Print Inspection: CHOW007140

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 conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 10/06/25 through 10/10/25, a quality improvement program developed to ensure adequate resident care, services and satisfaction was found to be ineffective. Refer to the deficiencies in the report.

1.We will conduct a monthly quality improvement program envolving the RN, RCC, and Administrator to evaluate services, resident outcomes, and satisfaction. 2. Once a month we will conduct a quality improvement program. 3. Once a month. 4. The Administrator and RN will be responsible for ensuring this program is conducted once a month.

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 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (# 7) who had a known history of physical and verbal behaviors toward other residents and staff. This placed residents at risk and constituted an immediate threat to the residents' physical and emotional health and safety. Findings include, but are not limited to: Resident 7 moved to the facility's MCC in 08/2025 with diagnoses including dementia. During the acuity interview on 02/17/26 at 2:02 pm, Resident 7 was identified to require two people present for all care needs due to increased agitation and “possible exit-seeking behavior.” The resident's service plan that was available to staff, dated 12/18/25, incident reports, and observation notes were reviewed, observations of the resident were made, and interviews with staff were conducted. The following was identified: * The service plan noted Resident 7 “does not have current history of disruptive, aggressive, verbal or socially inappropriate behavior” and provided no instructions to staff on de-escalation interventions in case the resident acted in an aggressive manner towards other residents; * An incident report dated 10/20/25 noted Resident 7 “hitting [MT] repeatedly with a closed fist in the stomach and back handing [sic] this med techs abdomen and hips while yelling [expletive deleted] repeatedly”; * An incident report dated 10/21/25 noted Resident 7 was observed by staff yelling at another resident and “shoving” that resident away; * An incident report dated 12/29/25 noted an unsampled resident of the MCC reported being “hit in the stomach by [Resident 7] and it was hard for [him/her] to breathe.” Consequently, the other resident was sent out for evaluation and admitted to the hospital due to “2 broken ribs and a bruise to [his/her] lung.” The incident was witnessed by another unsampled resident of the MCC; and * An incident report dated 02/12/26 noted a statement from Staff 4 (MT) reporting Resident 7 “swung [his/her] closed fist from the side, hitting the soft lower part of [MT] head/upper neck…. Resident went to continue to punch me when [Staff 10 (CG)] stepped into assist. [Resident] grabbed [Staff 10] neck leaving a welt then continued to hit and grab us.” During the survey, Resident 7 was observed alternatively pacing throughout the perimeter of the MCC or sitting in a chair in the television room. On 02/18/26 at 10:30 am, an unsampled resident was ambulating through the television room with a walker. While that resident was passing, Resident 7 hit the front right wheel of the walker with [his/her] foot, causing the unsampled resident to momentarily lose balance. Staff 29 (CG) came over and redirected the unsampled resident. On 02/19/26 at 10:16 am, Resident 7 loudly addressed another member of the survey team, “There you are again. Why are you walking around, this is my apartment, and I want you to get out.” The surveyor replied she was sorry and was leaving, and walked away from Resident 7. The incident was observed by Staff 4 who told the surveyor, “[S/he] choked me… [S/he] really shouldn’t be in this setting.” It was determined staff were aware of Resident 7's history of physical and verbal aggression toward other residents and staff. In an interview on 02/18/26 at 12:54 pm, Staff 4 stated Resident 7 “can be verbally and physically abusive. We have no prn meds, just have to make sure other residents are safe when [s/he] gets agitated. When [Resident 7] gets agitated, we are unable to re-direct. [S/he] moved here from jail due to assault. If we have agency staff, we tell them about the aggression. It is only verbal communication.” In an interview on 02/19/26 at 10:50 am, Staff 29 stated Resident 7 was easily agitated and combative, got “pretty angry with interactions, even with activities” and “gets verbally [abusive] at least once-twice daily… Usually [s/he] is the aggressor.” Staff 29 indicated the interventions used to de-escalate are based on her working experience but Resident 7 “does not respond to it 9 out of 10 [times].” There was no documented evidence what precautions or interventions the facility took to ensure the safety of residents. The facility's failure to evaluate behavior, determine interventions, and take actions to ensure the health, safety, and welfare of residents placed other residents at risk and constituted an immediate threat to other residents’ physical and emotional safety. An immediate plan of correction was requested on 02/19/26. The facility provided a plan of correction that was accepted on 02/19/26 at 3:31pm, prior to the survey team’s exit. The immediate risk was addressed; however, the facility must evaluate the overall systemic failures associated with this specific violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 22 (ED) and Staff 23 (Administrator) on 02/19/26 at 4:52 pm. They acknowledged the findings.

Please refer to POC presented to the survey team on 02/19/26

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local Seniors and People with Disability (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse for 3 of 4 sampled residents (#s 1, 2 and 4) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the community in 05/2023 with diagnoses including dementia. On 09/01/25, staff created an ISP (interim service plan) identifying a “cut (scabbed/ inflammed [sic])” on the resident’s left index finger. On 09/26/25, staff created an ISP identifying a “ping pong size yellow bruise on right shoulder blade.” There was no documented evidence that either injury of unknown cause was immediately investigated to rule out abuse. During an interview at 1:20 pm on 10/08/25, Staff 1 (Administrator) confirmed the above injuries lacked investigation and had not been reported to the local SPD office. The surveyor requested the above injuries be reported to the local SPD office, and confirmation was received at 3:44 pm on 10/08/25. The need to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse unless an immediate facility investigation reasonably ruled out abuse was reviewed with Staff 1, Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings. 2. Resident 4 moved into the community in 10/2024 with diagnoses including dementia. The resident’s clinical record was reviewed, and the following was revealed: * 08/07/25 – Injury of unknown cause, staff identified a bruise to the resident’s right shoulder; * 08/14/25 – The resident experienced a fall and sustained a skin tear and bruising to the left knee; * 09/19/25– Injury of unknown cause, staff identified a scab on the resident’s right upper thigh. On 10/08/25 at 1:48 pm, Staff 1 (Administrator) acknowledged there was no investigation to rule out abuse or neglect for the above incidents. The facility failed to promptly investigate the resident's fall with injury and injuries of unknown cause to rule out abuse or report the injuries to SPD as suspected abuse. The facility was instructed to report the fall with injury and injuries of unknown cause to the local SPD office. Proof of reporting was received by the survey team prior to survey exit. The need to ensure all injuries including injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, was discussed with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings. 3. Resident 2 moved into the community in 09/2023 with diagnoses including dementia. The resident’s clinical record was reviewed, and the following was revealed: On 09/28/25 the resident had an injury fall while “ambulating without [his/her] walker and wheelchair not within reach”. The description of the event also noted s/he “had one shoe on.” The resident returned from the hospital with a wrist fracture. On 10/07/25 at 12:40 pm, Staff 1 confirmed she completed the follow-up action while investigating the fall with injury but had not ruled out abuse. The facility failed to promptly investigate the resident's fall with injury to rule out abuse or report the injury to SPD as suspected abuse. Survey requested the facility report the injury fall to the local SPD office, and confirmation was received at 10/08/25 at 3:40 pm. The need to ensure all incidents contained all required areas of documentation including if abuse could be ruled out, and if not, incidents were reported to the local SPD office, was discussed with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

1. On 10/8/25 the injury of unknown cause for resident #1, the injury of unknown cause and fall with injury for resident #4, and the injury fall for resident #2 was reported to APS. 2. The Administor,RN, and all staff will be retrained on reporting injury of unknown cause. 3. Our system of training and reporting abuse of unknown cause will be evaluted monthly at our quality improvement program. 4. The Administrator and RN will be responsible for ensuring all injury of unknown cause will be reported.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: The MCC was divided into two separate units that included two distinct areas within each locked unit. At the time of the survey, the MCC was home to 34 residents. Observations during the survey, from 02/17/26 to 02/19/26, showed a lack of scheduled and unscheduled activities provided for residents living in the MCC. The activity calendar for February 2026 was provided and indicated scheduled activities for each day of the week. The activities scheduled according to the calendar for 02/18/26 and 02/19/26 included the following: 02/18/26: * 08:00 am -Coffee and Chronicle * 10:00 am – Chair Yoga * 10:30 am - Baking * 1:00 pm – Wednesday Craft Club-Paper Marbling * 3:00 pm – Word Search Game Observations at 10:00 am, 10:30 am, 1:00 pm and 3:00 pm were made and the activities did not take place. 02/19/26: * 8:00 am – Coffee and Chronicle * 10:00 am – Seated Calisthenics * 10:30 am – Virtual Tours * 1:00 pm – Craft-Winter Water coloring * 3:00 pm - Game Observations were made at 10:00 am, 10:30 am, 1:00 pm, and 3:00 pm, and the only activity observed was the 10:00 am Seated Calisthenics facilitated by Witness 2 (OT Assistant). Four residents participated in balloon batting. Interviews with Staff 27 (CG/MT) and Staff 28 (CG/MT) on 02/17/26 at 3:55pm indicated staff were responsible to perform activities with the residents. Staff 27 pointed at the posted activity calendar on the wall and acknowledged the activities on the calendar did not happen. “We have a calendar of what we’re supposed to do but 99% of the time we don’t know what the activity is and where it is happening.” She referred to Chair yoga and Coffee and Chronicles activities as examples. An unsampled resident’s family member was seated in the dining room and added, “There is nothing ever happening on that schedule.” During the survey multiple staff acknowledged the activity person was rarely present and believed the only activity staff was the Activity Director who was responsible for the entire campus, which included two MCCs and the assisted living facility. Throughout the survey, residents were observed wandering the units, sleeping in chairs in the common areas for long periods, sitting in front of the television, or remaining in their rooms, unengaged in individual or group activities. On 02/19/26 at 4:15 pm, Staff 22 (ED) acknowledged the lack of scheduled and unscheduled activities. She reported they had hired a new Activity Director, as the prior one left in 01/2026, and they are planning to hire additional activity staff. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests and physical, mental, and psychosocial needs was discussed with Staff 22 and Staff 23 (Administrator) on 02/19/26 at 4:15 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are that two additional activities team members were hired to ensure the facility is providing a daily program of social and recreational activities. 2. The system will be corrected so this violation will not happen again by hiring one additional activities team member to ensure activities are taking place as scheduled and are based upon individual and group interests as well as physical, mental, and psychosocial needs. 3. The area needing correction will be evaluated on a daily basis ensuring all scheduled activities are occuring. 4. The Engagement Director, Administrator, and Executive Director will be responsible to see that the corrections are completed/monitored.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. This is a repeat citation. Findings include, but are not limited to: Observations during the survey on 04/16/26 showed there was a lack of scheduled and unscheduled activities provided for residents living in the MCC. The MCC consisted of two wings, Riverside and Mountainside. An activity calendar was posted which noted scheduled activities for each day of the week. The activities noted for 04/16/26 included the following: · 10:00 am - Seated Yoga (Riverside); · 10:30 am – Seated Yoga (Mountainside); · 11:00 am – Lunch and Chronicles; and · 2:00 pm – Birthday Party. Observations made on 04/16/26 confirmed seated yoga did not take place at 10:00 am in Riverside or at 10:30 am in Mountainside. The scheduled activity at 11:00 am consisted of the chronicles page placed on the dining tables. The birthday party took place in the assisted living side of the facility, and staff determined which residents from the MCC they thought would like to attend. Three residents from Mountainside were observed being taken to the party. No other residents were included from Mountainside. The television remained on in the common areas of both Riverside and Mountainside throughout the period of the survey, with multiple residents present, some watching and some sleeping. Other residents were observed wandering the hallways or sitting at tables in the dining room. Residents who were in their apartments were not approached for activity invitations during observations. Staff 25 (MT) was asked during an interview on 04/16/26 at 10:49 am if she observed a structured activity program and responded “No, I don’t.” The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 23 (Administrator) on 04/16/26 at 2:45 pm. Staff 23 acknowledged the activities program was “not where it needed to be.”

1. The actions that will be taken to correct the rule violation are that the facility will ensure that there are scheduled and unscheduled activities provided for the residents living in the MCC. This will include the two wings, Riverside and Mountainside. 2. The system will be corrected so this violation will not happen again by ensuring that a daily program of social and recreational activites are taking place as scheduled and are based upon individual and group interests as well as physical, mental, and psychosocial needs. 3. The area needing correction will be evaluated on a daily basis ensuring all scheduled and unscheduled activities are occuring. 4. The Engagement Director, Administrator, and Executive Director will be responsible to see that the corrections are completed/monitored.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the initial evaluation for 1 of 1 sampled resident (#3) whose initial evaluation was reviewed. Findings include but are not limited to: Resident 3 was admitted to the facility on 09/04/25 with diagnoses including dementia and depression. The resident’s initial evaluation, dated 08/30/25, was reviewed. The evaluation failed to address the following required elements: * Preferred name, pronouns, and gender identity; * Customary routines: eating, bathing; * Interests, hobbies, social, leisure activities; * Mental health issues including history of treatment and effective non-drug interventions; * List of treatments: type, frequency, and level of assistance; and * Emergency evacuation ability. * Personality including how the person copes with change or challenging situations; * Nutrition habits; * List of treatments: type, frequency, and level of assistance; and * Emergency evacuation ability. The need to address all required areas in each initial evaluation was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings.

1. We will added the following to the service plan for resident #2. * Preferred name, pronouns, and gender identity; * Customary routines: eating, bathing; * Interests, hobbies, social, leisure activities; * Mental health issues including history of treatment and effective non-drug interventions; * List of treatments: type, frequency, and level of assistance; and * Emergency evacuation ability. * Personality including how the person copes with change or challenging situations; * Nutrition habits; * List of treatments: type, frequency, and level of assistance; and * Emergency evacuation ability. 2. All staff conducting the intial evaluation will be retrained to ensure all required elements are included in the initial evaluation and the above is added to resident #2 service plan. 3. This system will be monitored once a month at our quality improvement meeting. 4. The administrator and RN.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the initial evaluation for 1 of 1 sampled resident (#8) whose initial evaluation was reviewed. This is a repeat citation. Findings include but are not limited to: Resident 8 was admitted to the facility on 01/05/26 with diagnoses including dementia. The resident’s initial evaluation, dated 12/30/25, was reviewed. The evaluation failed to address the following required elements: * Emergency evacuation ability; * Customary routines: eating, bathing; * Interests, hobbies, social, leisure activities; * Nutrition habits and preferences; and * Personality, including how the person copes with change or challenging situations. The need to address all required areas in the initial evaluation was discussed with Staff 23 (Administrator) on 02/19/26 at 11:00 am. She acknowledged the findings.

1. The actions that will be taken to correct the rule violation are to ensure Resident #8's evaluation is updated and addresses the following areas: - Emergency evacuation ability - Customary routines: eating and bathing - Interests, hobbies, social, leisure activities - Nutrition habits and preferences - Personality, including how the person copes with change or challenging situations. 2. The system will be corrected so this violation will not happen again by ensuring that all required areas in all residents, new and existing, intitial evaluations are completed. 3. The area needing correction will be evaluated at move in, monthly, quarterly, and change of condition. 4. The Administrator, Health Services Director, and Executive Director will be responsible to see that the corrections are completed/monitored.

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

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

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 residents’ service plans were readily available to staff, were reflective of residents’ current care needs and preferences, provided clear direction to staff regarding the delivery of services, and/or service plans were implemented for 3 of 4 sampled residents (#s 1, 2, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the community in 05/2023 with diagnoses including dementia. The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The following was identified: a. During the entrance interview on 10/06/25, facility staff reported service plans were stored in the service plan binder located outside the MT office in each unit for direct care staff to review. Upon observation of the binder stored on a cart outside the MT office in the Riverside unit at 2:48 pm on 10/06/25, the service plan for Resident 1 was dated 05/20/25. A service plan dated 09/26/25 was provided by the facility at 1:30 pm on 10/07/25, but this was not available to staff at the time of survey entrance. b. The 09/26/25 service plan was not reflective of the resident’s current care needs and did not give clear direction to the staff in the following areas: * History of unexplained weight loss; and * Emergency evacuation assistance. The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1(Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings. 2. Resident 4 moved into the community in 10/2024 with diagnoses including dementia. Observations were made, and interviews with staff were conducted. On 10/06/25 at 11: 47 am, the resident's current service plan, dated 09/12/25, was not available to staff. The service plan was not reflective of the resident's needs and preferences, did not provide clear instructions to staff or was not implemented in the following areas: * Behaviors, including interventions; * Toileting; * Pain, including how the resident expresses pain; * Fall interventions; and * Emergency evacuation assistance. The need to ensure service plans were available, provided clear direction to staff, were reflective of resident needs and preferences, and were implemented was discussed with Staff 1, (Administrator) Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10: 25 am. They acknowledged the findings. 3. Resident 2 moved into the community in 09/2023 with diagnoses including dementia. The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The following was identified: a. During the entrance interview on 10/06/25, facility staff reported service plans were stored in the service plan binder located outside the MT office in each unit for direct care staff to review. Upon observation of the binder stored on a dining room table outside the MT office in the Mountainside unit at 2:50 pm on 10/06/25, the service plan for Resident 2 was dated 06/23/25. A service plan dated 09/19/25 was provided by the facility at 3:15 pm on 10/06/25, but this was not available to staff at the time of survey entrance. b. The 09/19/25 service plan was not reflective of the resident’s current care needs, and/or lacked clear instructions in the following areas: * Emergency evacuation assistance; * Outside provider services, including HH PT and OT; * How the resident exhibits anxiety and agitation; * Non-pharmaceutical interventions for behaviors; * Preferences for sleeping and bathing; and * Ability to communicate and understand others. During an interview on 10/09/25 at 1:15 pm, Staff 4 (CG) acknowledged communication with Resident 2 was “hard to figure out” because s/he was emotional, “cries more” and then takes time to figure out what s/he is trying to communicate. The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1(Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

1. We will ensure that the most recent service plans are readily availbable to staff, are reflective of residents current care needs and preferences, provide clear directions to staff regarding the delivery of services, and specifically for the residents. The below information will be added to the service plans; Resident #1 *History of unexplained weight loss; and *Emergency evacuation assistance. Resident #4 *Behaviors, including interventions *Toileting *Pain, including how the resident expresses pain *Fall interventions *Emergency evacuation assistance Resident #2 *Emergency Evacuation assistance *Outside provider services, including HH PT and OT *How the resident exhibits anxiety and agitation *Non-pharmaceutical interventions for behaviors *Preferences for sleeping and bathing *Ability to communicate and understand others 2. All staff conducting intial evaluations and service plan updates will be retrained on ensuring evaluations and service plans are reflective of residents care needs and preferences, provide clear directions to staff regarding services, and are readily available. 3. This system will be evaluated monthly at the quality improvement meeting. 4. Administrator and RN.

