Print Inspection: CHOW007168

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the licensee was responsible for the operation of the facility and the quality of services rendered in the facility and failed to ensure the licensee was responsible for the supervision, training, and overall conduct of staff. The findings include, but are not limited to: Refer to the number of citations in the report.

1. Refer to the responses located in C-0154.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to implement written policies and procedures that promoted high quality services and health and safety for residents, including effective methods for responding to and resolving resident complaints. The findings include, but are not limited to: Observations throughout the survey identified the following: * The building was under construction, and the front entrance was blocked; * There was no signage directing visitors, including mail service and state agencies, on how to enter the building; and * Multiple family members expressed concerns and needed assistance with entering the building. During a resident group interview conducted on 10/08/25 at 1:30 pm, the following concerns were reported: * Construction had been going on for three months, and they felt that was too long; * There were construction smells and noise within the building that bothered the residents; * Residents reported poor communication by the facility and feeling like they did not know what was happening; * Residents were not aware of when laundry was being done; * Carpets were dirty and stained in resident rooms; * There was no bus driver for activities outside of the facility; * At times, meals were being served on disposable plates and plastic cutlery; * Resident showers had slippery floors; * Visitors and medical transport could not get in; * Residents reported not knowing where to go for medical transport pickup; and * Keys were not provided for some residents. During a review of the previous three months of resident council meeting minutes, dated 07/2025 through 09/2025, the majority of the above concerns were also discussed at the monthly resident meetings. During an interview on 10/09/25 at 10:30 am, Staff 2 (Interim ED) reported Staff 7 (Life Enrichment Director) attended the meetings and reported back to all department heads, including Staff 2. Surveyor requested verification of the follow up actions taken after she received the complaints from resident council. Verification was not provided. The need to ensure the facility implemented written policies and procedures that promoted high quality services, including effective methods for responding to and resolving resident complaints, was discussed with Staff 2 (Interim ED) on 10/09/25 at 10:30 am. She acknowledged the findings.

1. Policies and procedures are being updated, or created (if not already in place) and implemented as outlined in OAR 411-054-0025 (7) Facility Administration: Policy & Procedure to promote high quality services. Specific to findings in the survey: Signage was put up directing visitors to administration, financial and clinical departments. The front lobby has been opened to all residents and visitors. Suggestion box near the med room is available for residents. Resident Council meetings are held monthly and allow for resident concerns. 2. Management will give written response to concerns raised at Resident Council meetings, so that Resident Council can discuss the following month. Weekly management team meetings will include documentation of resident concerns raised and documentation of all follow up actions. 3. Department heads will be responsible on a day to day basis, to ensure policies and procedures are in place, up to date and being followed by staff. 4. Administrator will review policies and procedures quarterly with department heads to ensure all policies/procedures are in place, up to date and being followed by staff.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

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, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 10/06/25 through 10/17/25, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective. During an interview with Staff 2 (Interim ED) on 10/09/25 at 10:30 am, survey requested verification of implementing a quality improvement program. Staff 2 confirmed the facility had failed to conduct ongoing quality improvement programs. Refer to deficiencies in the report.

1. A quality assurance policy was created and will be implemented. 2. A team represented by at least one member of each department in the facility will evaluate services, staff performance and resident satisfaction as well as review input from residents and staff. 3.The QA team will meet at least monthly to review the results of the evaluation of services, performance and resident satisfaction. 4. The administrator will lead the QA team and ensure monthly evaluations are completed and improvements implemented as needed.

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

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents' rights to be treated with dignity and respect and reside in a homelike environment for 1 of 1 sampled resident (#2) and multiple unsampled residents who were served meals with plastic cutlery and paper drinkware. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2025 with diagnoses including dementia and hypertension. The resident’s service plan, dated 06/18/25, identified the resident needed food items cut up. On 10/07/25 at 12:48 pm, Resident 2 had a food tray delivered to his/her room. The food tray included plastic cutlery and a paper cup with milk. During an interview on 10/07/25 at 1:10 pm, Resident 2 stated that meals were often delivered with plastic cutlery and a paper cup, and this made eating and drinking more difficult at times. S/he stated that s/he preferred reusable silverware and drinkware. During a group interview on 10/08/25 at 1:30 pm, multiple unsampled residents stated that they were often served food on disposable plates, given plastic utensils, and/or paper cups. The unsampled residents stated this occurred whether eating in the dining room or being delivered a room tray. Staff 5 (Dining Services Director) acknowledged in an interview on 10/07/25 at 2:00 pm that the facility currently had a low stock of silverware and plastic or glass drinkware and was not able to provide those items to all residents during meal service. The need to ensure residents’ rights to be treated with dignity and respect and to reside in a homelike environment was reviewed with Staff 2 (Interim ED) and Staff 3 (Business Office Director) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. Immediately additional dishes were purchased and put into use. Strategies to reduce breakage were discussed w/kitchen staff and employed. (Ex: moving garbage can away from edge of counter, adding bus tub next to sink). DSD will be regularly checking resident rooms for facility dishes. Plans to purchase dishware and silverware that is easily distinctive, to limit residents keeping dishes in their rooms. 2. DSD will be doing inventory weekly and routinely ordering dishes, silver and drinkware to build up a small surplus. Prohibit any sort of disposable dishware for regular, common, dining. 3. DSD check monthly that additional dishes are being purchased and no plastic/paper products are being used for regular, common, dining. 4. Administrator will check monthly that a small surplus of dishes exisists and no paper/plastic products are bieng used for regular, common, dining.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated quarterly, were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and were implemented, for 1 of 2 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2025 with diagnoses including dementia and hypertension. Resident 2 was noted to have severe right hip pain which affected all ADLs and had a history of weight loss. The resident's current service plan available to staff, dated 06/14/25, and 07/06/25 through 10/06/25 progress notes were reviewed. Staff and the resident were interviewed, and observations of the resident were completed. a. The resident’s service plan had not been updated within the past quarter. b. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following area: *Non-pharmacological interventions for pain. c. The service plan was not implemented in the following area: *Food was to be “easy to chew” and “large meat/items cut up due to poor dental health.” On 10/07/25 at 12:48 pm the resident was observed being served a large piece of pizza which appeared difficult to chew. At 2:00 pm the returned meal tray was observed, which included one bite out of the pizza which appeared the resident attempted to chew and then placed back onto the plate unchewed. The need to ensure service plans were updated at least quarterly, were reflective of residents’ needs, provided clear direction to staff, and were implemented, was reviewed with Staff 2 (Interim ED) and Staff 3 (Business Office Director) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. The resident that was identified in the survey, has had their service plan reviewed and updated to accurately reflect the current needs and clear directions to staff as it relates to pain and dietary needs. 2. Other residents that could potentially be affected by these practices are being reviewed and changes will be made to reflect current resident status. An interdisciplinary team will be responsible for input into the resident's service plans that will be reflective of current resident needs. Team will meet prior to service plan due dates, . 3. RN will review care plans due weekly to ensure they are complete and area a reflection of current resident needs. 4. Administrator will review monthly to ensure continued compliance.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine the resident-specific action or intervention that was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff on all shifts, and record weekly progress through resolution for 1 of 2 sampled residents (#2) who experienced short term changes of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2025 with diagnoses including dementia and hypertension. The resident was observed and described by staff as requiring assistance for ambulation outside of his/her room and assistance from staff for transferring, toileting, dressing, bathing and grooming. The resident’s service plan, dated 06/14/25, noted that the resident had disorientation to person, place time or situation, poor judgement, and was at risk for falls due to his/her hip pain. The resident’s clinical record from 07/06/25 through 10/06/25 was reviewed during the survey. The following was identified: a. The resident was noted to have a history of severe right hip pain which limited all ADLs. On 08/27/25, the resident underwent a right hip injection procedure and returned with after visit instructions noting that the injection could cause “lightheadedness, dizziness and sleepiness.” The resident was identified as having a bruise to the injection site and a dressing which required removal two days after returning to the facility. There was no documented evidence of staff instructions and weekly monitoring until resolution for the hip bruising and injection site. During an interview on 10/10/25, Staff 2 (Interim ED) stated she was not aware of the resident’s after visit summary or that there were side effects from the injection, or bruising, that should have been communicated to staff and monitored. b. The resident experienced two unwitnessed falls on 08/28/25 and 09/06/25. The fall on 08/28/25 provided instructions to staff to monitor for injuries and potential side effects from hitting his/her head. The resident had another fall on 09/06/25, was taken to the local emergency department, returned to the facility, and a Temporary Service Plan (TSP) was created which identified areas to monitor. For both unwitnessed falls, the facility failed to evaluate current fall intervention or put additional interventions in place to avoid or minimize further falls. During an interview on 10/10/25, Staff 2 acknowledged the fall interventions were not evaluated for effectiveness and no new interventions were determined or communicated to staff. c. The resident was noted to have severe hip pain and used a PRN narcotic pain medication, oxycodone, three times per day. On 09/17/25, the medication was noted to be unavailable and was not administered to the resident again until 09/24/25. Staff documented on 09/18/25 that the resident had “been in fetal position grimacing/moaning in pain and not wanting to get out of bed.” On 10/07/25 at 10:37 am, Staff 10 (MT) stated that the medication was not available as they were waiting on a new order from the resident’s doctor. The resident had orders for PRN pain medication including acetaminophen and diclofenac gel. The PRN acetaminophen and diclofenac gel were not used between 09/17/25 and 09/23/25. There was no documented evidence that the facility determined and documented interventions for the unavailability of PRN oxycodone and documented side effects including loose stool from 09/19/25 through 09/24/25 and the residents’ increased level of pain. In an interview on 10/07/25 at 1:45 pm, Staff 10 stated that she did not notify nursing staff or the resident’s doctor of the repeated loose stools as Staff 10 felt the loose stools were a consequence of the resident not receiving narcotic medication and felt that once the resident received narcotic medication again the loose stools would resolve. She stated the resident did not have a PRN medication to assist with the loose stools and did not receive any treatment to address the loose stools or evaluate for additional causes or symptoms. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored weekly progress through resolution was reviewed with Staff 2 (Interim ED) and Staff 3 (Business Office Director) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. Resident identified in the survey has been reassessed by the RN and placed on weekly updates to establish her new baseline. 2. Other residents that potentially could be affected by this practice have been reviewed and significant change of condition assessments have been initiated as appropriate. 3. RN will ensure coc monitoring and appropriate follow up is done on a weekly basis. 4. Administrator will review coc monitoring monthly to ensure continued compliance.

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 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication administration system was in place. Findings include, but are not limited to: During the change of ownership survey, conducted 10/06/25 through 10/17/25, professional oversight of the medication administration system was found to be ineffective, based on deficiencies in the following areas: * C 302 – Tracking Control Substances; * C 303 - Medication and Treatment Orders; * C 305 - Resident Right to Refuse; and * C 310 - Medication Administration. The need to ensure a safe medication system was in place was reviewed with Staff 2 (Interim ED) and Staff 3 (Business Office Director) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. The medication and treatment administration system has been reviewed and the areas identified in the survey have been corrected. 2. The overall system has been reviewed to identify any other potential deficiencies in the system. We changed how the system populates reminders. In addition we will be contacting PCP re:frequency of notification of refusals. Our MAR will be updated to reflect parameters received by PCP, and Med Techs will follow these parameters. 3. Clinical team (including RN) will be monitoring refusals 3x weekly, and perfoming MAR and narcotic log audits. RN will review audits weekly to ensure compliance. 4. Administrator will review audits monthly to ensure continued compliance.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 resident (# 2) whose controlled substance distribution log was reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2025 with diagnoses including dementia and hypertension. The resident had a signed physician order for PRN oxycodone (for pain), 5 mg, one tablet by mouth every eight hours as needed. Oxycodone is a narcotic pain medication and is a controlled substance. Review of the resident's 09/01/25 through 10/06/25 MARs and controlled substance disposition logs revealed the following: a. On 09/26/25 at 10:00 pm, oxycodone was shown as administered on the MAR but was not documented in the controlled substance disposition log as removed from the medication card. b. On the following dates, oxycodone was documented in the controlled substance distribution log as removed from the medication card, but was not documented as administered on the MAR: * 09/04/25 at 10:00 pm; * 09/05/25 at 2:00 pm; * 10/02/25 at 2:00 pm; * 10/04/25 at 10:00 pm; and * 10/05/25 at 10:00 pm. During interviews on 10/07/25 and 10/10/25, Staff 2 (Interim ED) and Staff 10 (MT) stated there was no process for tracking or reviewing errors or discrepancies between the MAR and the controlled substance log. Staff 2 and Staff 10 stated they were not aware of the discrepancies prior to the survey team identifying them. The need to ensure a system was in place for accurately tracking controlled substance distribution was reviewed with Staff 2 and Staff 3 (Business Office Director) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. The system for tracking narcotic substances has been reviewed and we removed the reminder option on the MAR, medtechs will now document in the MAR only for the administration. 2. Our shift change procedures will be modified by reconciling the electronic MAR with the Narcotic Log after each shift, no later than 11/30/2025. 3. RN will review these reconciliations weekly. 4. Admin will review reconciliations monthly to ensure continued compliance.

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2025 with diagnoses including dementia and hypertension. Resident 2’s current physician’s orders and MARs dated 09/01/25 through 10/06/25 were reviewed. The following was identified: a. The resident had an order for milk of magnesia (for constipation), 30 ml by mouth with full glass of water as needed. The order stated, “if no bowel movement occurs 6-8 hours after administration notify [physician].” The medication was administered five times between 09/01/25 and 10/06/25. The notes after each administration showed that the resident was checked on one to two hours after administration and was noted as having “no relief” from constipation. During an interview on 10/07/25 at 1:45 pm, Staff 10 (MT) confirmed the facility had not been tracking whether a bowel movement occurred six to eight hours after administration, and there had been no contact with the physician related to the efficacy of the medication or continued constipation. b. The resident had an order for PRN oxycodone, 5 mg, 1 tablet by mouth every 8 hours as needed for pain. The facility staff faxed the resident’s physician on 07/25/25 requesting that her current narcotic pain medication, which was PRN, be changed to scheduled. The resident’s physician replied on 08/02/25 and stated that she did not recommend scheduled opiates. During interviews with Staff 10 on 10/07/25 at 1:45 pm and Staff 2 (Interim ED) on 10/10/25 at 11:00 am, staff stated because the physician refused to schedule the PRN medication, the facility noted on the resident’s MAR at 6:00 am, 2:00 pm, and 10:00 pm to “please give PRN pain med as [s/he] does not remember to ask for it.” Review of the MAR confirmed the medication was administered at those times. There was no documented evidence the facility obtained written orders to administer Oxycodone as scheduled three times per day. c. The resident had an order for trazadone, 50 mg, take 0.5 tablets by mouth at bedtime PRN for insomnia. The facility had placed the medication as a scheduled medication and was administering it nightly. Staff 2 confirmed on 10/10/25 at 11:00 am that there was no documented evidence that the medication should be administered as scheduled instead of PRN as per the physician’s order. The need to ensure all orders were carried out as prescribed was reviewed with Staff 2 and Staff 3 (Business Office Director) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. The resident identified in the survey has been reassessed, orders have been reviewed and corrections in the EMAR have been made. 2. Other residents that could potentially be impacted by this process have been reviewed and corrections were made as needed. 3. RN or designee is responsible for 3rd checking all orders. 4. Administrator will review a sampling of orders monthly to ensure continued compliance.

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

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order for 1 of 1 sampled resident (#2) with documented refusals. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2025 with diagnoses including dementia and hypertension. The resident’s MARs dated 09/01/25 through 10/06/25 and physician’s orders were reviewed. The following was identified: Resident 2 had an order for senna (for constipation), 8.6 mg tablet, take one tablet by mouth every morning. The resident refused the medication four times during the reviewed period. During an interview on 10/10/25 at 11:00 am, Staff 2 (Interim ED) acknowledged there was no documented evidence the facility notified the provider when Resident 2 refused to consent to physician’s orders. The need to notify the provider when a resident refused to consent to an order was reviewed with Staff 2 and Staff 3 (Business Office Director) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. The resident identified in the survey has been reassessed, and the PCP has been contacted to determine how often they would like to be notified. 2. All residents that could potentially be impacted by this process, their PCPs will be contacted to clarify how often they would like to be notified of medication refusals. This will be complete by 11/15/2025. The MAR will be updated w/PCP preference, MedTech will follow-up by running a Med Refusal report daily and contacting the PCPs according to their stated preferences. 3. RN and/or designee will review on monthly basis to ensure continued compliance. 4. Administrator will review quarterly to ensure continued compliance.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. 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 resident-specific parameters and instructions were included for PRN medications for 1 of 2 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2025 with diagnoses including dementia and hypertension. The resident’s physician orders and MARs dated 09/01/25 through 10/06/25 were reviewed, and staff were interviewed. The following was identified: a. The resident had three PRN medications for pain which did not have parameters for order of administration by unlicensed staff: *Acetaminophen 325 mg, two tablets every four hours; *Oxycodone 5 mg, one tablet by mouth every 8 hours; *Diclofenac gel 1%, four grams to be applied topically up to three times daily. When asked how staff determine which pain medication to administer to the resident, Staff 10 (MT) stated on 10/07/25 at 1:45 pm that acetaminophen was not used due to the resident already receiving enough with his/her scheduled dose, the diclofenac gel didn’t appear to help the resident, and thus the oxycodone was utilized for the resident. The need to ensure resident-specific parameters and instructions were included on the MAR for PRN medications was reviewed with Staff 2 (Interim ED) and Staff 3 (Business Office Director) on 10/10/25 at 11:00 am. They acknowledged the findings.

1. The resident identified in the survey has been reassessed, and the appropriate parameters were added. 2. All other residents that could potentially be impacted by this process, were reviewed and appropriate parameters were added 3. RN and/or staff designee reviews all quarterly POs to ensure continued compliance with PRN parameters. 4. Administrator will review quarterly to ensure continued compliance.

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 411-054-0065 (1-3) Administrator Qualification and Requirements (1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below: Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure the licensed residential care facility employed a full-time administrator that was scheduled to be on-site in the facility at least 40 hours per week, and ensure the individual serving as an administrator of the residential care facility obtained an administrator’s license from the Health Licensing Office, Oregon Health Authority, as required. The findings include, but are not limited to: During the entrance conference interview on 10/06/25 at 10:15 am, verification of the facility’s licensed administrator was requested and discussed with Staff 2 (Interim ED). There was no documented evidence the facility provided the requested information to the Department or employed a licensed full-time administrator. The need to ensure the facility employed a full-time administrator that was scheduled to be on-site in the facility at least 40 hours per week and ensure the individual serving as an administrator of the residential care facility obtained an administrator’s license from the Health Licensing Office was discussed with Staff 2 and Staff 3 (Business Office Director) on 10/07/25 at 4:30 pm. They acknowledged the findings.

1.Ownership has submitted all appropriate licensing application/documentation for Interim Administrator Heather Miller, to licensing prior to the close of survey.

OAR 411-054-0065 (1-3) Administrator Qualification and Requirements (1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below: Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 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 observation, interview, and record review, it was determined the facility failed to ensure 2 of 3 residents’ (#s 2 and 3) and multiple unsampled residents’ ABST evaluations were updated and reviewed before move- in and/or no less than quarterly at the same time the resident's service plan was updated, and failed to ensure distinct posted staffing plans for segregated areas to meet the scheduled and unscheduled needs of residents who resided in each of the distinct segregated areas. Findings include, but are not limited to: Upon survey entrance on 10/06/25 at 9:15 am, observations of construction being done at the residential care facility (RCF) were made and identified the following: The entrance to the main door was blocked, and the building interior was separated by two heavy doors that remained closed during the survey. Multiple staff reported they were not allowed to go through the doorway and were observed transporting residents in wheelchairs outside of one area and into the other side of the RCF through the back patio entrance door. During the environmental tour of the building the posted staffing plans for each area could not be located on either side of the building. Review of the facility ABST identified the ABST was not completed for each separate area to determine the number of staff needed to meet the scheduled and unscheduled needs of the residents in each area, and the facility was not staffing each area separately. During an interview on 10/07/25 at 10:00 am, Staff 2 (Interim ED) reported she didn’t realize since the door was installed inside the facility that it caused a separation of the building, which required a staffing plan for each separate area. The need to ensure the facility updated and reviewed the ABST prior to a resident moving in and no less than quarterly at the same time the resident ' s service plan was updated and to ensure distinct posted staffing plans for segregated areas was discussed with Staff 2 and Staff 3 (Business Office Director) on 10/07/25 at 4:30 pm. They acknowledged the findings.

1.All residents have been re-evaluated in each area of the ABST with input from direct care staff, and will be updated in the ABST online by 11/15/25. 2. All residents' ABST questions will be re-evaluated and updated as part of their quarterly care plan. This has been added to the care plan evaluation procedure. Additionally, direct care staff will be trained on the ABST to ensure they communicate in real time when there are changes that would affect the ABST minutes This training will be complete no later than 11/30/25. 3. RN will review ABST statistics, for accuracy and timeliness monthly. 4. Administrator will review ABST statistics at least quarterly.

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 2 of 3 newly hired staff (#s 8 and 14) completed all required pre-service orientation training prior to beginning their job duties. Findings include, but are not limited to: Staff training records were reviewed on 10/08/25, and the following was identified: There was no documented evidence Staff 8 (Kitchen Aide) or Staff 14 (CG), hired 07/30/25 and 07/20/25, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Abuse reporting requirements; * Infectious disease prevention training; * Home and Community-Based Services training; and * LGBTQIA2S+ training. The need for staff to complete all required pre-service orientation training was discussed with Staff 2 (Interim ED) and Staff 3 (Business Office Director) on 10/08/25 at 3:35 pm. They acknowledged the findings.

1. The employee identified in the survey has been informed of the trainings missed and their training will be completed by 11/7/25. 2. All employee files are being audited to ensure all training pre-service requirements have been completed, and if they are not complete, they will be completed by 11/15/25. 3. Pre-service training checklist will be completed by BOD prior to any employee's first day of job duties. BOD approval must be given before new employee's can be put on the floor schedule. 4. Adminstrator will review new employee files monthly to ensure all training certificates are complete and in the employee's file.

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:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drill records from 04/2025 to 09/2025 were requested and reviewed with Staff 4 (Maintenance Director) on 10/07/25 at 11:18 am. The facility’s fire drill records lacked documentation of the following required elements on one or more of the drills reviewed: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. The need to ensure all required elements for fire drills were documented per the OFC was discussed with Staff 1 (Interim ED) and Staff 3 (Business Office Director) on 10/08/25 at 3:26 pm. They acknowledged the findings.

1. Maintenance Director (MD) participated in survey process and understands the elements of the fire drills that were not being appropriately recorded. Maintenance Director will ensure that all fire drills are documented fully and accurately. 2. The Fire Drill checklist will be updated to include all necessary elements, and MD will ensure each drill checklist is completely filled out. 3. MD will review records monthly for completion. 4. Admin will review Fire Drill records quarterly for all required elements.

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

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair; locked storage for all poisons, chemicals, rodenticides, and other toxic materials; and grounds were kept orderly and free of refuse. Findings include, but are not limited to: Between 10/06/25 and 10/08/25 the facility grounds were toured, and the following was identified: * Multiple drop-offs measuring between 1.5 inches and 11.5 inches were noted along pathway edges near the facility’s entrance, pathway edges surrounding the facility, pathway edges near the interior courtyard water feature, and pathways surrounding the duck pond. These drop-offs created tripping hazards; * The walkway surrounding the duck pond had seams in the concrete that were uneven and measured up to 1.25 inches, which created tripping hazards; * The facility’s janitorial closet, which stored toxic chemicals, was observed to be unlocked over multiple observations; and * Refuse and tools from the facility’s remodel were observed in the large carport and near the ramped entrance to the 200 hallway. On 10/08/25 at 12:03 pm the interior and exterior of the building were toured with Staff 2 (Interim ED) and Staff 4 (Maintenance Director). Staff 2 and Staff 4 acknowledged the need to ensure pathways were maintained in good repair, locked storage for chemicals, and grounds were free of refuse.

1. The general building exterior areas identified in the survey will be corrected as follows: drop-offs will be filled in with dirt/barkdust or blocked by gate/railings. The interior courtyard water feature will be blocked by a fence/gate, railing or border. The pathway surrounding the duck pond with be repaired, if repair is not imminent, the pathway with hazards will be closed. The janitor's closet now has signage to remain locked, and staff were re-educated. Refuse and tools in the large carport and near the entrance to 200 hallway will be removed from the property by 12/15/25. 2.Maintenance Director will perform walk-throughs of the exterior of the facility to identify areas of concern. 3.Maintenance Director will conduct these walk-throughs monthly and submit documentation of completion, repairs made, and report any identified new hazards to ownership and administration. 4. Administrator will perform quarterly walk-throughs of the exterior of the facility to identify hazards and submit to ownership.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior of the facility was free from unpleasant odors, and the environment was clean and in good repair. Findings include, but are not limited to: The residential care facility (RCF) included a single-level building and one wing (eight rooms) in the adjacent two-story building. The facility was toured between 10/06/25 through 10/08/25. The following areas of the single-level building needed cleaning and/or repair: * A pervasive urine odor was noted throughout the survey in the hallway between apartments 19 and 29; * Resident corridor carpets had multiple areas of dark staining; * Carpet in resident apartments 14 and 20 had dark staining; * Kitchenette cupboards and drawers were sticky to touch and had staining on interior surfaces. The cupboard that stored a garbage can was broken and did not close; * Both laundry rooms had a build-up of lint, dust, and debris; * The ‘Shut Off Valve’ laundry room had a broken washing machine, flooring pieces were missing, and the baseboard was missing and/or not connected to the wall; * Wooden furniture throughout the single-level building had white staining, lacked varnish, and/or was wobbly; * Fabric-covered furniture in the TV room had staining; * A resident apartment window along the southeast fenced pathway was cracked and repaired with tape; * Exit door from the television room had chipped paint; and * Smoking gazebo had broken railing near entrance. The areas needing cleaning and/or repair were shown to and discussed with Staff 2 (Interim ED) and Staff 4 (Maintenance Director) on 10/08/25 at 12:03 pm. They acknowledged the findings.

1.The Doors, Walls, Elevators, Odors areas identified in the survey will be corrected as follows: the odor in the hallway near room #29 was identified as coming from the resident room, which was cleaned. Carpets in hallways and resident rooms will be treated and cleaned by 12/15/25. RCF Kitchenette will be cleaned, repairs made and cupboard surfaces will be covered. Laundry rooms will be cleaned and repairs made. Furniture will be treated, cleaned and repaired or removed if repairs cannot be made. Resident windows identified in the survey will be repaired. The exit door in RCF tv room will be repainted. Gazebo railing will be repaired. 2.Maintenance Director will perform walk-throughs of the interior of the facility to identify areas of concern. 3.Maintenance Director will conduct these walk-throughs monthly and submit documentation of completion, repairs made, and report any identified areas of concern to administration. 4. Administrator will perform quarterly walk-throughs of the interior of the facility to identify areas of concern and submit to ownership.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees F when they were installed in locations that were subject to incidental contact by people or with combustible material. Findings include, but are not limited to: The residential care facility (RCF) was composed of a single-level building and one wing (eight rooms) in the adjacent two-story building. Observations were made of the interior of the facility from 10/06/25 through 10/08/25, and on 10/16/25. Resident apartments, common use restrooms and the staff breakroom in the single-level building had baseboard heaters controlled by a dial on the wall. On 10/06/25 at 2:09 pm, the temperature of the baseboard heaters in restroom 4 and apartment 1 were measured using a probe thermometer when the dial was in the highest position. The temperature readings were 144 degrees F, 126 degrees F, respectively. On 10/07/25 at 2:09 pm, this surveyor and Staff 4 (Maintenance Director) took additional temperature readings in apartment 13 and restroom 4 using a laser thermometer. Both baseboard heaters ranged from 125 degrees F to 155 degrees F. At this time, Staff 4 acknowledged the baseboard heaters exceeded 120 degrees F. On 10/16/25 at 11:53 am, the staff breakroom was toured, and the following was identified: A cardboard box of clothing and a plastic crate with Hoyer slings and gait belts stored in it was pushed up against the baseboard heater. Surveyor moved the items and turned on the wall dial thermostat. After a seven-minute time lapse the heater temperature measured 151.3 degrees F and was continuing to rise. On 10/16/25 at 2:00 pm the facility provided a plan to correct the deficient practice prior to survey exit. The need to ensure the covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees F was discussed with Staff 2 (Interim ED) and Staff 4 at 12:03 pm on 10/08/25 and 10/16/25 at 2:00 pm. They acknowledged the findings.

1. The baseboard heaters in resident rooms and bathrooms were measuring above 120 degrees using a laser thermometer. Maintenance Director checked all rooms to remove items within 12 inches above or in front of the baseboard heaters and staff check this daily. Facility tried several methods to reduce the temperatures (attempted to test locking thermostats, purchased and tested 2 different types of covers meant for safe touch use) and still the laser thermometer was recording temperatures significantly above 120. Due to suspected "mis-temping" a "ThermoWorks Pro-Surface Thermapen", with certificate of calibration was purchased. Rooms #1, #7, #12 and Bathroom #4 were all measured with the thermostat on high. Surface temps did not reach above 108/109 range even with thermostat at highest setting. 2. Maintenance Director will perform and document test of all baseboard heaters and record surface temperatures in each room/bathroom. Staff will continue to remove or report items that are within 12 inches above or in front of baseboard heaters. 3. Maintenance Director will audit all baseboard heaters once a month in the winter months, to ensure surface temperatures remain below 120. 4. Administrator will review MD monthly audits, and sample test at least 4 baseboard heaters quarterly.

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by:

OAR 411-054-0200 (10) Wiring Systems (10) ELECTRICAL REQUIREMENTS. (a) WIRING SYSTEMS. All wiring systems must meet the building codes in effect at the date of installation and shall be maintained and in good repair. (b) The use of extension cords and other special taps is not allowed. (c) LIGHTING. Lighting fixtures must be provided in each resident bedroom and bathroom, and be switchable and near the entry door. (A) Each resident bedroom must have illumination of at least 20-foot candles measured at three feet above the floor for way finding from the room entrance, to each bed, and to the adjoining toilet room, if one exists. (B) Lighting in toilet rooms and bathing facilities used by residents must be at least 50-foot candles, measured at the hand wash sink and three feet above the shower floor with the curtain open. (C) Corridor lighting must equal a minimum of 20-foot candles measured from the floor. (D) Table height lighting in dining rooms must equal a minimum of 25-foot candles, without light from windows. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the use of extension cords and other special taps was not permitted. Findings include, but are not limited to: During an environmental tour of the residential care facility (RCF) on 10/16/25, the following was observed: Extension cords, including electric power cords were used to extend the electric power source from main wall outlets in multiple resident units including unit numbers 4,18, and 24. The extension cord outlets were in full use, powering multiple appliances and other devices. The above findings were discussed with Staff 2 (Interim ED) and Staff 4 (Maintenance Director). Staff 2 stated she was aware the resident units had a limited number of wall outlets. She acknowledged the use of temporary wiring solutions such as extension cords posed a risk of overloaded circuits, potential fire and a tripping hazard. Staff 2 provided a plan to correct the deficient practice on 10/16/25 at 2:00 pm, prior to survey exit.

1.Residents were notified that extension cords, power strips and other special taps are prohibited. Many residents use these devices for medical equipment and necessary appliances. Maintenance Director has examined each room and attempted to make safer by inspecting for damage, removing any cords plugged into one another, keeping them away from water heat or pathways, and removed all cords that were in poor condition. 2. Current research is being done on how to add additional outlets in resident rooms. Staff will be educated on continuing to keep cords out of pathways and away from water and heat. 3. Maintenance Director will continue to follow up on options for additional wiring and submit to ownership. Until additional wiring can be added, Maintenance Director will perform safety checks on each room monthly and submit to Administration. 4. Administrator will review MD documentation quarterly and sample 4 resident rooms quarterly for safety in relation to wiring.

OAR 411-054-0200 (10) Wiring Systems (10) ELECTRICAL REQUIREMENTS. (a) WIRING SYSTEMS. All wiring systems must meet the building codes in effect at the date of installation and shall be maintained and in good repair. (b) The use of extension cords and other special taps is not allowed. (c) LIGHTING. Lighting fixtures must be provided in each resident bedroom and bathroom, and be switchable and near the entry door. (A) Each resident bedroom must have illumination of at least 20-foot candles measured at three feet above the floor for way finding from the room entrance, to each bed, and to the adjoining toilet room, if one exists. (B) Lighting in toilet rooms and bathing facilities used by residents must be at least 50-foot candles, measured at the hand wash sink and three feet above the shower floor with the curtain open. (C) Corridor lighting must equal a minimum of 20-foot candles measured from the floor. (D) Table height lighting in dining rooms must equal a minimum of 25-foot candles, without light from windows. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided to alert staff when residents exited the residential care facility (RCF). Findings include, but are not limited to: The interior and the exterior of the facility was toured between 10/06/25 and 10/08/25. The RCF was composed of a single-level building and one wing (eight rooms) in the adjacent two-story building. During the survey, the building was under construction with doors and hallways blocked for resident safety. Residents who resided in the wing of the two-story building had to exit from a side door and walk around the building to enter the single-level building for activities or to eat with other residents of the RCF. During the acuity interview on 10/06/25 at approximately 9:45 am, seven residents were identified to have cognitive decline, wandered, and/or would not be able to find their way back to the facility if they left independently. Review of the facility’s ABST Questionnaire, dated 10/06/25, indicated 14 of 34 residents required cognitive support. Resident 2 was identified in his/her service plan, dated 06/14/25, as having a diagnosis of dementia with disorientation to person, place, time or situation. The service plan stated that the resident “has poor judgement and should not leave the facility unsupervised.” Multiple staff interviewed on 10/07/25 confirmed that if the resident exited the facility s/he would not be able to find his/her way back independently. On 10/07/25 at 1:00 pm, Resident 2 was observed opening his/her apartment door and beginning to exit the room. The resident’s apartment was adjacent to an exit door that was propped open and lacking a method to alert staff if the resident exited the facility. On 10/07/25 at 2:09 pm, Staff 4 (Maintenance Director) reported the facility’s exit doors were alarmed nightly at 7:30 pm when the doors locked. Therefore, the facility lacked a system to alert staff when a resident exited the RCF prior to 7:30 pm. The need to ensure an exit door alarm or other acceptable system was provided to alert staff when residents exited the RCF was discussed with Staff 2 (Interim ED) and Staff 4 on 10/08/25 at 12:03 pm. They acknowledged the findings, and at 12:45 pm on 10/08/25 it was confirmed all exit doors were alarmed and would remain alarmed.

1. All exterior doors had been on a setting to alert our monitoring system from 9pm - 7am. Prior to the close of survey, the exterior doors were changed to alert our monitoring system 24/7. 2. The I-alert system will remain with the settings for 24/7 alerts for exterior doors. 3. MD will test all exterior doors to ensure they are alerting our monitoring system, no less than monthly. 4. Administrator will review MD records and test doors at least quarterly.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 3 sampled residents (#3) and one unsampled resident had a key to their unit. Findings include, but are not limited to: a. During an observation and interview on 10/09/25 at 11:18 am with Resident 3, it was determined the resident did not have a key to his/her unit. The resident showed the surveyor the keys provided to him/her which was only a mailbox key. During a follow up interview with Staff 3 (Business Office Director) and Staff 6 (Community Relations Director) on 10/10/25 at 10:30 am, both staffed stated “we don't have residents sign for receiving keys at move in.” Staff 3 stated “this is not something we have ever done in the past.” Staff 6 stated "as part of Marketing I do admissions, give tours and tell them an approximate bill amount, I have a checklist for a potential new resident.” Review of a blank copy of the resident move in checklist identified there was no indication the facility discussed or provided any type of keys to new residents. Review of Resident 3’s service plan dated 07/10/25 and updated on 08/10/25 did not have information regarding access to keys to his/her unit. b. During a group interview of five unsampled residents on 10/08/25 at 1:30 pm, an unsampled resident stated that s/he had never received a key to his/her room. During a follow-up interview on 10/10/25, the resident confirmed that s/he did not have a key to his/her room despite having requested a key from facility management multiple times in the past. The need to ensure residents had a key to access their unit was reviewed with Staff 2 (Interim ED) on 10/09/25 at 1:45 pm. She acknowledged the findings.

1. The residents that were identified in the survey, were re-issued any keys to their apartment, lock box and mail box that they were missing. 2. All other resident's are to be audited to ensure they have all necesary keys. BOD will complete key forms and residents will be re-issued any keys they are missing. Residents will be educated that if they lose a key, they may contact the BOD to get a replacement. 3. BOD will review a sample of the new move in key forms to ensure complete and a sample of residents to ensure they have all necessary keys, at least quarterly. 4. Administrator will review BODs documentation of the sample audits quarterly.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: