assistance including the use of compression stocking, frequency for escorts in wheelchair, frequency of housekeeping and frequency of laundry assistance. Resdident 2 was admitted 10/22. Resident service plan did not note relationship with another resident, refusal of care, dressing, grooming, bathing,and personal hygiene status, frequency of hospice services provided, environmental risks that impacted the residents behavior,preference to eat meals in the apartment, pet living in the apartment, and residents ability to care for the pet. 1. Service plans will be updated to reflect resident needs and preferences quarterly or with change of condition. 2. All binders will be reviewed to ensure all resident service plans arein charts and updated to resident specific directions. 3. Service plan binders will be updated and placed in service plan binders quarterly or with changes of condition. 4. Executive Director, Wellness Director, RCC or other designee is responsiblet to see that corrections are completed and monitored.

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

OAR 411-054-0040 (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 for residents following a short-term change of condition, communicate interventions to staff on each shift, and/or monitor and document weekly progress until the condition resolved for 4 of 6 sampled residents (#s 1, 4, 5, and 6) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living community in 09/2019 with diagnoses including Parkinson’s disease and late-onset cerebellar ataxia (movement disorder). The resident’s progress notes, dated 04/28/25 through 07/18/25, service plan, dated 05/20/25, and temporary service plan, dated 07/08/25, were reviewed. The following was identified: Progress notes documented the resident fell on 07/06/25 when s/he tripped over the foot pedal of his/her power chair. The resident sustained a laceration on his/her head and was sent to the hospital, returning the same day. On 07/09/25 staff documented in the progress notes the following injuries: * 07/09/25 – scrape on right knee; and * 07/09/25 – bruising around left eye. There was no documented evidence that the facility monitored the knee scrape or the bruising around the eye. The need to ensure the facility monitored the resident at least weekly according to their evaluated needs through resolution, was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 1:50 pm. They acknowledged the findings. 2. Resident 6 moved into the assisted living community in 05/2025 with diagnoses including hypertension, atrial fibrillation, and congestive heart failure. The resident’s progress notes, dated 05/06/25 through 07/21/25, service plan, dated 07/15/25, and temporary service plans were reviewed during the survey. There was no documented evidence the facility determined actions or interventions, communicated the interventions to staff on each shift, and monitored the changes of condition with weekly progress noted in the resident’s record until the condition resolved, for the following short-term changes of condition: * 05/06/25 - New move-in; * 05/27/25 - Resident sent to the emergency room for swelling in both legs and feet. Resident returned to the assisted living the same day; * 06/17/25 - Sent to emergency room for edema and CHF symptoms. Resident returned to the assisted living the same day; * 06/30/25 - Progress note dated 06/30/25 noted, “resident reported to me [his/her] right wrist to mid forearm is having pain. [S/he] states it feels like the gout [s/he] had...” * Missed medication colchicine (for gout) from 05/06/25 through 07/09/25; and * Missed treatment fluorouracil cream (for skin condition) from 05/06/25 through 07/21/25. The need to ensure the facility determined actions or interventions needed for changes of condition, communicated the actions or interventions to staff, and monitored the condition weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 04/2025 with diagnoses including muscle weakness. Observations of the resident, interviews with staff, review of the resident's 04/30/25 service plan, and 04/30/25 through 07/21/25 temporary service plans and progress notes were completed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Multiple medication changes; * Fall with injury; * Low oxygen saturation levels; and * Urinary tract infection. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. The staff acknowledged the findings. 4. Resident 5 was admitted to the facility in 06/2023 with diagnoses including diabetes. Observations of the resident, interviews with staff, review of the resident's 07/21/25 service plan, and 04/01/25 through 07/21/25 temporary service plans and progress notes were completed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Multiple medication changes; * Edema, shortness of breath, and oxygen use; * Elevated blood sugars; * Skin injury and rashes; and * Fall with fracture and right arm pain. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 07/24/25. The staff acknowledged the findings.

C 270- Change of condition and monitoring:Resident 1 fell on 7/6/25 when he/she tripped over the foot pedal of the power chair. The resident sustained a head laceration and was sent to the hospital with a same day return. There were no progress notes until 7/9 and no documented evidence that the community monitored the knee scrape or bruising around the eye. Resident 6 lacked documentation of new move in, resident ED visit for swelling to both legs and feet, resident ED visit for edema and CHF symptoms, progress note about right wrist pain with no follow up noted, missed medications. Resident 4 no documentation on multiple medication changes, fall with injury, low oxygen saturation levels and UTI. Resident 5 lacked documentation of Multiple medication changes, Edema, shortness of breath and oxygen use, elevated blood sugars, skin injury with rashes and fall with fracture and right arm pain. 1. Staff instructed on how to report Change of Condition. 2. Wellness staff to monitor each resident for evaluation of needs and service plan. 3. Changes of Condition to be monitored weekly until new baseline has been determined and resolution note documented. 4. Wellness Director, RN and Executive director to monitor and discuss at daily clinicial meeting and weekly high risk meeting.

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:

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 observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment for 1 of 1 sampled resident (#6) who experienced severe weight gain. Findings include, but are not limited to: Resident 6 moved into the assisted living community in 05/2025 with diagnoses including congestive heart failure (CHF). During the acuity interview on 07/21/25, Resident 6 was identified to have experienced weight gain. Review of the resident’s clinical record and weights and vitals summary from 05/13/25 through 07/21/25 identified the following: * 05/13/25: 157.2 pounds (weight at move-in); * Progress notes dated 05/27/25: was sent out to the emergency room for swelling in both legs and feet and exacerbated CHF symptoms; and * 06/01/25: 175 pounds. The facility’s “weights and vitals summary” triggered a weight warning in the electronic health management system indicating the resident gained 17.8 pounds since 05/13/25, which was an 11.3 % severe weight gain in less than one month. * 06/17/25: the resident was sent out to the emergency room for swelling in both legs and feet and exacerbated CHF symptoms. There was no documented evidence an RN completed a significant change of condition assessment for Resident 6’s severe weight gain until 07/01/25. During an interview on 07/23/25 at 11:06 am, Staff 5 (Wellness Coordinator/RN) stated she was not made aware of the weight gain until 07/01/25. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

C 280- Resident health services: Resident 6 was noted to weigh 157.2 on 5/13 and 175 on 6/1. A gain of 17.8 pounds or 11.3%. Resident was sent to ED on 6/17 for swelling in both legs and feet and exacerbated CHF symptoms. There was no documented evidence of weight gain by RN until 7/1/25. 1. Staff to be inserviced on when to notify nursing of a weight gain. 2. System will be monitored at any mention of weight gain and weekly high risk meetings. 3. Weekly high risk meetings will address weights for residents. 4. Executive director, Wellness Director and RN will hold weekly high risk meetings and RN will chart on changes of condition unitl a new baseline has been established, and a resolution note has been documented.

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:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 2) whose MAR and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease, hypertension, and depression. Resident 2 had a signed physician order for morphine sulfate oral solution 100 mg/5 ml, take 0.5 ml by mouth every two hours as needed for pain or shortness of breath. Resident 2's Controlled Substance Disposition logs and MAR, reviewed from 07/01/25 through 07/20/25, identified the following: * A 07/05/25 dose of morphine at 9:19 am was reflected on the MAR but not on the disposition log; * A 07/12/25 dose of morphine at 12:00 pm was reflected on the disposition log but not on the MAR; * A 07/14/25 dose of morphine at 2:15 pm was reflected on the disposition log but not on the MAR; and * A 07/18/25 dose of morphine at 12:06 am was reflected on the disposition log but not on the MAR. The need to ensure the facility maintained an accurate system for tracking controlled substances was reviewed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25. They acknowledged the findings.

C 302- Tracking controlled substances. Resident 2 was admitted to the community 10/2022 with a diagnosis of COPD, Hypertension and depression. On 4 occasions a dose of morphine was reflected on the disposition log but not the MAR. 1. Med tech training on 8/8 on narcotic handling, documentation protocols,and waste procedure. 2. Wellness director or RCC will complete weekly audits of narcotic documentation to ensure ongoing compliance. 3. Narcotic documentation will audited weekly by the Wellness director and RCC and will discuss findings with medication technitions. 4. Executive Director, Wellness Director and RCC's are responsible to see that corrections are completed and monitored.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer and failed to ensure all medications and treatments were carried out as prescribed for 4 of 6 sampled residents (#’s 1, 2, 6, and 8). Findings include, but are not limited to: 1. Resident 6 moved into the assisted living community in 05/2025 with diagnoses including congestive heart failure. Review of the resident’s 06/01/25 through 07/21/25 MARs and signed physician orders noted the following medications were not administered as prescribed: * Colchicine, give one tablet twice daily (for gout); * Fluorouracil cream, apply twice daily (for skin condition); and * Eliquis 10 mg, give one tablet daily (for blood thinner). The MAR noted MA’s were documenting the colchicine and fluorouracil were not available to administer and the Eliquis was being administered 5 mg twice daily. During an observation of the medication cart on 07/23/25, Staff 19 (MA) confirmed the Colchicine and Fluorouracil cream were not available. During an interview with Staff 5 (Wellness Coordinator/RN) on 07/23/25 at 1:20 pm, it was confirmed the order for Eliquis was transcribed onto the MAR by the pharmacy who changed the order to twice daily dosing rather than once a day as the order was prescribed. Staff 5 confirmed there was not a signed order for twice daily dosing, and she said she would be following up with the prescriber. The need to ensure medications and treatments were being administered as the prescriber ordered was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings. 2. Resident 8 moved into the assisted living community in 03/2024 with diagnoses including hypothyroidism. An interview with Resident 8 and a review of the resident’s 07/01/25 through 07/24/25 MAR and signed physician orders identified the following medications were not administered as prescribed: * On 07/04/25 and 07/11/25 - Levothyroxine 150 mcg tablet 5 days per week Sunday through Thursday (for hypothyroidism); * Retaine mineral eye drops, one drop in both eyes every two hours. If [s/he] is sleeping wake to instill the drops (for dry eyes); and * On 20 occasions from 07/01/25 to 07/24/25, staff noted on the MAR they didn’t follow the Retaine eye drop order because the resident was sleeping. The need to ensure medications and treatments were being administered as the prescriber ordered was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings. 3. Resident 1 moved into the community in 09/2019 with diagnoses including Parkinson’s disease and late-onset cerebellar ataxia (movement disorder). Resident 1’s MAR, dated 07/01/25 through 07/21/25, and corresponding prescriber orders were reviewed. The following was identified: a. The resident had a nurse practitioner’s order for carbidopa/levodopa 25-100mg tablet two tablets by mouth three times daily at 8:00 am, 2:00 pm, and 8:00 pm (for Parkinson’s disease). The MAR documented the medication being administered every day at 8:00 am, 1:00 pm, and 8:00 pm. Staff 11 (MA) confirmed the medication was administered at 1:00 pm every day and not at 2:00 pm. b. The resident had a nurse practitioner’s order for “Check blood pressure daily. Notify front desk to make appointment for resident with PCP if resident has blood pressure over 140/90.” The MAR documented blood pressure checks three times per day. On 18 occasions in July 2025 the resident had blood pressure readings over 140/90. On 07/24/25, Staff 23 (Business Office Assistant/Lead Concierge) reported that the system for notifying the front desk for PCP appointments was verbally or, in her absence, a sticky note. Staff 23 reported the last time she was asked to call the PCP for an appointment due to Resident 1’s high blood pressure was approximately two months prior. The need to ensure all orders were carried out as prescribed was discussed Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 1:50 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease, hypertension, and depression Resident 2's signed physician orders and 07/01/25 through 07/21/25 MAR were reviewed. Resident 2's MAR indicated the resident was taking ropinirole 40 mg once daily to treat restless leg syndrome. There was no current signed order for the medication. The need to ensure signed physician or other legally recognized practitioner orders were documented in the resident’s record for all medications the facility was responsible to administer was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25. They acknowledged the findings.

C 303- Treatment Orders:Resident 6 moved into the community with orders for Colchicine, give 1 tablet 2x daily, Flourouracil cream, apply 2x daily, and Eliquis 10mg give one tablet daily. Colchicine and Flourouracil were not available and had not been given. Pharmacy changed the order for eliquis to 2x daily dosing rather than once daily as written. Resident 8 had an order for Levothyroxine 150mcg tablet Sunday throug Thursday, Retaine eye drops in both eyes every 2 hours, if sleeping wake to instill drops. On 20 occasions staff noted they did not instill the retaine drops because the resident was sleeping.Resident 1 had an order for Carbidopa/levodopa 25-100 mg tablet 2 tablets by mouth 3 times daily at 8am, 2pm and 8pm for parkinsons. The MAR had the adminstration times at 8am, 1pm, and 8pm.The NP had an order for check BP daily. Notify front desk to make and appointment is BP 140/90. on 18 occasions the resident had readings over the parameters in July and the last time the front desk had been asked to make an appointment was 2 months before. Resident 2 had no signed orders for ropinirole 40mg 2x dialy. 1. The med techs were instructed on the importance of 1st and 2nd checks for accuracy. 2. The 1st and 2nd checks will be looked at daily and 3rd checks will be looked at by Wellness director or RCC's for accuracy. 3. 1st, 2nd , 3rd checks will be done daily. 4. Wellness Director and RCC's will ensure checks are being completed.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed at least quarterly to determine their ability to safely self-administer medications for 2 of 2 sampled residents (#s 4 and 5) reviewed for self-administration. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including muscle weakness. During the record review for Resident 4, it was determined the resident self-administered part of his/her medications. The resident's 04/30/25 through 07/21/25 progress notes, evaluations, physician’s orders, and the 07/01/25 through 07/21/25 MAR were reviewed. A self-administration evaluation could not be located for the resident. The need to ensure residents who self-administered any of their own medications were evaluated at least quarterly was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 4 (Wellness Director/LPN), and Staff 5 (Wellness Coordinator) on 07/22/25 and 07/24/25. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 06/2023 with diagnoses including diabetes. During the record review for Resident 5, it was determined the resident self-administered part of his/her medications. The resident's 04/01/25 through 07/21/25 progress notes, evaluations, physician’s orders, and the 07/01/25 through 07/21/25 MAR were reviewed. A self-administration evaluation was last completed in December 2024. Staff 1 (ED) confirmed there was no other evaluation completed more recently for the resident. The need to ensure residents who self-administered any of their own medications were evaluated at least quarterly was discussed with Staff 1, Staff 2 (Vice President of Operations), Staff 4 (Wellness Director/LPN), and Staff 5 (Wellness Coordinator) on 07/22/25 and 07/24/25. The staff acknowledged the findings.

c 325- Self Medication Administration:Resident 4 and 5 were both noted to self adminster some of their medications. Neither had a current self medication adminstration evaluation. 1. Self medication administration evaluation completed for all residents with any self meds. August 18-19 pharmacy consultant and technition will perform an audit of medications. 2. Self medications evaluations will be performed quarterly and at move in or a change of condition. 3. Evaluations will be updated quarterly, change of condition or move in. 4. Wellness Director, RN will ensure self medication administration evaluations will be completed timely.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review it was determined the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents, per the facility’s posted staffing plan. Findings include, but are not limited to: 1. A review of the facility's posted staffing plan, staff schedule from 07/11/25 through 07/21/25, and current ABST indicated the following staffing schedule: * Day Shift: 6:00 am- 2:30 pm – 9 direct care staff; * Swing Shift: 2:00 pm – 10:30 pm – 8 direct care staff; and * Overnight Shift: 10:00 pm - 6:30 am – 3 direct care staff. A review of the facility scheduled from 07/11/25 through 07/21/25 identified 16 out of 33 shifts or 48.48% were staffed below the posted staffing plan. 2. Multiple staff and resident interviews identified concerns regarding long call light times. Review of the call log reports for sampled Resident’s 1, 4, 5, and 7 showed the following: * 05/17/25 through 05/27/25 - 101 calls over 20 minutes and two calls over one hour long; * 06/08/25 through 06/21/25 - 209 calls over 20 minutes and one call over one hour long; and * 07/01/25 through 07/20/25 - 264 calls over 20 minutes and four calls over one hour long. On 07/23/25 at 11:25 am, Resident 7 reported that s/he had excessive call light times when calling staff to help him/her get into bed in the evening or to assist with toileting needs. Resident 8 reported not having a shower for up to one month. Resident 8 reported “staffing issues began after [the new owners] took over.” Multiple unsampled resident interviews also reported showers were not being provided per the resident’s service plan. Some residents reported not receiving shower assistance for multiple weeks. During an interview on 07/21/25 at 3:40 pm, Staff 20 (MA) reported call light times “are usually more than 30 minutes long and we have a few residents that need showers that take upwards of two hours to complete, and we just can’t get to them because we don’t have enough staff.” Staff 20 further reported she was trained to answer call lights within 15 minutes. Staff 1 (ED) stated on 07/24/25 at 1:50 pm that staff were trained to answer the call lights within 15 minutes. The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. The need to ensure the facility was staffing sufficient staff per the posted staffing plan was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

C 360- Staffing requirements and training. It was identified that 16 of 33 shifts were understaffed according to the ABST. Call light times were long due to understaffing and showers were not being completed as scheduled. 1. A contract was signed with a staffing agency, pick up shift bonuses were implemented, job vacancies posted with timely interviews and 11 new people hired in August. 2. Staffing is monitored everyday by the Executive Director. Shift bonuses still in effect and agency used where needed. 3. Staffing monitored daily 4. RCC's and Executive Director to monitor staffing, request agency and apply bonuses to stay in compliance.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to consistently staff to meet or exceed the minimum staffing standards required by the Department. Findings include, but are not limited to: On 12/11/25, the posted staffing plan and the 11/30/25 through 12/06/25 staffing schedule were reviewed. The facility’s posted staffing plan, based on the minimum staffing required by the Department, indicated the following: * Eight and one-half direct care staff scheduled for day shift, 6:00 am to 2:00 pm; * Eight and one-half direct care staff scheduled for evening shift, 2:00 pm to 10:00 pm; and * Four direct care staff scheduled for overnight shift, 10:00 pm to 6:00 am. Review of the 11/30/25 through 12/06/25 staffing schedule identified that the facility did not meet the posted staffing plan on 6 of 21 shifts. The facility's staffing schedule was reviewed with Staff 26 (Administrator) on 12/11/25 at 3:00 pm, and she confirmed that the facility was not staffed according to the posted staffing plan on the following six shifts: * Day shift on 12/06; * Evening shifts on 12/04, 12/05, and 12/06; and * Overnight shifts on 11/30 and 12/06. The need to ensure the facility consistently staffed to meet the minimum staffing standards required by the Department was discussed with Staff 26 and Staff 27 (Regional RN) on 12/11/25 at 4:15 pm. They acknowledged the findings.

What actions will be taken to correct the rule violation? - Each shift will be staffed based on the ABST set forth by the state. How will the system be corrected so this violation will not happen again? - Facility will proactively hire staff and address employees with excessive absenteeism or tardiness timely. How often will the area needing correction be evaluated? - Administrator to review schedule with RCC daily x 7 days, then weekly x 4 weeks. Who on your staff will be responsible for seeing that the corrections are completed/monitored? - RCC or Administrator will complete audit of schedule and any open shifts daily and as needed. Date facility alleges compliance. DOC: 1.10.26

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements staff were providing to residents for 5 of 6 sampled residents (#s 1, 3, 4, 5, and 6). Findings include, but are not limited to: Observations of Resident’s 1, 3, 4, 5, and 6, interviews with direct care staff from 07/21/25 through 07/24/25, and review of Resident 1, 3, 4, 5, and 6’s service plans and acuity-based staffing tool (ABST) evaluations were completed and revealed the residents’ allotted care minutes were not reflective of current needs in one or more of the 22 care elements of the ABST. The need to ensure the ABST accurately captured the care time and care elements for all residents in each of the 22 ADL areas was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

C 362- ABST Time: Residents 1, 3, 4, 5 and 6 service plans and ABST times were not reflective of each other. 1. Staff inserviced on noting times it takes for cares for residents to be reflective of care times in ABST accurately. 2. ABST updated with care plan updates, changes to care plan or Changes of condition. 3. ABST will be checked weekly to monitor compliance and accuracy. 4. Executive Director and Wellness Director to ensure accuracy.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to accurately capture the care time staff provided to each resident, as outlined in their individual service plans, for 3 of 3 sampled residents (#s 9, 10, and 11) whose Acuity-Based Staffing Tool (ABST) data was reviewed. This is a repeat citation. Findings include, but are not limited to: On 11/04/25 at 11:00 am, Staff 1 (ED) provided the surveyor with ABST caregiving time detail summaries for residents #9, 10, and 11. Review of the documentation identified care time was not accurately captured for Residents 9, 10, and 11 in one or more of the following areas: * Responding to call lights; * Ambulation, escorting to and from meals or activities; * Dressing and undressing; * Grooming, such as nail care and brushing hair; and * Resident specific housekeeping and laundry services. The need to accurately capture care time on the resident's ABST was discussed with Staff 1 and Staff 4 (Wellness Director)/LPN). On 11/05/25 at 1:30 pm. They acknowledged the findings.

C362- 1. Implementation of a paper version of ABST ADL's done for each resident. Original copies in the Executive Director Office with a binder of copies in the breakroom for staff to make changes as noted by providing the cares to have more accuracy in times needed according the care provided. 2. Monitoring the sheets with input from staff will assist in capturing times and care accuracy in a timely manner and will be entered into ABST at times changes are noted. 3. Executive Director and RCC will monitor sheets for changes 3 times weekly. 4. Executive Director and RCC will be responsible for monitoring and implentation in ABST.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to accurately capture the care time staff provided to each resident, as outlined in their individual service plans, for 2 of 2 sampled residents (#s 4 and 13) whose Acuity-Based Staffing Tool (ABST) was reviewed. This is a repeat citation. Findings include, but are not limited to: On 12/11/25, Staff 26 (Administrator) provided the surveyor with ABST caregiving time detail summaries for Residents 4 and 13. Review of the documentation identified the following: 1. Resident 4 moved into the community in 04/2025 with diagnoses including post-polio syndrome and cognitive communication deficit. Interviews with staff and review of the resident’s service plan indicated Resident 4's ABST minutes did not accurately capture the care time staff provided in the following areas: * Safety checks; and * Laundry services. 2. Resident 13 moved into the community in 08/2025 with diagnoses including chronic pain syndrome, overactive bladder, and history of urinary tract infections. Interviews with staff and review of the resident’s service plan indicated Resident 13's ABST minutes did not accurately capture the care time staff provided in the following areas: * Bathing; and * Laundry services. The need to accurately capture care time on the resident's ABST was discussed with Staff 26 and Staff 27 (Regional RN) on 12/11/25 at 4:15 pm. They acknowledged the findings.