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 residents’ current service plans were readily available to staff, reflective of residents’ current care needs, and provided clear direction to staff regarding the delivery of services, for 3 of 3 sampled residents (#s 5, 6, and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2025 with diagnoses including dementia and stage III kidney disease. Resident 5’s most recent service plan, dated 01/21/26, and temporary service plans were reviewed. Observations were made, and interviews with staff were conducted. The service plan was not reflective of the resident’s status and did not provide information or instructions to staff in the following areas: * Use of a side rail; * Emergency evacuation ability; * Hospice services; and * Home health counseling. Observations during the survey showed a side rail in use and review of records confirmed hospice services and home health counseling. The need to ensure residents’ current service plans were reflective of the resident’s status and care needs and provided clear instructions to staff regarding the delivery of services was reviewed on 02/19/26 at 11:45 am with Staff 23 (Administrator). She acknowledged the findings. 2. Resident 6 moved into the community in 09/2025 with diagnoses including Alzheimer’s dementia. The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The following was identified: a. During the acuity interview on 02/17/26, facility staff reported service plans were stored in the service plan binder located in the MT office in each unit for direct care staff to review. Upon observation of the binder in the Mountainside unit at 3:25 pm on 02/17/26, the service plan for Resident 6 was dated 10/21/25. A service plan, dated 02/02/26, was provided by the facility at 1:47 pm on 02/18/26, but this was not available to staff at the time of survey entrance. b. The 02/02/26 service plan was not reflective of the resident’s current care needs and lacked clear instructions in the following areas: * Outside provider services, including hospice RN and shower aide; * How the resident exhibits\ed anxiety and agitation, including possible triggers; * Pain, including location and how the pain was exhibited; * Non-pharmaceutical interventions for behaviors; * Dressing, personal hygiene and grooming assistance, including what interventions were effective when resistant to care; * Incontinence care, including who provided the services; * Bathing, including one- to two-person assist due to behaviors; * Cognition, including confusion and difficulty finding words; and * Preferences for sleeping. The resident’s service plan indicated the resident was independent with bathing, grooming, personal hygiene, dressing, and toileting, was continent of bowel and bladder, had no impairment with communication, and experienced occasional disorientation that did not interfere with functioning. The resident was taking a PRN psychotropic medication for agitation/anxiety but the non-pharmaceutical interventions were not on the service plan for staff to try prior to administering the medication. Observations during the survey showed the resident preferred to sleep in past 9:30 am and required assistance from staff for ADL care including dressing, grooming, personal hygiene, and toileting assistance. In an interview with the resident, s/he was not able to complete sentences or answer questions about the care received. During interviews with care staff and the hospice RN between 02/17/26 through 02/19/26, they noted the resident was incontinent of bowel and bladder, confused and needed assistance locating the bathroom, resistant to care, and typically required one additional staff to assist the shower aide. The resident had pain in his/her hip and knee but was not always able to state where or reliably rate the pain. The need to ensure residents’ current service plans were readily available to staff, were reflective of the residents’ status and care needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 22 (ED) and Staff 23 (Administrator) on 02/19/26 at 4:15 pm. They acknowledged the findings. 3. Resident 7 was admitted to the facility in 08/2025 with diagnoses including dementia. Observations were made of the resident on 02/18/26 and 02/19/26, interviews with the resident and facility staff were conducted, and the service plan, dated 12/18/25, and the MARs from 01/08/26 through 02/17/26 were reviewed. Resident 7's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions for bleeding precautions and interventions while on anticoagulation therapy (Eliquis 5mg); * Instructions for behaviors related to verbal and physical aggression towards residents and staff; and * Instructions to staff regarding resident’s smoking. The service plan had no record of resident’s smoking habits. According to the MARs, the resident was taking varenicline 1mg twice daily for smoking cessation. On 02/19/26 at 3:39 pm, Resident 7 was observed smoking a cigarette in the interior courtyard. During an interview on 02/19/26 at 3:41 pm, Staff 4 (MT) confirmed the resident was a smoker who needed to be accompanied by staff when smoking and kept his/her cigarettes on the medication cart. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 22 (ED) and Staff 23 (Administrator) on 02/19/26 at 4:52 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are for the following service plans to be made readily available to care staff, reflective of residents' current care needs and provide clear direction to staff regarding the delivery of services. Resident #5 service plan will be updated as follows: - Use of a side rail - Emergency evacuation ability - Hospice services - Home health counseling Resident #6 service plan will be updated as follows: - Outside provider services (hospice RN and bath aide) - How resident exhibits anxiety and agitation including potential triggers - Pain, including location and how the pain is exhibited - Non-pharm interventions for behaviors - Dressing, personal hygiene and grooming assistance, including what interventions were effective when resistant to care - Incontinence care, including who provides service - Bathing, including one to two preson assist due to behaviors - Cognition, including confusion and difficulty finding words - Preferences for sleeping Resident #7 service plan will be updated as follows: - Instructions for bleeding precautions and interventions while on anticoagulation therapy - Instructions for behaviors related to verbal and physical aggression towards residents and staff. 2. The system will be corrected so this violation will not happen again by ensuring all resident service plans are updated, made available to the care team, reflect the residents' current needs, and provide clear instructions to staff regarding the delivery of services. 3. The area needing correction will be evaluated at move-in, quarterly, and with change of condition. 4. The Administrator, Health Services Director, and Executive Director will be responsible to see that the corrections are completed/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: Based on observation, interview, and record review, it was determined the facility failed to ensure residents’ current service plans were reflective of residents’ current care needs and provided clear direction to staff regarding the delivery of services, for 1 of 2 sampled residents (#9) whose service plan was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 9 moved into the community in 08/2025 with diagnoses including dementia. Resident 9’s 04/15/26 service plan and interim service plans were reviewed. Observations were made, and interviews with staff were conducted. The service plan was not reflective of the resident’s status and did not provide information or instructions to staff in the following areas: * Use of a side rail; * Shower status including provided by hospice team versus facility staff; * Ambulation status; * Use of an air mattress; * Use of wheelchair for ambulation; * Level of staff assistance for ambulation with a front-wheeled walker; * Use of floor mattress; and * Instructions for the use of heel protection boots. Observations on 04/16/26 showed a side rail was in use. An air mattress and floor mattress were in place and staff interview confirmed the resident had been using these devices. The need to ensure the resident’s current service plan was reflective of the resident’s status and care needs and provided clear instructions to staff regarding the delivery of services was reviewed on 04/16/26 at 1:55 pm with Staff 23 (Administrator) and Staff 31 (Charge Nurse). They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are for the following service plans to be made readily available to care staff, reflective of residents' current care needs and provide clear direction to staff regarding the delivery of services. Resident #9 service plan will be updated as follows: - Use of a side rail - Shower status including provided by hospice team versus facility staff - Ambulation status - Use of an air mattress - Use of wheel chair for ambulation - Level of staff assistance for ambulation with a front wheeled walker - Use of floor mattress - Instructions for the use of heel protection boots 2. The system will be corrected so this violation will not happen again by ensuring all resident service plans are updated, made available to the care team, reflect the residents' current needs, and provide clear instructions to staff regarding the delivery of services. 3. The area needing correction will be evaluated at move-in, quarterly, and with change of condition. 4. The Administrator, Health Services Director, and Executive Director will be responsible to see that the corrections are completed/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 ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, interventions were communicated to staff, the condition was monitored at least weekly to resolution and interventions were re-evaluated to determine effectiveness and/or failed to evaluate residents who experienced a significant change in condition, refer to the facility nurse, document the change, and update the service plan for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced changes of condition. Resident 2 experienced severe ongoing weight loss and ongoing falls with injuries including a wrist fracture and Resident 4 experienced severe ongoing weight loss. Findings include, but are not limited to: 1. Resident 4 moved into the community in 10/2024 with diagnoses including dementia. Resident 4’s weight record noted the following: * 05/05/25 – 117.2 pounds; * 06/04/25 – 106.9 pounds; * 07/14/25 – 96.4 pounds; * 08/02/25 – 101.2 pounds; * 09/07/25 – 97.9 pounds; * 10/05/25 – 90 pounds; and * 10/07/25 – 96 pounds. Between 05/05/25 and 06/04/25, the resident was noted to have lost 10.3 pounds, or 8.78% of his/her total body mass in one month. This constituted a severe weight loss and required an RN assessment. There was no documented evidence the facility evaluated Resident 4, referred to the facility nurse, documented the change, and updated the resident’s service plan when the severe weight loss was discovered. The resident continued to lose weight. * 08/08/25 - The facility communicated with the resident’s PCP, noting the resident’s weight loss and resulting in an order to increase administration of protein shakes from twice daily to three times daily at 8:00 am, 1:00 pm and 6:00 pm; and * 08/14/25 - Progress note “…Resident has had a significant [weight] loss of 17 pounds in the last six months, PCP has been notified and orders received, encourage protein shakes and monitor caloric intake as well as weigh weekly. In an interview with Staff 1 (Administrator) on 10/08/25 at 11:02 am, she confirmed the facility did not evaluate Resident 4 for the severe weight loss, refer the resident to the facility nurse, document the change and update the resident’s service plan when the severe weight loss was initially discovered. She confirmed the facility had not monitored the interventions for Resident 4’s severe ongoing weight loss for effectiveness or determined if new interventions were needed and the resident continued to lose weight through 10/05/25. The facility's failure to evaluate Resident 4 for severe weight loss when first detected, put the resident’s health and safety at risk for further weight loss. b. Review of Resident 4’s progress notes dated 07/06/25 through 10/06/25, it was noted the following short- term changes of condition: * 08/07/25 - Injury of unknown cause, bruise to the right shoulder; * 08/14/25 - The resident experienced a fall with a skin tear and bruising to the right knee; and * 09/19/25 - Injury of unknown cause, scab on right upper thigh. There was no documented evidence these reportable events were monitored with progress noted at least weekly to resolution. The need to evaluate residents who experienced significant changes in condition, refer to the facility nurse, document as required, monitor interventions for effectiveness and monitor short-term changes of condition with progress noted at least weekly to resolution was reviewed with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. The resident's 09/19/25 service plan, 07/07/25 through 10/06/25 progress notes, weight records, and interim service plans (ISP) were reviewed. a. The service plan indicated Resident 2 required a gluten free diet and needed “reminding/cueing to maintain adequate intake." Resident 2 was on thin liquids and a regular texture diet. Resident 2’s weight records were reviewed during the survey and revealed the following: * 08/07/25: 119.8 pounds; * 09/05/25: 111.8 pounds; and * 10/09/25: 107 pounds (requested during the survey). Between 08/07/25 and 09/05/25 the resident experienced a severe weight loss of 8 pounds, or 6.7% of his/her total body weight, in one month. This change in weight constituted a severe loss and indicated a significant change of condition. There was no documented evidence the facility evaluated the resident, referred the significant weight loss to the facility nurse for assessment, documented the weight loss and updated the service plan. A current weight for Resident 2 was requested on 10/07/25 at 12:26 pm. On 10/09/25 at 10:36 am the resident weighed 107 pounds. From 09/05/25 through 10/09/25, the resident continued to lose weight, an additional 4.8 pounds, or an additional 4.3% of his/her total body weight. During the survey the following was observed: * On 10/07/25 for breakfast, Resident 2 consumed 50% of his/her scrambled eggs, two pieces of bacon, and a fruit cup. S/he initially attempted to eat with his/her fingers until intermittent assistance was provided from a care staff. * On 10/09/25 for breakfast, Resident 2 consumed 100% of pears and 50% of scrambled eggs and cottage cheese. A care staff provided meal assistance until Resident 2 was finished. During an interview on 10/07/25 at 3:05 pm, Staff 1 (Administrator) and Staff 2 (RCC) acknowledged Resident 2 had not been evaluated and referred to the facility nurse for the severe weight loss identified on 09/05/25. Resident 2 experienced a severe weight loss on 09/05/25. The facility’s failure to ensure the resident’s severe weight loss was evaluated and referred to the facility nurse put the resident’s health and safety at risk. Resident 2 continued to experience additional weight loss after 09/05/25. An immediate plan of correction was requested by the survey team on 10/09/25. The facility provided a plan of correction on 10/10/25 at 8:26 am, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. b. Fall prevention interventions listed on the 09/19/25 service plan included a wheelchair was used for mobility and Resident 2 required two person assistance for ambulation and transfers with use of a gait belt. On 08/10/25 Resident 2 experienced a fall and sustained a femur (hip) fracture that required surgical repair. S/he returned to the facility on 08/18/25. An evaluation was initiated on 08/19/25 with an ISP completed on 08/26/25 which instructed staff ensure Resident 2 “is in common area to reduce fall risk. When resident is in bed provide hourly checks. Ensure floor is free of clutter [sic] she is wearing appropriate footwear and is toileting frequently.” Following the 08/10/25 fall, Resident 2 experienced the following four unwitnessed falls between 08/29/25 through 09/28/25: * 08/29/25: Fall with skin tear to right arm; * 09/24/25: Fall with “goose egg” to back of head and additional bruising was identified on 09/25/25; * 09/27/25: Non-injury fall, found on floor in bedroom; and * 09/28/25: Fall with wrist fracture, found with one shoe off. On 08/31/25 the facility ISP instructed staff to "place on alert charting for 72 hours. Monitor for: Bruising, changes in mobility, decreased range of motion, increased need for assistance with ADL’s, or changes in condition. Provide increased amount of assistance as needed. Cue and remind resident to call for assistance with ADL’s, reaching for objects, answering the phone, etc. as needed and when feeling dizzy or weak. Remind the resident to use walker or wheelchair for mobility, to decrease further risk of falls." Additionally, an ISP dated 08/29/25 instructed staff to check on resident three times per shift to offer assistance and also monitor for dizziness/weakness. An ISP, dated 09/24/25, for the 09/24/25 fall, had the same pre-determined instructions as the 08/31/25 ISP. No ISP had been completed for the non-injury fall on 09/27/25. Although the facility completed ISPs for two additional falls on 08/29/25 and 09/24/25, there was no documented evidence the current interventions were reviewed for effectiveness or new interventions were developed, to help prevent possible future falls. On 09/28/25 Resident 2 had an additional fall and sustained a wrist fracture with an emergency room visit, resulting in a significant change of condition. During an interview on 10/09/25 at 9:59 am, Staff 21 (CG) indicated he needed to “keep a close eye” on Resident 2. When the resident was awake, staff would ensure s/he was in the common area and when in bed, staff would complete hourly checks. He stated Resident 2 liked to stand up from the wheelchair often. Observations of Resident 2 during the survey on 10/06/25 through 10/09/25 identified Resident 2 required staff to provide wheelchair escort, was not ambulatory, and needed two person assist with transfers. Staff provided hourly checks when s/he was in his/her room. During an interview on 10/07/25 at 12:40 pm, Staff 1 (Administrator) confirmed there was no additional documentation current fall prevention interventions were reviewed for effectiveness following subsequent falls and if not determined effective, new interventions were put in place. There was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident subsequent to each fall. The resident continued to have falls with injury and an emergency room visit that included a significant change of condition. c. The facility lacked documented evidence the following short-term changes of condition were monitored at least weekly until resolution: * 08/18/25: Return from the hospital; * 08/18/25: Surgical incision following hip surgery; * 08/29/25: Fall; * 08/29/25: Skin tear to right arm; * 09/24/25: Fall; * 09/24/25: Bruising to back of head; and * 09/25/25: Bruising to left bottom, right calf and left wrist. d. On 09/29/25 the resident was prescribed oxycodone 5 mg 0.5 to 1 tablet PRN for severe pain following an emergency room visit for a wrist fracture. There was no documented evidence the resident had been monitored through resolution as to whether the pain control measures were effective and any adverse effects from the opioid pain medication. The need to evaluate changes of condition, refer changes to the facility nurse when needed, determine actions or interventions and communicate them to staff, and monitor through resolution, with at least weekly documentation, was discussed with Staff 1, Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings. 3. Resident 1 moved into the community in 05/2023 with diagnoses including dementia. The resident’s clinical record was reviewed and revealed the following: The following short-term changes of condition lacked documentation the facility determined what resident specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/ or documented weekly progress until the condition resolved: The facility created ISPs for three of four changes in dosage or administration frequency to PRN Lorazepam, however, the ISPs were not resident specific, nor was there evidence staff monitored the resident until resolution; 09/01/25: staff created an ISP identifying a “cut on left index finger,” but did not determine interventions or monitor for weekly progress until resolved; 09/12/25: staff created an ISP for a new order for Bupropion HCl (anti-depression medication) after it was discontinued for one week and reordered with dosage change, however, the ISP was not resident specific as to what side effects to monitor, nor did staff monitor the resident until resolution; 09/22/25: progress notes documented “red and irritated… cluster of pimple-like spots on resident’s right upper buttock,” but this was not communicated to staff, interventions were not determined, and the condition was not monitored through resolution; 09/26/25: staff created an ISP documenting a “ping pong sized yellow bruise on right shoulder blade,” however, interventions were not determined, nor was the condition monitored through resolution; and 10/03/25: staff created an ISP for a witnessed fall resulting in the resident hitting the “back of head,” however, the ISP did not specify what staff should monitor, and the condition was not monitored through resolution. The need to ensure the facility documented short term changes of condition and determined resident specific interventions, communicated these interventions to staff, and monitored the resident for progress at least weekly until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Operations Director) on 10/10/25 at 11:00 am. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 09/2025 with diagnoses including dementia and depression. A review of the resident’s clinical record and chart notes indicated the following: Between 09/20/25 and 09/23/25 the resident started four new medications and had a dosage change to one of these new medications. The facility created ISPs informing staff of potential side effects, directing them to report changes from resident’s baseline to MT/LN. There was documentation from staff noting resident’s progress however no indication these short term changes of condition were resolved and monitoring discontinued. The need to ensure changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings and no further documentation was provided.

1. We will ensure residents who have short-term changes of condition are evaluated, resident-specific instructions are developed, interventions are communicated to staff, the condition is monitored weekly to resolution, and interventions are reevaluated to determine effectiveness and to evaluate residents who experience a significant change in condition are refered to the RN, changes are documented, and service plans are updated for residents 1, 2, 3, and 4. A change of condition and plan of correction was completed by RN on 10/9/25 for resident #2. 2. Through weekly clinical meetings, ISP's, and updated service plans. 3. This will be monitored weekly at the clinical meetings. 4. The Administrator and RN.

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 assessment included documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled residents (#s 2 and 4) who experienced a significant change of condition. Residents 2 and 4 experienced ongoing, significant weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. The resident's service plan, dated 09/19/25, progress notes, dated 07/07/25 through 10/06/25, weight records, and interim service plans were reviewed. a. Weight records showed Resident 2 experienced a severe and ongoing weight loss between 08/07/25 and 10/09/25: * 08/07/25: 119.8 pounds; * 09/05/25: 111.8 pounds; and * 10/09/25: 107 pounds. Between 08/07/25 and 09/05/25 the resident experienced a severe weight loss of 8 pounds, or 6.7% of his/her total body weight, in one month. This change in weight constituted a severe loss and indicated a significant change of condition, which required an RN assessment. There was no documented evidence an RN assessment had been completed that included findings, resident status, and interventions made as a result of the assessment, after Resident 2’s severe weight loss was identified on 09/05/25. A current weight for Resident 2 was requested on 10/07/25 at 12:26 pm. On 10/09/25 at 10:36 am the resident weighed 107 pounds. From 09/05/25 through 10/09/25, the resident continued to lose weight, losing an additional 4.8 pounds, or an additional 4.3 % of his/her total body mass. Refer to C 270, example 2a. b. Resident 2 experienced the following: * On 08/10/25 the resident experienced a fall with a right hip fracture and was hospitalized for surgery from 08/10/25 through 08/18/25. * On 09/28/25 the resident experienced a fall with a left wrist fracture and resulted in an emergency room visit. The hip and wrist fractures constituted a significant change of condition, for which an RN assessment was required. On 10/07/25 an RN assessment for the hip and wrist fractures were requested. During an interview on 10/07/25 at 2:28 pm, Staff 17 (Health Services Director) acknowledged she had not completed an RN assessment for Resident 2’s left wrist fracture. She was recently hired in 09/2025 and was not employed when Resident 2 returned to the facility following surgery for the hip fracture. During an interview on 10/10/25 at 12:15 pm, Staff 1 (Administrator) indicated there was no documented evidence an RN assessment had been completed for the hip or wrist fracture which documented findings, resident status, and interventions made as a result of the assessment. No further documented evidence was provided. The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment was discussed with. Staff 1, Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings. 2. Resident 4 moved into the community in 10/2024 with diagnoses including dementia. Review of the resident’s 09/12/25 service plan and interviews with direct care staff noted the resident ate a regular diet with thin liquids. Staff were instructed to provide finger foods when available. The resident required cueing and occasional feeding assistance. Resident 4 had a physician’s order for a wellness protein shake, one bottle, three times a day at 8:00 am, 1:00 pm and 6:00 pm. Resident 4 was observed to consume the following foods during the survey: * On 10/07/25 for breakfast, the resident consumed two medium sized pancakes with maple syrup and two sausage links; * On 10/07/25 for lunch, the resident received assistance with feeding and consumed 100% of a Mexican casserole and steamed cauliflower and a small pastry for dessert; and * On 10/08/25 for breakfast, the resident consumed a bowl of scrambled eggs with bacon and 10 oz of wellness protein shake. Resident 4’s weight record noted the following: * 04/08/25 – 121.4 pounds; * 05/05/25 – 117.2 pounds; * 06/04/25 – 106.9 pounds; * 07/14/25 – 96.4 pounds; * 08/02/25 – 101.2 pounds; * 09/07/25 – 97.9 pounds; * 10/05/25 – 90 pounds; and * 10/07/25 – 96 pounds. Between 05/05/25 and 06/04/25, the resident was noted to have lost 10.3 pounds, or 8.78% of his/her total body mass in one month. This constituted a severe weight loss and required an RN assessment. There was no documented evidence an RN completed an assessment after Resident 4’ s severe weight loss was identified on 06/04/25. From 06/04/25 through 10/05/25, the resident continued to lose weight, losing an additional 16.9 pounds, or an additional 15.8 % of his/her total body mass. A current weight for Resident 4 was requested on 10/08/25. At 1:32 pm the resident was observed to weigh 96 pounds. In an interview with Staff 1 (Administrator), on 10/08/25 at 11:02 am, she confirmed the lack of an RN assessment, which included findings, resident status, and interventions made as a result of the assessment, for Resident 4's severe and ongoing weight loss. The facility's failure to ensure an RN assessment, which included findings, resident status and interventions made as a result of the assessment, was completed for Resident 4's severe and ongoing weight loss put the resident's health and safety at risk. The need for the facility RN to assess significant changes of condition and document findings, resident status, and interventions made as a result of the assessment was discussed with Staff 17 (Health Services Director/RN) on 10/08/25 at 11:46 am and with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings. ?

1. We will ensure that an RN assessment with documented findings, resident status, and interventions is completed when a significant change of condition is noted. The below information will be added to these specific service plans; Resident #2 and #4 * Significant change of condition assessment completed. * ISP * 1:1 cuing for meal consumption (staff to sit with them and encourage them to eat) * Request an order for gluten free protein drink for resident #2. Offered at each meal after she has eaten her food. * During medication pass offer high calorie snack: ie yogurt, ice cream, cookies * Start meal log, monitor, and record food intake for two weeks. * Offer her food preference. * Update her nutrition and hydration plan. * Request assessment by Physician. 2. The system will be corrected by conducting weekly clinical meetings that will identify changes in condtion. 3. RN will assess weekly * Review medications for any meds that would suppress appetite or cause gastric discomfort. * Check weight weekly. * Evaluate for special diet, request order for mechanical soft with extra gravy and butter for resident #2 and finger foods for resident #4. * Review all residents weights, respond to significant change up to 5% for one month, 7.5% within three months, up to 10% change six months. * All identified weekly review will be monitored and any changes an ISP will be created and placed. 4. The administrator and RN.

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 411-054-0045(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 coordinate on-site health services with outside services providers, to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 1 of 2 sampled residents (# 2) who received outside services. Findings include, but are not limited to: Resident 2 moved into the community in 09/2023 with diagnoses including dementia. Progress notes, dated 07/07/25 to 10/06/25, outside agency services notes, dated 09/03/25 to 10/03/25, and the service plan, dated 09/19/25, were reviewed, and interviews with staff were conducted. There was no documented evidence staff were informed of the new instructions, and the service plan was updated, as necessary, for the following recommendations: * 09/03/25 – HH PT note stated, “Encourage patient to move knees out and in when sitting in wheelchair can do 10-15 X up to every hour. Can walk with patient short distances but at this time would need 2 people supporting, 1 with wheelchair following and 1 standing with patient using walker and gait belt”; * 09/06/25 – HH PT note stated “Focus to remain on encouraging separation between knees [right] knee [sic] out throughout the day. Encourage walking with staff assist. Frequency better than distance…”; * 09/09/25 – HH PT note stated “Walk with patient 1-2X/day with walker. Encourage knees apart when sitting”; * 09/11/25 – HH PT note “…Walk with walker frequency over distance 1 person assist”; * 09/16/25 – HH nursing note instructed “Please keep dressing in place until PT visit. If dressing comes off, ok to leave OTA (open to air)”; * 09/17/25 – HH PT note provided instructions for walking, “Requires 1 person assist, gait belt and shoes. Remind patient to keep knees apart when sitting.”; and * 10/03/25 – HH OT note instructed “Please elevate L UE (left arm) periodically throughout day to [decrease] swelling, encourage [him/her] to wiggle fingers.” Also “Suggested stool softener…seems possibly constipated/impacted (seems firm (hard) when assisting [him/her] with peri-hygiene.) Encourage fluids.” During an interview with Staff 2 (RCC) on 10/08/25 at 2:24 pm, she confirmed there was no documented evidence the HH instructions were communicated to staff. She indicated the MT would verbally communicate the information to staff and update the progress notes. The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after on-site health services were provided was discussed with Staff 1(Administrator), Staff 2, and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

1. We will coordinate onsite health services with outside providers through outside provider forms, to ensure staff are notified of new interventions through ISP's, and service plans are updated with new information when needed. 2. We will provide outside providers an outside provider form to be completed after each visit outling any new instructions. This form will be turned into the MT to process, who will chart the new instructions in progress notes,complete an ISP, and place ISP in RA ISP binder. All paperwork is processed through a three person check. First check is the MT, second check is the RCC, third check is the RN, all to ensure instructions are relayed to staff and service plans are updated. ISP's will be created for resident #2 for the most recent HH visit with their instructions to communicate with direct care staff. 3. This will be evaluated weekly at the clinical meetings. 4. The Administrator and RN.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 2 of 3 sampled resident (#s 2 and 4) whose ADL care was observed, and for multiple sampled and unsampled residents during meal service. Findings include, but are not limited to: During general resident observations on 10/07/25 at 9:41 am, Staff 6 (CG) was observed entering the unit carrying a plate of bite-sized pancake pieces and a cup of juice, setting them next to a resident whose wheelchair was positioned at the table. Without performing hand hygiene or donning gloves, she sat beside the resident and proceeded to hand the pieces of pancake to the resident. The need to ensure infection prevention and control protocols were maintained to provide a safe, sanitary and comfortable environment was reviewed on 10/10/25 at 11:00 am with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations). They acknowledged the findings. 2. Resident 4 moved into the community in 10/2024 with diagnoses including dementia. The resident was identified as requiring occasional assistance with feeding during meal service. Observations of meal service were completed between 10/06/25 and 10/09/25. Direct care staff were observed to serve meals and beverages to the residents, provide physical feeding assistance to Resident 4, collect soiled dishes and clean tables during meal service. On 10/07/25 at 11:28 am, Staff 6 (CG) and Staff 12 (CG) were observed eating their individual lunches during the facility’s lunch meal service. Staff 12 was observed standing at the kitchenette counter, eating from her plate of food. Staff 12 reached into a container and handed a resident a pastry using her bare hand. Staff 12 then began clearing resident’s dishes and pouring drinks for several residents. Staff 12 was not observed to perform hand hygiene after eating and before serving the pastry or pouring drinks for the residents. At 12:28 pm, Staff 12 was observed to use a paper towel to wipe her mouth and then used the same paper towel to wipe the kitchenette counter before throwing it in the garbage can. At 12:26 pm, Staff 6 was observed seated at the kitchenette counter, next to Resident 4, rotating between feeding the resident with a fork out of the resident plate of food and feeding herself with a fork out of her own bowl of food using the same hand. Staff 6 was not observed to perform hand hygiene after eating and before feeding the resident. The need to ensure infection prevention and control protocols were maintained was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. A review of his/her current service plan and interviews with staff revealed s/he was dependent on two staff for toileting tasks. On 10/08/25 at 9:53 am, the surveyor observed two staff provide incontinence care for Resident 2 in bed. Prior to removing the soiled brief, a clean brief was pulled up onto the resident’s thighs. Resident 2 was assisted onto his/her side, the soiled brief was removed, not bagged and placed on the resident’s sheets and draw sheet, near the head of the bed. One staff used wipes to clean the perineal area and tossed the wipes onto the soiled brief. Prior to assisting the resident roll onto his/her back, the soiled brief and wipes were not bagged and tossed onto the floor. Additionally, staff did not change gloves between “clean” and “dirty” tasks and with the same soiled gloves were observed touching the resident’s legs, clean brief, draw sheet, bedding, and the pillow placed under the resident’s legs. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

1. We will ensure all staff are following the established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment. 2. By providing retraining on hand hygeine, donning and doffing of PPE, appropriate cleaning chemicals and supplies, and ensuring staff are consuming their meals in the staff break room during their mandatory lunch breaks. 3. Annually for structured certified learning and daily for on the spot corrections. 4. The Administrator and RN.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

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 tracking controlled substances administered by the facility, for 1 of 1 sampled resident (# 2) whose MARs and Controlled Substance Drug Disposition logs were compared for accuracy. Findings include, but are not limited to: Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. Resident 2’s 09/29/25 through 10/07/25 MARs and Controlled Substance Disposition Log, dated 09/29/25/25 to 10/06/25, were reviewed and showed the following: * Physician orders for oxycodone 5 mg to give 0.5 to 1 tab as needed every four hours for severe pain; * A dose was signed out in the disposition log on 09/29/25 at 1:40 pm. The MAR reflected it was administered at 2:54 pm; * A dose was signed out in the disposition log on 10/01/25 at 8:00 am. The MAR reflected it was administered at 8:44 am; * A dose was signed out in the disposition log on 10/04/25 at 6:00 pm, and the dose was not reflected on the MAR; * A dose was signed out in the disposition log on 10/05/25 at 8:30 am, and the dose was not reflected on the MAR; * A dose was signed out in the disposition log on 10/05/25 at 5:00 pm. The MAR reflected it was administered at 4:14 pm; and * A dose was signed out in the disposition log on 10/06/25 at 3:00 pm. The MAR reflected it was administered at 3:55 pm. The inconsistencies were reviewed on 10/07/25 at 2:28 pm with Staff 17 (Health Services Director). She indicated she was recently hired and was not aware of a process to review the Controlled Substance Drug Disposition logs for accuracy. Comparison of the medication tablet bottle to the disposition log showed the amount of medication left was reflected accurately on the log. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (Administrator) on 10/07/25 and on 10/10/25 at 11:45 am with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations). They acknowledged the findings.

1. We will ensure that we have an effective system for tracking controlled substances. 2. We will conduct weekly narcotics audits to ensure that the time of administration is correct and matches the time checked out in the MAR. 3. Weekly audits. 4. The Administrator and RN.

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 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility for 3 of 4 sampled residents (#s 1, 2 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the community in 10/2024 with diagnoses including dementia. Resident 4’s 09/01/25 through 10/06/25 MARs were reviewed and the following orders were noted: * Acetaminophen 650 mg suppository, one every six hours PRN (for moderate pain); * Acetaminophen 650 mg suppository, one every six hours PRN (for mild pain or fevers); and * Acetaminophen 325 mg tablet, two tablets every six hours PRN (for mild to moderate musculoskeletal pain, headache or fever above 100 degrees F). The MAR did not indicate resident specific parameters and instructions for the PRN Acetaminophen suppository and tablets including the sequential order for administration of the medications which were prescribed for the same diagnoses. On 10/10/25 at 10:26 am, the need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. Resident 2's MARs, dated 09/01/25 through 10/09/25 were reviewed. a. Resident 2 had two PRN medications for pain with conflicting parameters regarding sequential order of administration: * Acetaminophen 325 mg give 2 tablets every four hours PRN mild pain; and * Oxycodone 5 mg give 0.5 tablet PRN every four hours. “Additional Physician Directions: Take 0.5 tablet (one half) to 1 (one whole tablet) every 4 hours PRN for severe pain. Additional notes: give another 0.5mg if pain is severe.” According to the 09/29/25 through 10/09/25 MAR, when both acetaminophen and oxycodone were prescribed, the resident was administered acetaminophen seven times and oxycodone 10 times. b. Resident 2 had four PRN medications for constipation with conflicting parameters regarding sequential order of administration: * Lactulose give 30 ml once daily PRN constipation or if resident eats gluten with no BM (bowel movement) in 24 hours; * Milk of magnesia give 30 ML once a day if no BM in 3 days or if pt (patient) reports constipation; * Polyethylene glycol give once a day as needed *start 72 hours after no BM; and * Senna-Time 8.6 mg give 2 tablets once a day as needed for constipation. Resident 2 had been administered lactulose one time in September and one time in October. Milk of magnesia was administered two times in October. Polyethylene glycol and senna-time had not been administered. During an interview on 10/08/25 at 1:30 pm, Staff 4 (MT) acknowledged the lack of instructions for which medication to take first for pain and/or constipation. “I use my best judgement” regarding which PRN medication she provided for constipation. “If [s/he] is super impacted I will use the milk of magnesia over polyethylene glycol.” The need to ensure medications on the MARs included reason for use, and resident-specific parameters for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings. 3. Resident 1 moved into the community in 05/2023 with diagnoses including dementia. The resident’s MAR dated 08/01/25 - 10/06/25, corresponding physician orders, and progress notes dated 07/11/25 through 10/05/25 were reviewed. The following was identified: Resident 1 had orders for Lorazepam 0.5 mg sublingual tablet: give two tablets as needed for mild agitation/ anxiety/ dyspnea. Progress notes documented administration of the Lorazepam on five occasions in August and once in September, but these administrations were not on the MAR. The need to ensure residents’ MARs were accurate was reviewed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. We will ensure there is an accurate MAR for all medications that are ordered by a legally recognized provider. 2. Daily all paperwork is processed through a three person check. First check is the MT, second check is the RCC, third check is the RN, all to ensure instructions are relayed to staff and service plans are updated. Weekly we will review the accuracy of orders and ensure the correct sequential order of medications is clear in the instructions given. 3. This will be evaluated weekly at the clinical meetings. 4. The Administrator and RN.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility for 2 of 3 sampled residents (#s 5 and 6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 moved into the community in 09/2025 with diagnoses including Alzheimer’s dementia. Resident 6's MARs, dated 01/08/26 through 02/17/26, were reviewed. a. The resident had a new physician’s order on 01/29/26 for routine acetaminophen 500 mg two tablets at 8:00 pm and acetaminophen 500 mg two tablets PRN mild fever/pain. Parameters for both acetaminophen medications included the instruction, “No more than 3000 mg in 24 hours.” The parameters for both of the new medications were not transcribed on the MAR. The MAR also lacked parameters for the PRN acetaminophen tablet to be used for “mild fever/pain.” b. Resident 6 had three PRN medications for pain with no sequential order of administration: * Acetaminophen 500 mg tablets, give two tablets three times a day PRN pain or fever, was discontinued on 01/29/26, and the order was changed from three times to twice a day PRN pain; * Acetaminophen 650 mg suppository, give one suppository every six hours PRN pain/fever; and * Oxycodone 5 mg give one tablet every two hours PRN pain. According to the 01/08/26 through 02/17/26 MAR, the resident was administered acetaminophen tablets two times and oxycodone eight times. c. Resident 6 had two PRN medications for constipation with no sequential order of administration: * Bisacodyl 10 mg suppository once a day PRN constipation; and * Senna-Time 8.6 mg give two tablets once a day as needed for constipation. Resident 6 had not been administered either PRN medication for constipation from 01/08/26 through 02/17/26. During an interview on 02/18/26 at 2:50 pm, Staff 4 (MT) acknowledged the lack of instructions for which medication to take first for pain and constipation. She stated, “It depends on the situation. If [Resident 6] can tell me [his/her] head or leg hurts, I’ll try Tylenol (Acetaminophen) first. But if [s/he] was screaming in pain then I’ll go straight to oxycodone.” Staff 4 indicated that for constipation, the suppository was for “end of life” and would only give if hospice “told me to.” She confirmed the instructions to call hospice prior to administering the bisacodyl suppository for constipation were not on the MAR. The need to ensure medications on the MARs included instructions and resident-specific parameters for PRN medications was discussed with Staff 22 (ED) and Staff 23 (Administrator) on 02/19/26 at 4:15 pm. They acknowledged the findings. 2. Resident 5’s 01/08/26 through 02/17/26 MARs were reviewed and the following orders were noted: * Acetaminophen 325 mg give one tablet by mouth every six hours as needed; * Morphine sulfate 15 mg give half- tablet (7.5 mg) by mouth every two hours as needed for pain or shortness of breath; and * Oxycodone HCL oral tablet 5mg give one tablet by mouth every four hours as needed. The MAR did not indicate resident-specific parameters and instructions for the PRN pain medications including the sequential order for administration of the three medications which were prescribed for the same diagnoses. During an interview on 02/18/26 at 11:00 am, Staff 4 (MT) acknowledged the lack of clear instructions for which medication to take first if Resident 5 had pain. On 02/19/26 at 11:00 am, the need to ensure MARs included resident-specific parameters and instructions for PRN medications was discussed with Staff 23 (Administrator). She acknowledged the findings.

1. The actions that will be taken to correct the rule violation include updating the MAR so that it indicates resident-specific parameters and instructions for PRN medications, including the sequential order for administration of PRN medications for the following: Resident #6 - Acetaminophen 500 mg tablets - Acetaminophen 650 mg suppository - Oxycodone 5 mg - Bisacodyl 10 mg suppository - Senna-Time 8.6 mg Resident #5 - Acetaminophen 325 mg - Morphine sulfate 15 mg - Oxycodone HCL oral tablet 5 mg 2. The system will be corrected so this violation will not happen again by ensuring all resident MAR indicate resident-specific parameters and instructions for PRN medications, which includes the sequential order for administration of medications. 3. The area needing correction will be evaluated weekly 4. The Administrator, Health Services Director, and Executive Director will be responsible to see that the corrections are completed/monitored.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility for 2 of 2 sampled residents (#s 9 and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 10 moved into the community in 09/2023 with diagnoses including dementia. Resident 10's MARs, dated 04/06/26 through 04/16/26, were reviewed. a. Resident 10 had two PRN medications for pain with no sequential order of administration: * Acetaminophen 325 mg tablets, give 2 tablets by mouth every six hours as needed for pain or fever; and * Morphine 15 mg tablet, give 1 tablet by mouth every four hours as needed for pain or shortness of breath. Resident 10 had not been administered any PRN medications for pain from 04/06/26 through 04/16/26. b. Resident 10 also had three PRN medications for agitation and/or anxiety with no sequential order of administration: * Haloperidol lactate oral concentrate, 2 mg/ML, 1 milliliter by mouth every four hours for agitation; * Lorazepam, 0.5 mg tablet, give 1 tablet by mouth every four hours as needed for anxiety, or restlessness or agitation; and * Hydroxyzine, 25 mg, 1 capsule by mouth as needed two times per day for anxiety. Resident 10 had not been administered any of the PRN medications for agitation/anxiety from 04/06/26 through 04/16/26. During an interview on 04/16/26 at 11:51 pm, Witness 3 (Agency MT) acknowledged the lack of instructions for which medication to take first for pain and agitation. When asked how she would know which medication to use first, she stated, “I would not, to be honest.” Regarding the pain medication, she stated “I always know hospice wants you to try Tylenol first.” This surveyor and Witness 3 reviewed the electronic MAR and confirmed it did not indicate the sequential order PRN medications should be administered. The need to ensure medications on the MARs included instructions and resident-specific parameters for PRN medications was discussed with Staff 23 (Administrator) on 04/16/26 at 2:45 pm. She acknowledged the findings. 2. Resident 9 moved into the community in 08/2025 with diagnoses including dementia and left femur fracture. Resident 9's MARs, dated 04/06/26 through 04/16/26, were reviewed. The MAR indicated that staff were to administer Tylenol every six hours as needed for mild pain and oxycodone every two hours as needed for severe pain. However, there were no clear parameters defining what constituted mild pain versus severe pain for the resident. Oxycodone was administered 13 times and Tylenol was administered five times between 04/06/26 and 04/16/26. During an interview on 04/16/26 at 11:57 am, Staff 5 (CG/MT) acknowledged the lack of clear parameters for which medication to administer first if Resident 9 had pain. The need to ensure medications on the MARs included instructions and resident-specific parameters for PRN medications was discussed with Staff 23 (Administrator) and Staff 31 (Charge Nurse) on 04/16/26 at 1:55 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include updating the MAR so that it indicates resident-specific parameters and instructions for PRN medications, including the sequential order for administration of PRN medications for the following: Resident #10 - Acetaminophen 325 mg tablets, give 2 tablets by mouth every six hours as needed for pain or fever. - Morphine 15 mg tablet, give 1 tablet by mouth every four hours as needed for pain or shortness of breath. - Haloperidol lactate oral concentrate, 2 mg/ML, 1 milliliter by mouth every four hours for agitiation. - Lorazepam, 0.5 mg tablet, give 1 table by mouth every four hours as needed for anxiety, restlessness, or agitation. - Hydroxyzine, 25 mg, 1 capsule by mouth as needed two time per day for anxiety. Resident #9 - Tylenol, every six hours as needed for mild pain - Oxycodone, every two hours as needed for severe pain. 2. The system will be corrected so this violation will not happen again by ensuring all resident MAR indicate resident-specific parameters and instructions for PRN medications, which includes the sequential order for administration of medications. 3. The area needing correction will be evaluated weekly 4. The Administrator, Health Services Director, and Executive Director will be responsible to see that the corrections are completed/monitored.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medications that were given to treat a resident's behavior had resident specific parameters including when to contact a health professional regarding side effects, non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 3 of 3 sampled residents (#s 1, 2, and 3) who were prescribed and administered a PRN psychotropic medication. Findings include, but are not limited to: 1. Resident 1 moved into the community in 05/2023 with diagnoses including dementia. The resident’s MAR dated 08/01/25 - 10/06/25, corresponding physician orders and progress notes were reviewed, and interviews with staff were conducted. The following was identified: The resident had orders for PRN two Lorazepam 0.5 mg sublingual tablets every two hours for mild agitation/ anxiety/ dyspnea. The MAR indicated the resident received the medication 25 times between 08/01/25 and 10/06/25. The resident’s record lacked documented evidence non-pharmaceutical interventions were attempted and/ or documented as ineffective for 23 of the 25 administrations. The record also lacked instruction to staff on when to contact a health professional regarding side effects. For four of the six Lorazepam administrations not recorded on the MAR, there was no documented evidence staff attempted non-pharmaceutical interventions and/ or documented them as ineffective prior to administering the medication. On 10/07/25 at 11:23 am, Staff 3 (MT) confirmed there was no information on the MAR as to non-pharmaceutical interventions staff should attempt prior to administering the Lorazepam, nor was there information regarding how or when to contact the prescriber if the resident experienced adverse side effects. The need to ensure PRN medications administered to treat a resident’s behavior had resident specific parameters and non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. Review of the resident's MAR dated 09/01/25 through 10/09/25, current physician orders, and progress notes identified the following: The resident had orders for Lorazepam 0.5 mg every eight hours as needed for anxiety or agitation. The MAR indicated the resident received the medication 11 times between 09/01/25 and 10/08/25. The MAR did not contain resident-specific parameters for staff describing how the resident expressed anxiety or agitation and there was no documented evidence that non-pharmacological interventions had been tried first with ineffective results. Additionally, the record lacked instruction to staff on when to contact a health professional regarding side effects. During an interview on 10/07/25 at 12:25 pm, Staff 4 (MT) acknowledged the MAR lacked non-pharmacological interventions to be attempted prior to administration of the PRN lorazepam. She also confirmed there were no instructions on when to call if the resident experienced side effects from the lorazepam. The need to ensure medications given to treat a resident's behavior had resident-specific parameters, non-pharmacological interventions were attempted and documented as ineffective prior to the administration for psychotropic medications, and when to contact the prescriber if the resident experienced adverse side effects was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2025 with diagnoses including dementia and depression. Review of the resident's MAR dated 09/01/25 through 10/13/25, current physician orders, and progress notes identified the following: Risperidone 0.5 mg every twelve hours as needed for agitation. The risperidone PRN dose was administered on 09/25/25, 9/28/25 and 10/06/25. The MAR did not contain resident-specific parameters for staff describing how the resident expressed agitation and there was no documented evidence non-pharmacological interventions had been tried first with ineffective results. The need to ensure medications given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented as ineffective prior to the administration for psychotropic medications was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings.

1. We will ensure that medications that are given to treat residents #2 and #3's behavior has resident specific parameters including when to contact a health professional regarding side effects, nonpharmacological interventions are attempted and documented with effectiveness prior to administering psychotropic medications. 2. We will provide training to ensure that PRN psychotropic medications have resident specific nonpharmacological interventions are listed, documenting the effectiveness of nonpharmacological intervention, and ensure the health professional instructions are clear and followed prior to administering PRN pschotrope. 3. Weekly clinical meetings and daily RN review. 4. The Administrator and RN.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. 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 ensure 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. Findings include, but are not limited to: a. During the acuity interview at 10:52 am on 10/06/25 the following was reported: * The facility was a one story MCC with two segregated units separated by locked doors and a lobby. The facility had a current census of 40 residents; and * Five residents required a two-person assist to transfer, four resided in the Mountainside unit and one in the Riverside unit; b. The facility reported on the Acuity-Based Staffing Tool (ABST) Facility Entrance Questionnaire the following: * All 40 residents were identified as having support for behavioral symptoms; and * All 40 residents were identified as having support for cognitive impairments. c. The staffing plan posted by the facility was as follows: * Mountainside unit: day shift: 2 CGs and 1 MT, swing shift: 2 CGs and 1 MT, * Riverside unit: day shift: 2 CG and 1 MT, swing shift: 2 CGs and MT 1; and * Mountainside and Riverside units: night shift, 1 CG and 1 MT shared between the two units. d. Review of the facility staffing schedule for night shifts from 09/28/25 through 10/06/25 revealed the following: * On 09/28/25, 09/29/25, 09/30/25, 10/01/25, and 10/05/25 the facility staffed only one direct care staff for the Mountain unit; and * On 10/02/25, 10/03/25, and 10/04/25, the facility staffed one direct care staff for both Riverside and Mountainside units. e. Interviews with direct care staff conducted on 10/06/25 confirmed the four residents in Mountainside unit and one resident in Riverside unit who required two-person assistance with transfers. The night shift staffing plan did not include a minimum of two direct care staff in each segregated unit whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. The need to ensure a minimum of two direct care staff was scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10: 25 am. They acknowledged the findings.

1. We will schedule two direct care staff on River side and Mountain side to ensure two person assists care needs, scheduled and unscheduled, are properly conducted when needed. 2. The RCC and RN will pull the abst report weekly to ensure the schedule reflects the correct number of staff. ABST will be updated upon changes of resident care needs. 3. Weekly ABST review during clinical meeting. 4. The Administrator and RN.

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 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to adopt a proprietary Acuity-Based Staffing Tool (ABST) that addressed and documented all required individual care elements. Findings include but are not limited to: Review of the ABST Facility Questionnaire and ABST documents provided by the facility on 10/09/25 at 9:26 am found the facility’s proprietary ABST did not address all required individual care elements, including the following: * Repositioning; * Providing treatments; * Cueing or redirecting due to cognitive impairment or dementia; * Ensuring non-drug interventions for behaviors; * Responding to call lights; * Monitoring physical conditions or symptoms; and * Safety checks and fall prevention. In an interview on 10/10/25 at 9:26 am, Staff 1(Administrator) confirmed the proprietary ABST did not address each required individual care elements and did not include the staff time needed to complete each individual care element. On 10/10/25 at 10:26 am, the need to ensure the proprietary ABST addressed and documented all required individual care elements was discussed with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10: 25 am. They acknowledged the findings.

1. We will ensure that our ABST tool individually address and document the care time required to complete the ABST care elements: a. peronal hygiene. b. grooming. c. dressind and undressing. d. toileting, bowel, and bladder management. e. bathing. f. transfers. g. repositioning. h. ambulation. i. supervising, cueing,or supporting while eating. j. medication administration. k. providing non-drug interventions for pain management. l. providing treatments. m. cueing or redirecting due to cognitve impairment or dementia. n. ensuring non-drug interventions for behaviors. o. assisting with leisure activities assist with social and recreational activities. p. monitoring physical conditions or symptoms. r. assistng with communiation, assistive devices for hearing, and speech. s. responding to call lights. t. safety checks, fall prevention. u. completing resident specific housekeeping or laundry services performed by care staff. v. providing additional care services. If additional servicesare not provided, this element can be omitted. 2. The Director of Health Services has reviewed the findings and will ensure that the ABST tool is updated to reflect all 22 ADL's, time performing ADL is captured correctly, and that the ABST report can be pulled per segregated unit. 3. The ABST was updated 10/29/25 to allow the ABST report to pull information per segregated unit. The community will be in compliance for all other updates by 12/9/25. 4. The Administrator and RN.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. 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 ensure the Acuity-Based Staffing Tool (ABST) developed reports that reflected distinct and segregated areas and accurately captured care time and care elements staff were providing to residents for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to: 1. Observations made during the survey found the facility was a one story MCC with two segregated units separated by locked doors and a lobby. Review of ABST documents provided by the facility on 10/09/25 at 9:26 am found the facility’s proprietary ABST did not provide an ABST report that reflected the distinct and segregated areas of the facility. 2. Resident 4 was admitted to the facility 10/2024 with diagnoses including dementia. The service plan, dated 09/12/25, Interim Service Plans, and the resident's corresponding ABST record were reviewed. The resident was observed, and interviews were conducted with staff. The resident's care time and care elements were found to be not reflective in the following areas: * Transfers; * Supervising, cueing, or supporting while eating; * Medication administration; * Cueing or redirecting due to cognitive impairment or dementia; * Providing treatments; * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; and * Assisting with leisure activities, assist with social and recreational activities. The need to ensure the facility ABST developed reports that reflected distinct and segregated areas and accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings. 3. Resident 1 moved into the community in 05/2023 with diagnoses including dementia. The resident’s service plan, dated 09/26/25, interim service plans, and the resident’s ABST were reviewed. The resident was observed and interviews with staff were conducted. The resident’s care time and care elements were found to be not reflective in the following areas: Toileting, bowel, and bladder management; Bathing; Medication administration; Cueing or redirecting due to cognitive impairment or dementia; Ensuring non-drug interventions for behaviors; Assisting with leisure activities, assist with social and recreational activities; Monitoring physical conditions or symptoms; and Safety checks, fall prevention. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1(Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. The service plan, dated 09/19/25, Interim Service Plans, and the resident's corresponding ABST record were reviewed. The resident was observed, and interviews were conducted with staff. The resident's care time and care elements were found to be not reflective in the following areas: * Assisting with communication; * Transfers; * Supervising, cueing, or supporting while eating; * Safety checks and fall prevention; * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; and * Dressing and undressing. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings. 5. Resident 3 was admitted to the facility 09/2025 with diagnoses including dementia and depression. The service plan, dated 10/06/25, Interim Service Plans, and the resident's corresponding ABST record were reviewed. The resident was observed and interviews were conducted with staff. The resident's care time and care elements were found to be not reflective in the following areas: * Toileting, bowel, and bladder management; * Medication administration; * Cueing or redirecting due to cognitive impairment or dementia; * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; and * Safety checks, fall prevention. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings.

1. We will ensure that our ABST tool reports reflect distinct and segregated areas and accurately capture care time and care elemnts that staff are providing. 2. A. We will ensure resident #4 service plan reflects the following care time and care elements: *transfers *Supervising, cueing,or suporting while eating. *medication adminstration. *cueing or redirecting due to cognitive impairment or dementia. *providing treatments. *monitoring behavioral conditions or symptoms. *ensuring non-drug interventions for behaviors. * assisting with leisure actvities, assist with social and recreational activities. B. We will ensure resident #2 service plan reflects the following care time and care elements: *assisting with communication * transfers *supervising, cueing, or supporting while eating. *safety checks and fall prevention. *monitoring behavioral conditions or symptoms. *ensuring non-drug interventions for heaviors. *dressing and undressing. C. We will ensure resident #3 service plan reflets the following care time and care elements: *toileting, bowel, and bladder management. *medication administration. *cueing or redirecting due to cognitive impariment or dementia. *monitoring behavioral conditions or symptoms. *ensuring non-drug interventions for behaviors. *safety checks, fall preventions. 3. The ABST tool was updated on 10/29/25 to allow information to be pulled per segregated unit.We will be in compliance by 12/9/25 and service plans are monitored by evaluations initial, 30day, and 90day. 4. The Administrator and RN.

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 update and review the acuity-based staffing tool (ABST) evaluation when a resident experienced a significant change of condition for 2 of 2 sampled residents (#s 2 and 4) who experienced a significant change in condition. Findings include, but are not limited to: ? 1. Resident 4 moved into the community in 10/2024 with diagnoses including dementia. Review of Resident 4’s ABST and clinical records during the survey identified the resident experienced a significant change in condition due to a severe weight loss between 05/2025 and 06/2025. The facility failed to update and review the ABST no less than quarterly at the same time the resident’s service plan was updated. The above findings were discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. The service plan, dated 06/19/25, progress notes, dated 07/07/25 to 10/06/25, and the resident’s corresponding ABST evaluation were reviewed. It was noted Resident 2 experienced a significant change of condition on 09/28/25 following a fall with a wrist fracture. However, the last ABST evaluation update for the resident was dated 09/18/25. The need to ensure the ABST was updated and reviewed whenever there was a significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

1. We will review and update the ABST evaluation when a resident experiences a significant change of condition. 2. Both resident #2 and #4 experienced a change of condition for severe weightloss. Resident #2's service plan has been updated and is reflected in the ABST on 10/9/25. Resident #4's change of condtion was completed prior to survey on 8/7/25 and reviewed and updated by RN on 10/12/25. 3. Change of conditions will be reviewed weekly at the clinical meetings. Service plans are updated otherwise with the initial, 30day, and then every 90 days. 4. The Administrator and RN.

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 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 10, 13, and 16) demonstrated competency in first aid and/or abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/09/25 at 11:40 am with Staff 14 (Operations & Administration Director) and the following was identified: Staff 10 (CG), Staff 13 (MT), and Staff 16 (CG), hired 05/12/25, 06/23/25, and 08/13/25, respectively, lacked documented evidence they had completed first aid and/or abdominal thrust training within 30 days of hire. During an interview on 10/09/25 at 11:40 am with Staff 14, she acknowledged Staff 10 and Staff 13 did not have either first aid or abdominal thrust training. Staff 16 had taken first aid training but Staff 14 acknowledged it did not include abdominal thrust training. The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 10, 13, and 16) demonstrated competency in first aid and/or abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/09/25 at 11:40 am with Staff 14 (Operations & Administration Director) and the following was identified: Staff 10 (CG), Staff 13 (MT), and Staff 16 (CG), hired 05/12/25, 06/23/25, and 08/13/25, respectively, lacked documented evidence they had completed first aid and/or abdominal thrust training within 30 days of hire. During an interview on 10/09/25 at 11:40 am with Staff 14, she acknowledged Staff 10 and Staff 13 did not have either first aid or abdominal thrust training. Staff 16 had taken first aid training but Staff 14 acknowledged it did not include abdominal thrust training. The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

1. We will ensure all direct care staff hired are able to successfully demonstrate any duty they are asigned. 2. Knowledge and performance will be demonstrated in all areas within the first 30 days of hire including: a. the role of service plans in providing individualized resident care. b. providing assistance with the activities of daily living. c. changes associated with normal aging. d. identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the residents changes of condition. e. conditions that require assessments, treatments, ovservation and reporting. f. general food safety, serving and sanitation. g. if the direct care staff duties include the adminstration of medication or treatments, appropriate staff, in accordance with OAR 411-054-0055 will document that they have observed and evaluated the individual's abilityh to perform safe medicaion and treatment administration unsupervised. h. direct care staff have certified in CPR and first aid to include the abdominal thrust. 3. Within the first 30days of hire and annually after that . 4. The Administrator and RN.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired direct care staff (#30) demonstrated competency in first aid and/or abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 02/19/26 at 11:00 am with Staff 23 (Administrator), and the following was identified: There was no documented evidence Staff 30 (CG), hired 01/13/26, had completed first aid and/or abdominal thrust training within 30 days of hire. During an interview on 02/19/26 at 11:00 am with Staff 23, she acknowledged Staff 30 did not have either first aid or abdominal thrust training. The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 22 (ED) and Staff 23 on 02/19/26 at 4:15 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation will be Staff #30 will receive training in first aid and abdominal thrust training. 2. The system will be corrected so this violation will not happen again by ensuring all team members will complete demonstrated competency of job duties within 30 days of hire. This training will include first aid and abdominal thrust. 3. The area needing correction will be evaluated at time of hire and monthly. 4. The Administrator, Health Services Director, and Executive Director will be responsible to see that the corrections are completed/monitored.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. 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 each resident was instructed within 24 hours of admission and re-instructed, at least annually, in fire and life safety procedures. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 10/08/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities during fire drills within 24 hours of admission and at least annually. In an interview with Staff 18 (Maintenance Manager) on 10/08/25 at 8:08 am, he confirmed there was no system in place for instructing residents of the facility’s fire and life safety procedures. The need to ensure the facility instructs residents on fire and life safety procedures within 24 hours of admission and at least annually was reviewed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. We will ensure residents are instructed within the first 24 hours of admission and reinstructed annually in fire and life safety procedures. 2. The Administrator and Maintenance Manager will be retrained. The Maintenance Manager will conduct training for current residents on the communities fire and life safety procedures and going forward all new admits will be instructed within the first 24hrs of move in. 3. All residents will be trained by 12/9/25 and going forward all new admits will be trained within 24hrs of admission. 4. The Administrator and the Maintenance Manager.

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 411-054-0105 (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 interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C252, C260, C310, and C372.

Please refer to C252, C260, C310, C372, Z155, Z163, and Z164

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 their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include but are not limited to: Refer to C260, C242, C310, Z142 and Z162.

Please refer to C260, C242, C310, Z142, and Z162

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:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure individual rights of privacy, dignity, and respect for sampled residents (#s 1, 2, 3 and 4) and multiple unsampled residents. Findings include, but are not limited to: During the acuity interview on 10/06/25 and observations made during the survey, it was identified residents 1, 2, 3 and 4 and multiple unsampled residents' service plans were kept in binders found in the common area of each memory care unit. The service plans were accessible to residents and visitors who entered the units. The need to ensure residents’ right to have medical and other records kept confidential was reviewed with Staff 1 (Administrator) on 10/07/25 at 2:50 pm. She acknowledged the findings.

1. We will ensure through retraining of all direct care staff of residents individual rights to privacy, dignity, and respect. 2. We will store the service plan binders in the med room to be given to the scheduled care staff at the beginning of shift to read and initial and returned back to the med room when complete. 3. Daily 4. The Administrator and RN.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for 2 of 4 sampled residents (#s 1 and 4) and multiple unsampled residents who shared a bathroom. Findings include, but are not limited to: 1. Observations of Riverside and Mountainside units were conducted on 10/06/25 and 10/07/25. The shared bathrooms all had two doors that would each open to a different resident unit. The doors could be locked from the residents’ rooms, but not from inside the bathroom. Therefore, each individual was not ensured privacy when using his/her shared restroom. The need to ensure each resident had privacy in his or her own unit was reviewed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 10/2024 with diagnoses including dementia. On 10/08/25 at 10:03 am, Staff 3 (MT) and Staff 19 (CG), were observed providing ADL care to Resident 4 in the resident’s unit. Staff 3 and Staff 19 removed the resident’s pants and soiled brief and provided incontinent care to the resident without closing the blinds to the unit window that look out into the facility courtyard. There were two residents in the courtyard, within line of sight of the window at the time staff were providing ADL cares to Resident 4. On 10/10/25 at 10:25 am the need to ensure residents’ right to dignity and privacy in their own unit was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations. They acknowledged the findings.

1. We will ensure that resident #1 and #4 have privacy in their own apartment by ensuring blinds are closed, apartment door is closed, and locks are engaged. 2. Installing locks on the inside of the each bathroom door, blinds in the apartment are closed, and apartment door is closed while providing ADL cares. Direct care staff will be retrained. 3. We will be in compliance by 12/9/25. 4. The Administrator, Maintence Manager, RN, and RCC.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including pronouns and gender identity, for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252

1. We will ensure that the initial evaluation addresses all required elements, including pronouns and gender identity and enter information into resident #4's care plan. 2. The initial evaluation will be updated to include gender identity and pronouns. 3. We will be in compliance by 12/09/25. 4. The Adminstrator.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by:

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to: During the change of ownership survey, conducted 10/06/25 through 10/10/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of the citations. 1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following areas: * C0270: OAR 411-054-0040 (1-2) Change of Condition and Monitoring; and * C0280: OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health and Services. The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. 2. Refer to deficiencies in the report.

1. We will ensure there will be adequate administrative oversight for resident care and services rendered in the community. 2. Administrator will be trained on responsibilities and oversite. We developed and implemented an immediate plan of correction during the survey to address the threat to residents safety and the immediate risk was addressed: Change of condition and monitoring, resident health and services. 3. This was met at the time of survey on 10/9/25. Going forward change of conditions and resident health services will be monitored weekly at the clinical meetings. 4. The Administrator and RN.

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to: During the first re-visit to the change of management survey of 10/10/25, conducted 02/17/26 through 02/19/26, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the severity of citations. 1. A situation was identified which constituted immediate jeopardy to residents' health and safety. An immediate plan of correction was requested in the following area: OAR 411-054-0025 (4) (C0160) - Reasonable Precautions. The facility put an immediate plan of correction in place during the survey and the situation was abated. 2. Refer to deficiencies in the report.

Please refer to C160

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by:

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. 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 licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to: During the change of ownership survey, conducted 10/06/25 through 10/10/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of the citations. 1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following areas: * C0270: OAR 411-054-0040 (1-2) Change of Condition and Monitoring; and * C0280: OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health and Services. The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. 2. Refer to deficiencies in the report.

1. We will ensure there will be adequate administrative oversight for resident care and services rendered in the community. 2. Administrator will be trained on responsibilities and provide oversight. We developed and implemented an immediate plan of correction during the survey to address the threat to residents safety and the immediate risk was addressed: Change of condition and monitoring, resident health and services. 3. This was met at the time of surveyon 10/9/25. Going forward change of conditions and resident health services will be monitored weekly at the clinical meetings. 4. The Administrator and RN.

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. This is a repeat citation. Findings include, but are not limited to: Refer to C160, C242, and C372.

Please refer to C160, C242, and C372

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. This is a repeat citation. Findings include, but are not limited to: Refer to C242.

Please refer to C242.

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 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 10, 13, 15, and 16) completed all required pre-service orientation training topics; 3 of 3 newly-hired direct care staff (#s 10, 13, and 16) completed all required pre-service dementia training topics and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/09/25 at 11:40 am with Staff 14 (Operations & Administration Director). The following was identified: a. There was no documented evidence Staff 10 (CG), Staff 13 (MT), Staff 15 (Cook) and Staff 16 (CG), hired 05/12/25, 06/23/25, 07/28/25, and 08/13/25, respectively, had completed one or more of the following pre-service orientation topics before completing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Food handler’s certificate; * Infectious disease prevention; * HCBS course; * LGBTQIA2S+ course; * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach. b. There was no documented evidence Staff 10, Staff 13 and Staff 16 completed one or more of the following pre-service dementia training topics for direct care staff: * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 10, Staff 13 and Staff 16 demonstrated competency in one or more of the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documenting and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to ensure the required pre-service training was completed by staff in the time frames specified in the rules and staff demonstrated competency in assigned job duties within 30 days of hire was discussed on 10/09/25 at 11:40 am with Staff 14, and with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

1. We will ensure all newly hired staff have completed all required pre-sevice orientation training, pre-service dementia training and can demonstrate their competency in all assigned job duties within the first 30 days of hire. 2. We will ensure all current and new direct staff have completed the following training: * Resident rights and values of CBC care; * Abuse reporting requirements; * Food handler’s certificate; * Infectious disease prevention; * HCBS course; * LGBTQIA2S+ course; * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach. * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on going assessment; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documenting and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. 3. Within the first 30day of hire and annual training. 4. The Administrator and RN.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 24 and 30) completed all required pre-service orientation training topics and 1 of 1 newly hired direct care staff (#30) completed all required pre-service dementia training topics and demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation Findings include, but are not limited to: Staff training records were reviewed on 02/19/26 at 11:00 am with Staff 23 (Administrator), and the following was identified: a. There was no documented evidence Staff 24 (Housekeeper) and Staff 30 (CG), hired 02/03/26 and 01/13/26, respectively, had completed one or more of the following pre-service orientation topics before completing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious disease prevention; * HCBS course; * LGBTQIA2S+ course; * Dementia disease process, including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia, including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach. b. There was no documented evidence Staff 30 completed the following pre-service dementia training topics for direct care staff: * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 30 demonstrated competency in the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documenting and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to ensure the required pre-service training was completed by staff in the time frames specified in the rules and staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 22 (ED) and Staff 23 on 02/19/26 at 4:15 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation will be to ensure Staff #24 and #30 complete all required pre-service orientation trainings and dementia trainings. Staff #24 and #30 - Resident rights and values of CBC care - Abuse reporting requirements - Infectious disease prevention - HCBS course - LGBTQIA2S+ course - Dementia disease process - Techniques for understanding, communicating, and responding to distressfull behavioral symptoms - Strategies for addressing social needs and engaging persons with dementia in meaningful activities - Specific aspects of dementia care and ensuring safety of residents with dementia Staff #30 - Environmental factors that are important to residents well-being - Family support and the role the family may have in the care of the resident - How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment - How to provide personal care to residents with dementia - Use of supportive devices with restraining qualities - Role of the service plans - Changes associated with normal aging - Identification, documenting, and reporting changes of condition - Conditions that require assessment, treatment, observation, and reporting - General food safety, serving, and sanitation 2. The system will be corrected so this violation will not happen again by ensuring the required pre-service training is completed by staff in the time frames specified in the rules and staff demonstrate competency in assigned job duties within 30 days of hire. 3. The area needing correction will be evaluated weekly 4. The Administrator, Assistant Operations Director, and the Executive Director will be responsible to see that the corrections are completed/monitored.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C270, C280, C290, C302, C310, C361, C362 and C363.

1. We will ensure the licensing rules for Residential Care and Assisted Living Facilities referring to C252, C260, C270, C280, C290, C302, C310, C361, C362 and C363 are met. 2. See plan of corrections for C252, C260, C270, C280, C290, C302, C310, C361, C362 and C363. 3. We will be in compliance by 12/9/25. 4. The Administrator.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C252, C260, and C310.

Please refer to C252, C260, and C310

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. This is a repeat citation. Findings include, but are not limited to: Refer to C260 and C310.

Please refer to C260 and C310.

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(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3 and 4’s current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop an individualized nutrition and hydration plan based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings and no further documentation was provided.

1. We will ensure that there is an individualize nutrition and hydration plan for each resident. 2. Information will be collected and service plans will be updated with residents 1, 2, 3, and 4, nutrition and hydration status, preferences, and needs of the resident. 3. We will be in compliance by 12/9/25. 4. The Administrator and RN.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 2 of 3 sampled residents (#’s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Residents 5’s current service plan (dated 01/21/26) was reviewed during survey. Resident 5 was dependent on staff to transfer out of bed or a wheelchair, and their preference was to eat all meals alone in their room. The service plan lacked information and staff instructions related to the individualized nutrition and hydration status, preferences for fluids, and nutrition needs of the resident. The need to develop an individualized nutrition and hydration plan based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 23 (Administrator) at 11:00 am on 02/19/26. She acknowledged the findings. 2. Resident 6 moved into the community in 09/2025 with diagnoses including Alzheimer’s dementia. Residents 6’s current service plan was reviewed during survey and indicated s/he needed reminding/cueing to maintain adequate intake. Observations during survey indicated Resident 6 could eat and drink independently and consumed 80% of his/her cranberry juice for lunch on 02/18/26. The service plan lacked information and staff instructions related to the individualized nutrition and hydration status, preferences for fluids, and nutrition needs of the resident. The need to develop a nutrition and hydration plan based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 22 (ED) and Staff 23 (Administrator) on 02/19/26 at 4:15 pm. They acknowledged the findings and no further documentation was provided.

1. The actions that will be taken to correct the rule violation will be to update Resident #5 and Resident #6 service plans to ensure an individualized nutrition and hydration plan is developed and listed in each residents service plan. 2. The system will be corrected so this violation will not happen again by ensuring all resident service plans, both new and existing, include an individualized nutrition and hydration plan based on the residents individual preferences and needs 3. The area needing correction will be evaluated at move in, quarterly, and with change of condition. 4. The Administrator, Executive Director, and Health Services Director will be responsible to see that the corrections are completed/monitored.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

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 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose evaluations and services plans were reviewed. The most recent evaluations and current service plans were reviewed for Residents 1, 2, 3 and 4. The following was identified: a. There was no documented evidence an activity evaluation had been completed for sampled residents that addressed the following: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no documented evidence an individualized plan was developed for the sampled residents. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 and Staff 2 (RCC) on 10/09/25 at 11:31 am. The findings were acknowledged, and no further documentation was provided.

1. We will ensure each resident is evaluated for activities addressing all require elements and to develop an individualized activity plan based on their evaluation. 2. Residents 1, 2, 3, and 4 and their POA will be interviewed for the activity evaluation and an individualize activity plan will be developed with their preferences and service plans will be updated. 3. We will be in compliance by 12/9/25. 4. The Administrator.

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 failed to develop an individualized activity plan based on their evaluation for 3 of 3 sampled residents (#s 5, 6, and 7) whose evaluations and services plans were reviewed. This is a repeat citation. Findings include, but are not limited to: The most recent evaluations and current service plans were reviewed for Residents 5, 6, and 7. The following was identified: a. There was no documented evidence an activity evaluation had been completed for sampled residents that addressed the following: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. b. There was no documented evidence an individualized plan was developed for the sampled residents which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 23 (Administrator) at 11:00 am on 02/19/26. She acknowledged the findings.

1. The actions that will be taken to correct the rule violation will be to ensure Resident #3, Resident #6, and Resident #7 are evaluated for activities and individualized activity plans are developed and made available to staff. As well, there will be documented for each resident detailed what, when, how, and how often staff should offer and assist the residents with individualized activites. This will include: - Past and current interests - Current abilities and skills - Emotional and social needs and patterns - Physical abilities and limitations - Adaptations necessary for the resident to participate - Activities that could be used as behavioral interventions 2. The system will be corrected so this violation will not happen again by ensuring all residents, both new and existing, are evaluated for activities and individualized activity plans are developed for each. The activity plans will detail what, when, how, and how often staff should offer and assist the residents with individualized activities. 3. The area needing correction will be evaluated at the time of move in, quarterly, and with change of condition. 4. The Engagement Director, Administrator, and Executive Director will be responsible to see that the corrections are completed/monitored.

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 411-057-0160(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: