Print Inspection: CHOW006077

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the service plan was updated with new interventions left by outside service providers for 1 of 1 sampled resident (#1) who received home health nursing services. Findings include, but are not limited to: Resident 1 admitted to the facility in 06/2020 with diagnoses including dementia. During the acuity interview on 08/12/25, the resident was identified as receiving home health nursing services for bilateral heel wounds. Review of the Home Health Provider visit notes on 08/12/25 noted the following interventions and recommendations left by the Resident’s home health providers: * 07/14/25 - “Recommend [patient] to elevate legs and heels as much as possible to relieve pain to heel...”: * 07/15/25 - "Encourage [patient] to participate in activities”; and * 07/23/25 - “Encourage [patient] to elevate heels to allow healing. Encourage [patient] to increase intake of protein to promote wound healing and prevent weight loss.” In a 08/12/25 interview with Staff 1 (Memory Care Director), she confirmed the facility had not updated the Resident 1’s service plan with the new interventions. On 08/12/25 the need to ensure Resident 1’s service plan was updated with new interventions left by outside service providers was discussed with Staff 1, Staff 2 (Administrator) and Staff 3 (Assistant Administrator). They acknowledged the findings.

Regulation Cited: OAR 411-054-0045(2) – Resident Health Services: On and Off-Site Health Services Deficiency: Home health recommendations were not consistently reviewed or implemented. Corrective Action-To ensure all home health recommendations are reviewed, implemented, and documented in compliance with state requirements, the following process has been established: 1. Collection of Home Health Notes-All Home Health notes will be submitted to the front desk upon receipt. The front desk will place the documentation in the designated Med Room box for processing. 2. Processing of Home Health Notes-Med Tech, RN, or Memory Care Director (MCD) will collect all Home Health paperwork from the Med Room box. Each note will be processed as an order, which includes: Making a corresponding chart note in the resident record. Initiating an Interim Service Plan (ISP), if indicated and placing the completed documentation into the “RN Review” file. 3. RN/MCD Oversight and Compliance Verification-The RN or MCD will review the “RN Review” file daily. During this review, the RN/MCD will confirm that: Chart notes have been entered. Interim Service Plans have been initiated when required and any discrepancies will be corrected immediately to ensure compliance and resident safety. Monitoring-The RN/MCD will monitor this process daily for 90 days to verify consistent compliance. Findings will be reported in the monthly Wellness Meeting. Continued adherence will then be incorporated into standard practice to prevent recurrence.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. 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 interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (# 2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 moved into the facility with diagnoses including hypotension (low blood pressure). Resident 2's MARs, dated 07/01/25 through 08/11/25, corresponding progress notes and prescriber orders were reviewed and revealed the following: a. The resident had an order for midodrine (for hypotension) to be administered one tablet three times daily. If the systolic blood pressure was greater than 110 or if the diastolic blood pressure was greater than 70, the order stated to hold medication dose. * In July, there were 38 occasions when Resident 2’s blood pressure was outside of parameters, but the midodrine was not marked as “no pass per vitals” on the MAR on 13 of those occasions. *In August, there were 22 occasions when Resident 2’s blood pressure was outside of parameters, but the Midodrine was not marked as “no pass per vitals” on the MAR on four of those occasions. During an interview on 08/12/25 at 2:57 pm, Staff 1 (Memory Care Director) was unable to confirm if the medications were administered as indicated on the MARs, when Resident 2’s blood pressure was outside of parameters. The need to ensure medications were carried out as prescribed was discussed with Staff 1, Staff 2 (Administrator), and Staff 3 (Assistant Administrator) on 08/12/25. The findings were acknowledged.

Regulation Cited: OAR 411-054-0055(1)(f-h) – Systems: Treatment Orders Deficiency: Parameters established by a physician were not consistently followed when administering medications. Corrective Action: To ensure all physician-ordered parameters are consistently followed and documented, the following corrective actions have been implemented: Staff Education and Expectations-All Med Techs have been re-educated on the requirement that vital signs must be taken prior to opening (“popping”) medication. Staff must confirm that vital signs, particularly blood pressure, are within the parameters established by the prescribing physician. Medication Administration Process-If a vital sign is outside of the prescribed parameters, staff must select “No Pass” in the electronic medication record to document that the medication was not administered. The doctor, family, and RN/Memory Care Director are to be notified. Staff will be reminded that the system requires a response to the parameter question prior to clicking “Administer.” Oversight and Quality Assurance-The MCD or RN will conduct weekly spot checks of all medications that have vitals attached to ensure: Parameters were checked and documented prior to administration. “No Pass” was appropriately used when parameters were not met. Any discrepancies will be addressed immediately with the responsible staff, and additional re-education will be provided as needed. Monitoring: This process will be monitored weekly for 90 days by the MCD/RN, findings will be reviewed daily in the Daily Clinical Meeting and monthly in the QA meeting. findings reported in the monthly Wellness Meeting. If compliance is consistently demonstrated, monitoring will transition to monthly spot checks as part of ongoing quality assurance.

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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: Six months of facility fire drill and fire and life safety records from 02/2025 to 08/2025 were reviewed on 08/12/25 and revealed the following: a. Fire drills lacked documented evidence of the following: * The escape route used; * Evacuation time period needed; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. b. In an interview on 08/12/25 at 2:12 pm, Staff 5 (Maintenance Director) confirmed there was a lack of documented evidence staff were trained in fire and life safety procedures on alternate months of fire drills. The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 (Memory Care Director), Staff 2 (Administrator), and Staff 3 (Assistant Administrator) on 8/12/25. They acknowledged the findings.

Citation: OAR 411-054-0090 (1-2) Fire and Life Safety Deficiency: The facility failed to ensure fire drills were conducted per Oregon Fire Code (OFC) and failed to provide fire and life safety training to staff on alternate months from drills. Documentation for required elements of drills (escape route, evacuation time, problems encountered, number of occupants evacuated) was incomplete. Staff training records were not available for alternate months. Plan of Correction: What actions will be taken to correct the rule violation for each example/resident: Immediately upon identification, the Maintenance Director, Administrator, and Memory Care Director reviewed and implemented the use of the Fire Drill Record form which includes all required elements: escape route, evacuation time, problems encountered/residents who resisted or failed to participate, and number of occupants evacuated. Additionally, the use of the Fire Drill Evaluation document will be completed following each drill that is conducted to evaluate the drill and identify areas of necessary improvement and identify the need for additional training. How will the system be corrected so this violation does not happen again? The Administrator or designee will review completed drill and training documentation monthly to ensure required elements are present. Staff responsible for conducting fire drills (Maintenance Director, shift supervisors) will be retrained on documentation requirements and use of the Fire Drill and Evaluation forms. How often will the area needing correction be evaluated? This will be evaluated monthly during the required drills and evidenced by completion of the Fire Drill Evaluation form as well as during monthly QA meetings. Who will be responsible to see that the corrections are completed/monitored? The Maintenance Director will audit drill and training records monthly. Any missing or incomplete documentation will be addressed immediately with the staff member responsible, and retraining will occur as needed. Audit results will be reviewed during monthly QA meetings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at least annually. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 08/12/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities at least annually. The need to ensure residents were instructed in fire and life safety procedures at least annually, was discussed with Staff 1 (Memory Care Director), Staff 2 (Administrator), and Staff 3 (Assistant Administrator) on 08/12/25. They acknowledged the findings.

Regulation Cited: OAR 411-054-0090(5) – Fire and Life Safety: Training for Residents Deficiency: Yearly fire and life safety instruction was not provided to residents capable of following instruction. Corrective Action-To ensure all residents capable of understanding and following safety procedures receive required fire and life safety training, the following corrective measures have been implemented: Resident Training-The Maintenance Director and Memory Care Director will hold a meeting with all Memory Care residents capable of following instructions. Training will include: Basic safety procedures, Evacuation methods, Resident responsibilities during fire drills, and Designated outdoor meeting locations. Ongoing Training Upon Admission and Annually-The Memory Care Director and/or Maintenance Director will provide the above fire and life safety training to each new resident upon move-in. Annual training will be conducted for all applicable residents to ensure continued compliance. Documentation and Verification-Documentation of resident fire and life safety education will be maintained in the Disaster Binder under “Resident Trainings.” The Memory Care Director and Administrator will review the binder monthly for 90 days to ensure compliance, transitioning to quarterly reviews thereafter. Any discrepancies identified will be addressed immediately, and corrective education will be provided as needed. Monitoring: The Memory Care Director and Administrator will oversee the ongoing compliance of this process. Compliance checks and documentation audits will be reported at the monthly QA Meeting to ensure training remains current and consistent.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: During a walk-through of the facility on 08/12/25, doors to the interior MCC courtyard were found to lack a working alarm or other system to alert staff when a resident exited the building. This lack of alarm or system was confirmed by an interview with Staff 1 (Memory Care Director) on 08/12/25 at 3:15 pm. The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited the building was discussed with Staff 1, Staff 2 (Administrator), and Staff 3 (Assistant Administrator) on 08/12/25. The findings were acknowledged.

Regulation Cited: OAR 411-054-0200(11-13) – Call System, Exit Door Alarms, Phones, TV, or Cable Deficiency: Required door alarms were not present or functioning to alert staff when individuals entered or exited the Memory Care wing. Corrective Action-The deficiency has been corrected and the following actions were taken to ensure ongoing compliance: Immediate Correction-The Maintenance Director replaced the nonfunctioning door alarms on all Memory Care entrance doors, courtyard doors, and the designated fire exit. Signal boxes were securely installed above resident reach to prevent tampering or accidental unplugging. The Maintenance Director and/or Memory Care Director (MCD) will conduct monthly checks of all door alarms to confirm: Alarms are operational, batteries are functional, and signal boxes remain securely in place. Any deficiencies identified will be corrected immediately to ensure uninterrupted compliance. Monitoring-The Maintenance Director and/or MCD will oversee weekly checks for 90 days, reporting findings at the monthly QA Meeting. Thereafter, alarm checks will remain part of the community’s ongoing monthly safety inspection protocol.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420 and C422.

Regulation Cited: OAR 411-057-0140(2) – Administration Compliance Deficiency: The facility failed to follow licensing rules for Residential Care and Assisted Living Facilities, as referenced in deficiencies C420 and C422. Corrective Action-To ensure ongoing compliance with licensing requirements, the following corrective measures have been implemented: Resolution of Deficiencies. Corrective actions associated with tags C420 and C422 have been implemented and remain in place. The Administrator, Memory Care Director, and Maintenance Director are responsible for ensuring these corrections are fully maintained and integrated into daily practice. Ongoing Oversight and Accountability-The Administrator will conduct random monthly audits with the Memory Care Director and Maintenance Director to confirm that all corrective actions remain in compliance with licensing rules. Any deficiencies identified during audits will be corrected immediately, and additional education or retraining will be provided as necessary. Sustained Compliance-Audit findings will be documented and reviewed during monthly QA Meetings. Continued monitoring will ensure that corrective actions remain effective and that compliance is sustained. Monitoring-The Administrator will oversee this process and ensure that compliance is reviewed, documented, and maintained through ongoing monthly audits. This monitoring will remain in place to prevent recurrence of non-compliance.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C290 and C303.

Regulation Cited: OAR 411-057-0160(2)(b) – Compliance with Rules: Health Care Deficiency: The facility failed to follow licensing rules for Residential Care and Assisted Living Facilities, as referenced in deficiencies C290 and C303. Corrective Action-To ensure compliance with all applicable healthcare licensing rules, the following corrective measures have been implemented. Resolution of Deficiencies-Corrective actions associated with tags C290 and C303 have been completed and remain in place.These corrections address the gaps identified in following healthcare service requirements. Ongoing Oversight and Accountability-The Memory Care Director (MCD) and Registered Nurse (RN) will review and monitor compliance with physician orders, interim service plans, and care documentation on a daily basis. Any discrepancies identified will be corrected immediately, with retraining provided to staff as necessary to reinforce compliance. Sustained Compliance-The RN and MCD will maintain daily oversight to ensure these corrective actions are integrated into routine practice. Findings and compliance status will be documented and reviewed during monthly QA Meetings. This practice will remain in effect to prevent recurrence of non-compliance with healthcare regulations.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements and to develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose evaluations and services plans were reviewed. The most recent evaluations and current service plans were reviewed for Residents 1 and 2. The following was identified: a. There was no documented evidence an activity evaluation had been completed for both sampled residents that addressed the following: * Current abilities and skills; * Emotional and social needs and patterns; and * Identification of activities for behavioral interventions. b. There was no documented evidence an individualized plan was developed for both sampled residents. During an interview on 08/12/25 at 3:20 pm, Staff 1 (Memory Care Director) confirmed there was no additional documentation regarding the activity evaluation or plan for Resident 1 and Resident 2. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1, Staff 2 (Administrator), and Staff 3 (Assistant Administrator) on 08/12/25. The findings were acknowledged.

Regulation Cited: OAR 411-057-0160(2)(d) – Activities Deficiency: The facility failed to follow licensing rules for Residential Care and Assisted Living Facilities by not maintaining documented evidence that an activity evaluation was completed and an individualized activity plan developed in the resident’s care plan. Corrective Action: To ensure compliance with activity requirements, the following corrective measures have been implemented: Review of Existing Care Plans-All current resident care plans will be reviewed for accuracy and completeness. An activity evaluation will be completed and placed on file for each resident who does not already have one documented. Individualized Activity Plans-An individualized activity plan will be developed for each resident to address: Current abilities and skills, emotional and social needs and patterns, and identification of activities appropriate for behavioral interventions. Ongoing Compliance-The Memory Care Director, RN, and Life Enrichment Coordinator will be responsible for ensuring that: A completed activity evaluation and individualized activity plan are in place for each resident. For new residents, this requirement will be met within 30 days of move-in. Monitoring: The Memory Care Director will conduct monthly audits of resident records to confirm that activity evaluations and individualized activity plans are documented and current. Audit results will be reviewed during the Wellness Meetings. Any deficiencies identified will be corrected immediately to maintain compliance.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by:

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather and to ensure that fencing surrounding the perimeter of the outdoor recreation area was no less than six feet in height. Findings include, but are not limited to: During the survey, the doors to the interior courtyard were observed to be locked on in the afternoon hours of 08/11/25 and 08/12/25, when the heat was above 95 degrees F. During a tour of the building on 08/12/25 at 12:40 pm, Staff 1 (Memory Care Director) reported the courtyard doors were locked by an electronic keypad when temperatures were above 95 degrees F, and it was written on the white board in the dining area. She confirmed there was no written policy for severe weather. A tour of the facility courtyard on 08/12/25 at 9:00 am with Staff 5 (Maintenance Director) showed 18 of the 25 sections of fencing around the perimeter of the secured outdoor area, including the gate, were less than six feet in height. The shortest sections were approximately 5 feet 10 inches. The need to ensure the facility had a written policy for severe weather when the doors to the courtyard would be locked and to ensure the perimeter fencing of the outdoor recreation area was no less than six feet in height reviewed with Staff 1, Staff 2 (Administrator), and Staff 3 (Assistant Administrator) on 08/12/25. The findings were acknowledged.

Regulation Cited: OAR 411-057-0170(6) – Secure Outdoor Recreation Area Deficiency: The facility failed to meet licensing requirements for Residential Care and Assisted Living Facilities due to: Courtyard fencing measuring below the required six (6) feet in several sections. As well as Absence of a posted community policy next to exterior doors regarding door locking during inclement weather or nighttime hours. Corrective Action: Fence Correction-The Maintenance Director and Memory Care Director coordinated with Quality Fence Company to install a 1 ½” x 5 ½” rail on the top of all courtyard fence panels. This correction ensures all fencing meets the six-foot height requirement. Community Policy Posting-A written policy regarding courtyard access was created and posted next to the exterior door leading to the courtyard. The policy specifies when doors will be locked due to inclement weather or during nighttime hours. Ongoing Oversight-The Maintenance Director and Memory Care Director will conduct monthly safety inspections to ensure: Fence height remains in compliance. Policy postings are present, legible, and up to date. Any deficiencies identified will be corrected immediately and reviewed at monthly QA Meetings. Monitoring: The Administrator will oversee monthly compliance audits for 90 days, transitioning to quarterly audits thereafter.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by:

OAR 411-057-0170(10) Exit Doors (10) EXIT DOORS. (a) Locking devices used on exit doors, as approved by the Building Codes Agency and Fire Marshal having jurisdiction over the memory care community, must be electronic and release when the following occurs: (A) Upon activation of the fire alarm or sprinkler system; (B) Power failure to the facility; or (C) By activating a key button or keypad located at exits for routine use by staff. (b) If the memory care community uses keypads to lock and unlock exits, then directions for the keypad code and their operation must be posted on the outside of the door to allow access to the unit. However, if all of the community is endorsed, then directions for the operation of the locks need not be posted on the outside of the door. (c) Memory care communities may not have entrance and exit doors that are closed with non-electronic keyed locks. A door with a keyed lock may not be placed between a resident and the exit. (d) If the memory care community does not post the code, the community must develop a policy or a system that allows for visitor entry. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: During a walk-through of the facility on 08/12/25, doors to the interior MCC courtyard were found to lack a working alarm or other system to alert staff when a resident exited the building. This lack of alarm or system was confirmed by an interview with Staff 1 (Memory Care Director) on 08/12/25 at 3:15 pm. The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited the building was discussed with Staff 1, Staff 2 (Administrator), and Staff 3 (Assistant Administrator) on 08/12/25. The findings were acknowledged.