What actions will be taken to correct the rule violation? - 100% audit of resident #4 and #13 service plan and the ABST. How will the system be corrected so this violation will not happen again? - 100% audit of all residents service plans and ABST. How often will the area needing correction be evaluated? - Administrator or designee will audit service plans and ABST quarterly and with significant changes per resident Who on your staff will be responsible to see that the corrections are completed/monitored? - Administrator or designee Date facility alleges compliance. DOC: 1/10/2026

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review 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 at the same time the resident’s service plan is updated 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 routinely 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. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) 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. (g) Distinct posted staffing plans for 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. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) 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 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 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 and reviewed before a resident moved in and no less than quarterly at the same time as the service plan update for 4 of 6 sampled residents (#s 2, 3, 4, and 5) and one unsampled resident. Findings include but are not limited to: The facility’s ABST was reviewed on 06/23/24 at 1:30 pm. The following was identified: a. Resident 3 and one unsampled resident did not have an ABST evaluation completed. b. Resident 2, 3, 4 and 5’s ABST evaluations did not have evidence they were updated quarterly at the same time as the service plan update. The need to ensure residents’ ABST evaluations were updated before move-in and no less than quarterly corresponding with the service plan update was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 7 (Business Office Manager) on 07/24/25 at 11:40 am. They acknowledged the findings.

C-363 ABST Updates and Staffing Plan: ABST not updated timely at service plan reviews, changes of condition, hospital returns or Changes of Condition. It was noted that Resident 3 did not have an ABST evaluation completed. Residents 2, 3, 4 and 5 did not have evidence that they were updated quarterly at the same time as the service plan update. 1. Executive Director is updating service plans and ABST on the same day. 2. Calendar with service plan due date on the executive directors desk to ensure service plans and abst are updated simultaneously. 3. This will be evaluated daily. 4. Executive director is responsible for daily updates, unless absent and designee will step in.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review 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 at the same time the resident’s service plan is updated 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 routinely 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. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) 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. (g) Distinct posted staffing plans for 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. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) 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 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 exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C342 and C613.

Reflect to tab C362 and C613.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure its re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C362.

Please reference POC for C362

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must 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: The facility was toured on 07/21/25. The following deficiencies were identified: * Many of the dining room chairs had significant peeling on the vinyl seats. * The caulking around the base of the toilet in the men’s restroom on the first floor was black. * Carpeting in the following common areas had large dark stains: the area in front of the mailboxes, the hallway outside Room 322, and the stairwell across from Room 226. * Carpeting in resident apartments 103, 108, 118, and 315 had large dark stains. * Apartment 133 had a cracked window. * The framing around the elevator on the first floor by the dining room had large areas that were gouged, splintered, and chipped, exposing bare wood and metal. The above areas needing cleaning and/or repair were reviewed with Staff 1 (ED) on 07/22/25 and 07/24/25. She acknowledged the findings.

C 613- General Building: Doors-walls cleanable Many dining room chairs have significant peeling. Carpeting in common areas and in front of apartments had stains. Apartment with a cracked window: framing around first door by dining room area that was gouged. 1: Carpets are cleaned in high traffic areas monthly by and outside provider. Carpet cleaning in between these visits to be done by onsight maintenance department. Areas around door in dining room and elevators have been repainted and will be monitored for upkeep. A bid is being sought to repair/replace the window in the residents apartment. Dining room chairs will be reupholstered or replaced. A bid is being sought to fix the broken window. 2. Maintenance director, Executive Director and Marketing Director will do a weekly walkthrough. 3. The walkthrough will be done weekly. 4. Executive Director and Maintenance Director will be responsible.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must 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. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 11/03/25. The following deficiencies were identified: * Carpeting in resident apartments 103, 108, 113, 118, 315, and 322 had large dark stains; and * Apartment 133 had a cracked window. The above areas needing cleaning and/or repair were reviewed with Staff 1 (ED) and Staff 8 (Environmental Services Director) on 11/04/25 and 11/05/25. They acknowledged the findings.

C-455- 1. Carpets in 103, 108, and 118 were cleaned on November 5, 2025. Resident in 315 refused to have carpet cleaned and case manager was emailed for assistance with asking resident to let this happen. 118 has been scheduled to have carpet removed on 11/18/25 and will be replaced with laminate flooring. Broken window in 133 is scheduled to be repaired on 11/24/25. 2. Environmental services will clean 2 apartment carpets per week per floor and keep a rotating schedule. 3. Environmental services director will monitor weekly and communicate with Executive Director for Compliance. 4. Executive Director and Environmental Services Director will be responsible.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure each resident had the freedom and support to control his/her own schedule and activities for 2 of 2 sampled residents (#s 4 and 5) who expressed concerns related to bathing. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including muscle weakness. The resident’s service plan indicated the resident was to have two showers a week and s/he preferred the morning. Shower sheets could not be located for two showers a week over the last month. In interview with the resident on 07/22/25, s/he indicated assistance with showers was not provided on a regular basis. The resident felt like s/he needed to take showers when staff were available rather than his/her preferred shower time. The resident stated some weeks there were no showers offered. The resident further indicated there were not enough staff to get things done. Review of the facility bathing schedule, and shower sheets was completed. The weekly shower schedules showed the following: * 06/29/25 through 07/05/25 showed the resident listed for showers on Wednesday and Sunday at 1:00 pm, and neither shower was signed as completed. * 07/06/25 through 07/12/25 showed the resident listed for showers on Wednesday and Thursday at 1:00 pm, and neither shower was signed as completed. * 07/13/25 through 07/19/25 showed the resident listed for showers on Thursday and Sunday at 1:00 pm, and only Thursday was signed as completed. The need to ensure each resident had the freedom and support to control his/her own schedule was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 3 on 07/21/25 and 07/24/25. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 06/2023 with diagnoses including diabetes. Review of the resident’s 06/11/25 evaluation and 07/21/25 service plan indicated the resident was to receive daily bathing, and the resident’s service plan indicated the resident was to have two showers a week. No resident preference on time was noted in the evaluation or service plan. In an interview with the resident on 07/21/25, s/he indicated showers do not happen on an actual schedule. The resident felt like s/he needed to take showers when staff were available rather than his/her preferred shower time. The resident stated s/he went close to three weeks with no shower before s/he finally complained. The resident was told s/he was not on the shower schedule and that was why nobody came to offer or check in on his/her showers. The resident further indicated there were frequently not enough staff working to get the showers done. Review of the facility bathing schedule and shower sheets was completed. The weekly shower schedules showed the following: * The 06/29/25 through 07/05/25 schedule did not have the resident listed at all. * The 07/06/25 through 07/12/25 schedule showed the resident was written in for one shower on 07/10/25; no time was indicated. * The 07/13/25 through 07/19/25 schedule did not have the resident listed at all. The need to ensure each resident had the freedom and support to control his/her own schedule was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 3 on 07/21/25 and 07/24/25. The staff acknowledged the findings.

H 1522- Individual Freedom and Support: Activities. Resident 4 was admitted to community on 4/2025 with diagnosis of muscle weakness. Service plan indicated resident was to get 2 showers per week. Shower sheets could not be located for 2 showers a week for the last month. Resident stated they felt like they had to take showers when staff were available rather than preferred shower time and that some weeks no showers were offered. Resident 5 admitted in 6/2023 service plan indicated resident was to have daily bathing no preference on time was noted in the service plan. Resident interview showed the resident felt like they had to take showers when staff where available rather than preferred shower time and resident went close to 3 weeks with no shower. 1. Staff inserviced on following care plans and showers. Resident preference and working with resident for agreeable time to get them complete. 2. Wellness Director and RCC's will monitor shower sheets daily for completion. 3. Shower sheets will be monitored daily. 4. Wellness Director and RCC's to monitor shower sheets.

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by: