Print Inspection: CHOW007409

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to report injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office, or the local Area Agency on Aging (AAA), as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injuries were not the result of abuse, for 1 of 1 sampled resident (#3) with injuries. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2025 with diagnoses including insulin-dependent diabetes and Wernicke dementia. During an interview with the resident on 10/27/25 at 11:15 am, two surveyors observed that Resident 3 had an approximate 1X.5 cm open wound on his/her left shin, a 1X.5 cm open wound on the right side of his/her lower leg, and .5 cm open wound on his/her right 4th toe. When asked, Resident 3 stated s/he was unsure how the injuries occurred. There was no documentation in the resident's record regarding the wounds. Incident investigations were requested during the survey. On 10/29/25 at 1:40 pm, Staff 2 (Assistant Manager) reported no incident investigations had been completed regarding the injuries. The injuries to Resident 3's legs and toe represented incidents that should have been reported to the local SPD office or the local AAA unless an immediate facility investigation reasonably concluded and documented that the physical injuries were not the result of abuse. There was no documented evidence the facility either reported the incidents or immediately investigated the incidents and ruled out abuse. The incidents were reviewed with Staff 1 (ED) and Staff 2 on 10/29/25 at 2:40 pm. They stated they were not aware of the injuries and had not reported or investigated the incidents. The surveyor directed the facility to self-report the incidents to the local SPD or AAA office as suspected abuse. Confirmation the facility reported the incidents was received on 10/29/25.

On 11/5/25 ED presented in our All-Staff meeting Abuse Reporting and Investigation training . A pre-service and ongoing training to ensure we all understand our roles in Abuse Prevention, Reporting and Investigation. We reviewed what is a Mandatory Reporting and responsibilities, abuse-self reporting requirements, Arbor Senior Living Policies and Procedures related to abuse and suspected abuse and injury of unknown causes, investigations, responses and reporting. We aew now implementing daily reviews of events in the last 24 hours and ensuring that all documentation and reporting has been completed with staff and education provided as needed. Executive Director and Asssistant Manager will continue a on going trianing.

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

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation for residents who resided on the first floor. Findings include, but are not limited to: The MCC was a two-story building and was home to 33 residents: 15 residing on the first floor and 18 residing on the second floor. The facility had an elevator allowing residents the opportunity to move between floors; however, it was not safely working during the survey. According to Staff 1 (ED) and resident council notes, the elevator had not been working properly since 06/2025. The activity calendar provided on 10/27/25 revealed multiple activities that would occur during the survey. Observations on 10/27/25 and 10/28/25 revealed activities occurred on the second floor, but none on the first floor. Most residents on the first floor remained in their rooms or were sitting in the common area with the television on. During an interview on 10/29/25 at 12:35 pm, Staff 3 (Activities Director) stated the elevator was currently not being used to transport residents between floors. He said that most activities were held on the second floor because “the residents are more engaged and ask for activities.” Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/29/25 at 2:20 pm. They acknowledged the findings.

On October 30th we had our resident council, hosted by the Activities Director, Chef, Executive Director and as a guest the Ombudsman. Our main topics were activities and how we will engage more participation. A Activities Survey was created by out Activities Director to increase more participation based on a personal level preference .The number of activities has been equally split on both floors, and we have noticed an immediate increase in participation. Also, the activities director enrolled for a Life Enrichment webinar from Oregon Care Partners on November 13, 2025 - 1:00 PM - 4:00 PM. Executive Director will have a weekly meeting with Activities Director to make sure all expectations are met.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in 10/2025. The new move-in evaluation failed to address the following elements: * Pronoun; * Gender identity; * Physical health status including list of medications and PRN use and visits to health practitioner(s), ER, hospital, or NF in the past year; * Mental health issues, including effective non-drug interventions; * Cognition, including decision-making abilities; * Personality, including how the person copes with change or challenging situations; * Pain, including non-pharmaceutical interventions and how a person expressed pain or discomfort; * Nutrition habits and fluid preference; * List of treatments; * Indicators of nursing needs, including potential for delegated nursing tasks; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; * Elopement risk or history; * Alcohol and drug use, not prescribed by a physician; and * Environmental factors that impact the resident’s behavior, including noise, lighting, room temperature. The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/29/25 at 1:20 pm. Staff acknowledged the findings.

Resident move-in Evaluation forms were updated on 10/30/25 with all the initial screening details requirements to be in compliance with OAR 411-054-0034. All initial, 30-day move-in and quarterly services plans have been updated with specific requirements.Exectuive Director and Assistant Manager will review all new-in documents to ensure we meet all requirements and have a quaterly audit to ensure proper documentation.

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

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 1 of 1 sampled resident (#3) reviewed for delegation. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the nursing procedure, and observing the staff demonstrate the task. Resident 3 was admitted to the facility in 04/2025 with diagnoses including insulin-dependent diabetes and Wernicke dementia. Resident 3 had physician orders for the following: * Blood sugar checks before meals and at bedtime; * Insulin Aspart (rapid acting insulin) 20 units via PEN three times a day before meals; * Insulin Glargine (long-acting insulin) 70 units via PEN once a day before breakfast; and * PRN Insulin Aspart 10 units via PEN once daily as needed for blood sugar of 400 or greater. According to the resident’s MAR, reviewed from 10/01/25 through 10/27/25, MAs initialed that they were checking the resident’s CBGs and administering insulin. However, during interviews with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/28/25, and Staff 4 (MA) on 10/29/25, they stated staff checked the resident’s CBGs, determined the amount of insulin to be given, dialed the appropriate dose on the insulin pen, handed it to the resident, and observed him/her inject the medication. Delegation documentation was requested on 10/28/25. On 10/28/25 at 3:20 pm, Staff 1 informed the survey team that he was unable to find delegation for any of the MAs. He further stated he called the facility RN responsible for delegation, and she reported that staff had not been delegated. The facility RN responsible for delegation was not present at the facility during the survey. On 10/29/25 at 9:30 am, Staff 1 informed the survey team that the facility RN came in at 5:30 am that morning, delegated two MAs, and would delegate the rest of the MAs as soon as possible. He stated MAs would be performing both the CBGs and administering the insulin moving forward. Copies of the delegation were provided to the survey team. The need to ensure staff were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 and Staff 2 on 10/29/25 at 2:40 pm. They acknowledged the findings. Additional information regarding CBC Delegation Division 47 – OSBN Nurse Practice Act Standards for Community-Based Care Registered Nurse Delegation was provided to Staff 1.

On 10/29/25 facility RN rectified this issue by delegating two med-technicians and as of 11/11/25 all med-tech have been delegated by the facility RN. Administrator also enrolled for a two-day training course for Nursing Practice in Community-based Care: Training for Nurses in ALFs, RCFs and Memory Care on 11/18/25 to 11/19/25 with Leading Age Oregon to be further educated in the delegation process to allow further collaboration with facility RN.Moving forward Exectutive Director, Assistant Manager and Resident Care Coordinator will enure all med-tech get delegated

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 moved into the MCC in 01/2011 and had diagnoses which included dementia and chronic pain and had recently been admitted to hospice services. Resident 2 had an order for oxycodone HCL (narcotic analgesic) 5 mg, one tablet every four hours PRN pain or shortness of breath. Resident 2's Controlled Substance Disposition Logs and MARs, reviewed from 10/01/25 through 10/27/25, revealed 14 occasions when staff signed on the drug disposition log that the oxycodone was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/29/25 at 2:30 pm. They reviewed the documentation and acknowledged the discrepancies.

As of 11/7/2025 all Med-Tech went under full training on proper documentation for full controlled Substances Disposition Logs and Mars. A weekly audit will be reviewed by the Resident Care Coordinator. Facility RN reviewed and updated protocols related to medication destruction with new recording system. As of 11/7/25 all residents’ physicians have been faxed a form to request how often they would like to be notified when a resident refuses their medication and our medication Refusal policy has been updated, reviewed it and signed by all med-tech. A weekly audit will be conducted by Resident Care Coordinator these requirements are met.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 3 sampled residents (#3) whose medications were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the MCC in 04/2025 with diagnoses including insulin-dependent diabetes and Wernicke dementia. Resident 3 had physician orders for the following: * Insulin Aspart (rapid acting insulin) 20 units via PEN three times a day before meals; * Insulin Glargine (long acting insulin) 70 units via PEN once a day before breakfast; and * PRN Insulin Aspart 10 units via PEN once daily as needed for blood sugar of 400 or greater. According to the resident’s MARs, reviewed from 10/01/25 through 10/27/25, MAs initialed that they were administering insulin. However, during interviews with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/28/25, and Staff 4 (MA) on 10/29/25, they stated staff checked the resident’s CBGs, determined the amount of insulin to be given, dialed the appropriate dose on the insulin pen, handed it to the resident, and observed him/her inject the medication. The MARs did not indicate that the resident self-injected his/her insulin. In an interview on 10/28/25 at 10:10 am, Staff 4 reviewed the MAR. She verified that staff did not administer the insulin even though the MAR indicated they did. The need for the facility to ensure MARs were accurate was discussed with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/29/25 at 2:40 pm. They acknowledged the findings.

As of 10/29/25 our Memory Care facility is fully responsible for administering prescription medication to all residents. Policies and procedures are in place where all pre- screening, new resident move in assessment and new resident policy will specify the facility is fully responsible for administering prescription medication. Moving forward Executive Direcor, Assistant Manager and RN facility will be responsible to address this with residents prior moving in.

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated quarterly for safety and ensure physician's orders were in place for the self-administration of prescription medications for 1 of 1 sampled resident (#3) who self-administered insulin. Findings include, but are not limited to: Resident 3 was admitted to the MCC in 04/2025 with diagnoses including insulin-dependent diabetes and Wernicke dementia. Resident 3 had physician orders for the following: * Insulin Aspart (rapid acting insulin) 20 units via PEN three times a day before meals; * Insulin Glargine (long-acting insulin) 70 units via PEN once a day before breakfast; and * PRN Insulin Aspart 10 units via PEN once daily as needed for blood sugar of 400 or greater. According to the resident’s MARs, reviewed from 10/01/25 through 10/27/25, MAs initialed that they were administering insulin. However, during interviews with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/28/25, and Staff 4 (MA) on 10/29/25, they stated staff checked the resident’s CBGs and dialed the appropriate dose on the insulin pen, then handed it to the resident and s/he administered it him/herself. A review of the clinical record revealed the following: * The initial move-in evaluation, dated 04/15/25, indicated the resident had “good hand dexterity” to use an insulin pen and was “able to self-inject.” However, additional evaluations, dated 05/15/25 and 08/15/25, lacked information about the resident’s continued ability to safely self-administer his/her insulin; and * There was no signed order from a legally recognized practitioner for the resident to self-administer insulin. Additional information was requested during the survey. In an interview on 10/29/25 at 9:30 am, Staff 1 (ED) and Staff 2 (Assistant Manager) stated the evaluation had not been completed quarterly nor was there an order from a legally recognized practitioner for the resident to self-administer insulin. The need to ensure residents were evaluated at least quarterly for their ability to safely self-administer prescription medications and to have a current signed order for self-administration was discussed with Staff 1 and Staff 2 on 10/29/25 at 2:40 pm. They acknowledged the findings.

As of 10/29/25 our Memory Care facility is fully responsible for administering prescription medication to all residents. Policies and procedures are in place where all pre- screening, new resident move in assessment and new resident policy will specify the facility is fully responsible for administering prescription medication. Moving forward Executive Director, Assistant Manager and RN facility will be responsible to address this with residents prior moving in.

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have adequate direct care staff present at all times to meet the 24-hour scheduled and unscheduled needs of each resident as outlined in the acuity-based staffing tool (ABST). Findings include, but are not limited to: The facility was licensed as a Memory Care Facility with a capacity of 40 beds. During the entrance conference and review of the ABST facility entrance questionnaire on 10/27/25, the following was identified: * The facility was home to 33 residents; * The facility consisted of a two-story building, and each floor had its own exit door; * Four residents required assistance in the dining room; * Three residents required multiple staff members to transfer or provide care, including using a mechanical lift; and * Three residents required support for behavioral symptoms. The posted staffing plan in the lobby indicated the following information: * Day shift: 5 CGs and 2 MAs; * Swing shift: 4.5 CGs and 1.5 MAs; and * Overnight shift: 2 CG and 1 MA. The facility’s Acuity-Based Staffing Tool (ABST) data indicated the facility required a minimum of the following direct care staff members: * Day shift: 5.3 staff; * Swing shift: 4.5 staff; and * Noc shift: 2.1 staff. The staff schedule was reviewed, and the following was identified: * On 7 of 21 shifts, the facility was understaffed and did not meet the ABST-outlined staffing level. The need to ensure the facility had adequate direct care staff members as outlined in their ABST was discussed with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/29/25 at 10:00 am. They acknowledged the findings.

The posted staffing plan in the lobby has been updated as of 11/10/25. Assistant Manager will update ABST weekly ensuring we have the adequate staff outlined in our lobby and our report. Executive Director will meet weekly with Assistant Manager to make sure we compliance with our ABST.

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

OAR 411-054-0037 (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 the Acuity Based Staffing Tool (ABST) was updated at least quarterly and to enter a new move-in resident prior to move-in and failed to determine appropriate staffing levels to address activities of daily living and other tasks related to care. Findings include, but are not limited to: Observations, interviews, and review of clinical records, including service plans for Resident 1, revealed the facility's ABST tool was not updated quarterly, and a newly admitted resident was not entered into the ABST at the time of the survey, in order to ensure the ABST was accurately determining the needed staffing levels. On 10/28/25 at 1:35 pm, the need to ensure the ABST tool was updated to determine appropriate staffing levels to address activities of daily living and other tasks related to care was discussed with Staff 1 (ED) and Staff 2 (Assistant Manager). They acknowledged the findings.

As of 11/3/2025 all residents ABST quarterly have been updated. A new system in place has been created with an updated service plan schedule with a quarterly ABST schedule reminder. Executive Director, Assistant Manager and RN will follow up quarterly to make sure this task is completed.

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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Six months of fire and life safety records were requested on 10/27/25 and reviewed on 10/28/25. The following was identified: a. Fire and life safety instruction to staff was not conducted consistently on alternating months. b. The documented fire drills conducted on 05/29/25 and 09/26/25 lacked the following required components: * Location of simulated fire origin; and * Number of occupants evacuated. The requirement regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ED) and Staff 2 (Assistant Manager) on 10/28/25 at 1:25 pm. They acknowledged the findings.

Executive Director has taken immediate action on implementing a rule as of 10/27/25 to conduct and document with all details to mention a few such as location, number of occupants evacuated etc., and a fire drill every other month and a fire and life safety in service training. Executive Director and Assistant manager will follow up and conduct this task monthly and has been added into our yearly calendar.

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 and outside areas were maintained in good repair. Findings include, but are not limited to: The courtyard was toured on 10/29/25. The concrete pathway had several areas of drop-offs and the concrete at the end of the parking lot had uneven surfaces. On 10/29/25 at 10:20 am, the area was reviewed with Staff 1 (ED). He acknowledged the findings.

Executive Director reached out to Jeanne Bristol to request an extended time to find a vendor, budget approval and project to be completed. On 11/12/2025 Jeanne Bristol approved two additional months for this citation. Our AOC date is no later than 12/28/2025. We are grateful for your support and are giving us two additional months. We are fully committed to meeting our deadlines and documenting all our progress.

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 an interview at 10:40 am on 01/14/26 with Staff 1 (Administrator), it was confirmed the facility had received an extension for the allegation of compliance until 02/28/26.

The parkign lot is currently under repair for this citation. with the extended approval we receive until 2/28/26 we precdict this project will be completed 2/4/26.The administrator will be responsbile moving forward to maitain the building in compliance.

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 environment was kept clean and in good repair. Findings include, but are not limited to: Observation of the facility on 10/27/25 through 10/28/25 showed the following areas were in need of cleaning and/or repair: First floor: * Ceiling and wall vents throughout the facility, especially next to Room 12, next to console, and above main entrance door, had accumulated dust; * Several sprinkler heads had spiderwebs; * First floor shower room walls and floor had significant chips; * Ceiling in the dining room had multiple areas with water damage and gaps between the frame and ceiling panels; and * Walls throughout the dining area had chips and gouges. Second floor: * The entrance wall of the kitchenette had visible spills; * Strong and pertinent unpleasant odors, particularly on the second-floor hallway and in the public bathroom across from the dining room; * Wall at the entrance of the Med-Room had visible spills; * Entrance floor of Room 3 had gaps between the hallway and the room due to missing transition material; and * The exterior of the building, especially along the parking lot, had accumulated spiderwebs. On 10/27/25 at 12:00 pm and 10/28/25 at 1:30 pm, the above areas were toured with Staff 1 (ED), who acknowledged the findings.

From 10/31/25 to 11/08/25 First floor ceiling and wall vents have been dusted including sprinkler heads. First floor shower and walls have been repaired. Ceiling tiles have been ordered and expected to arrive by 11/28/25 and to be installed immediately. Drywall repairs and paint are scheduled for 11/18/25. Moving forward Executive Director and Maintenance Technician will do a walkthrough of the building weekly and monthly projects recap. Second floor entrance of the kitchenette wall spills has been cleaned, and a weekly housekeeping walkthrough has been scheduled with the Executive Director to make sure this task has been completed. Strong odor on the second floor has been addressed by adding more housekeeping services to each room and public bathroom and shower rooms. Housekeeper will meet weekly with Executive Director to make sure all clean expectations are met. Entrance floor of room 3 door strip has been installed 11/7/25. The exteriors of the building with spiderwebs have been cleaned by our maintenance technician. Moving forward Executive Director and Maintenance Technician will do a walkthrough of the building weekly and monthly projects recap.

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

Resident move-in Evaluation Form was immediately updated on 10/30/25 with all the initial screening detail requirements to be in compliance with OAR 411-054-0034. All initial, 30-day move-in and quarterly services plans have been updated with specific requirements.Executive Director and Assistant manager will consult moving forward to our policy annalyst to make sure all our forms are current or if needs to be updated.

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

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 231, C 242, C 360, C 363, C 420, C 510, C 513, and C 545.

After state survey exit on 10/29/25 Executive Director took inmediate action to comply wiith both licensing rules. Same rules and policies and updated forms will also apply to C321,C242,C360,C363,C420,C510,C513and C545. Exectuive Director will continue to work with our Policy Analyst to continue to be in compliance.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on an interview at 10:40 am on 01/14/26 with Staff 1 (Administrator), it was confirmed the facility had received an extension for the allegation of compliance until 02/28/26. Refer to C510.

The parkign lot is currently under repair for this citation. with the extended approval we receive until 2/28/26 we precdict this project will be completed 2/4/26.The administrator will be responsbile moving forward to maitain the building in compliance.

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 4, 5, 6, and 7) completed all required pre-service orientation training topics, 3 of 3 newly-hired direct care staff (#s 4, 5, and 6) completed all required pre-service dementia training topics, and 4 of 4 newly-hired direct care staff (#s 4, 5, 6, and 8) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/28/25 at 9:55 am with Staff 2 (Assistant Manager) and the following areas were identified: 1. There was no documented evidence Staff 4 (MA), Staff 5 (CG), Staff 6 (MA), and Staff 7 (Maintenance), hired 06/20/25, 08/18/25, 08/29/25, and 06/06/25, respectively, had completed one or more of the following pre-service orientation topics before completing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious Disease Prevention; * Approved HCBS course; and * LGBTQIA2S+ course. 2. There was no documented evidence Staff 4 (MA), Staff 5 (CG), and Staff 6 (MA), hired 06/20/25, 08/18/25, and 08/29/25, respectively, completed the following pre-service dementia training topics: * Dementia disease process, including progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating, and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia, including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach; * Environmental factors that are important to a resident’s well-being; * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. 3. There was no documented evidence Staff 4 (MA), Staff 5 (CG), Staff 6 (MA), and Staff 8 (CG) demonstrated competency in one or more of the following areas within 30 days of hire: * Role of services plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documenting and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Other duties, medication administration. On 10/28/25 at 11:30 am, the surveyor requested Staff 6 (MA) be removed from the schedule until medication administration competency was completed and demonstrated. The need to ensure the required pre-service orientation and training was completed by staff in the time frames specified in the rules and staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 on 10/28/25. They acknowledged the findings.

All staff at Arbor got an immediate notice that all staff training must be completed by 12/1/25. Including their continuing CEU. Executive Director and Assistant Manager have reviewed all policies and procedures, creating a new system to keep all staff up to date with all training and all new hires must complete all mandatory training courses prior to starting employment at Arbor. Executive Director will meet monthly to audit all training courses are in compliance.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 252, C 282, C 302, C 310 and C 325.

After state survey exit on 10/29/25 Excetutive Director too inmediate action to comply wiith both licensing rules. Same rules and policies and updated forms will also apply to C252,C282,C302,310 and C325. Executive Director will continue to work with our Policy Analyst make sure all we are up to date with all licensing rules.

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

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation areas was of sufficient weight and design to not aid in elopement and that fencing was no less than six feet in height. Findings include, but are not limited to: On 10/27/25 and 10/28/25 tours of the facility courtyard showed the following: * Six metal patio chairs which were easily moveable and not of sufficient weight or design to prevent potential elopement; * The facility was asked on 10/28/25 to remove the chairs or secure them to prevent elopement; and * Staff 1 (ED) was asked to measure the metal fence on 10/27/25 at 12:00 pm, which was found to be less than six feet in height, with sections measuring approximately 71 inches tall. The fencing sections that were less than six feet in height, as well as the need for outdoor furniture in the recreation area to be designed and weighted adequately to prevent elopement, were discussed with Staff 1 on 10/27/25 and 10/28/25. The staff acknowledged the findings.

Patio furniture was easily moveable and not sufficient weight to prevent potential elopement. On 10/28/25 the six chairs were immediately removed by the Executive Director and will be reinstalled next spring with a safety security system in place to prevent the chairs to be used as a tool for elopement. Our building metal fence was found to be less than 6 feet in height with sections measuring 71 inches tall. Executive Director reached out to Jeanne Bristol to request an extended time to find a vendor, budget approval and project to be completed. On 11/12/2025 Jeanne Bristol approved two additional months for this citation. Our AOC date is no later than 12/28/2025. We are grateful for your support and are giving us two additional months. We are fully committed to meeting our deadlines and documenting all our progress.

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

OAR 411-057-0170(10) Exit Doors (10) EXIT DOORS. (a) Locking devices used on exit doors, as approved by the Building Codes Agency and Fire Marshal having jurisdiction over the memory care community, must be electronic and release when the following occurs: (A) Upon activation of the fire alarm or sprinkler system; (B) Power failure to the facility; or (C) By activating a key button or keypad located at exits for routine use by staff. (b) If the memory care community uses keypads to lock and unlock exits, then directions for the keypad code and their operation must be posted on the outside of the door to allow access to the unit. However, if all of the community is endorsed, then directions for the operation of the locks need not be posted on the outside of the door. (c) Memory care communities may not have entrance and exit doors that are closed with non-electronic keyed locks. A door with a keyed lock may not be placed between a resident and the exit. (d) If the memory care community does not post the code, the community must develop a policy or a system that allows for visitor entry. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure locking devices used on exit doors were electronic and were released when the fire alarm or sprinkler system was activated or in the event of a power failure to the facility. Findings include, but are not limited to: During the tour of the building, it was observed that there were few exit doors, and the following was noted: *The first-floor exit leading to the patio or gazebo area had an electronic keypad. However, on 10/28/25 at 12:00 pm, Staff 1 (ED) reported the door did not release during the fire drill and required a code to disengage the lock, even in the event of a fire; * The main entrance had a second door operated by a battery-powered keypad. Staff 1 confirmed that the door did not release automatically in the event of a fire; and * The secure courtyard was toured and observation showed one gate in the courtyard, which was secured with a non-electronic combination padlock. The need for all exit doors to have electronic locking devices which released automatically in specific situations was discussed with Staff 1 on 10/29/25. He acknowledged the findings.

First floor exit leading to the patio area has an electrical keypad but doesn’t release during a fire drill as is required in the event of a fire. Executive Director reached out to Jeanne Bristol to request an extended time to find a vendor, budget approval and project to be completed. On 11/12/2025 Jeanne Bristol approved two additional months for this citation. Our AOC date is no later than 12/28/2025. We are grateful for your support and are giving us two additional months. We are fully committed to meeting our deadlines and documenting all our progress. The main entrance has a second door battery operated and doesn’t not release automatically in an event of a fire and the secure courtyard showed one gate with a non-electric combination padlock as of 10/30/25 this padlock has been removed however we have been instructed that this door requires an automatic release in the event of a fire. Executive Director reached out to Jeanne Bristol to request an extended time to find a vendor, budget approval and project to be completed. On 11/12/2025 Jeanne Bristol approved two additional months for this citation. Our AOC date is no later than 12/28/2025. We are grateful for your support and are giving us two additional months. We are fully committed to meeting our deadlines and documenting all our progress.

OAR 411-057-0170(10) Exit Doors (10) EXIT DOORS. (a) Locking devices used on exit doors, as approved by the Building Codes Agency and Fire Marshal having jurisdiction over the memory care community, must be electronic and release when the following occurs: (A) Upon activation of the fire alarm or sprinkler system; (B) Power failure to the facility; or (C) By activating a key button or keypad located at exits for routine use by staff. (b) If the memory care community uses keypads to lock and unlock exits, then directions for the keypad code and their operation must be posted on the outside of the door to allow access to the unit. However, if all of the community is endorsed, then directions for the operation of the locks need not be posted on the outside of the door. (c) Memory care communities may not have entrance and exit doors that are closed with non-electronic keyed locks. A door with a keyed lock may not be placed between a resident and the exit. (d) If the memory care community does not post the code, the community must develop a policy or a system that allows for visitor entry. This Rule is not met as evidenced by: Based on an interview at 10:40 am on 01/14/26 with Staff 1 (Administrator), it was confirmed the facility had received an extension for the allegation of compliance until 02/28/26.

The administrator is currently working with the fire marshall designated to our facility to review the fire exit door.The facility Administrator is currently workig with an electrician team to install a fire door system in our gate. With the approved extended time we guaranteed we will be in complaince by 2/28/26

OAR 411-057-0170(10) Exit Doors (10) EXIT DOORS. (a) Locking devices used on exit doors, as approved by the Building Codes Agency and Fire Marshal having jurisdiction over the memory care community, must be electronic and release when the following occurs: (A) Upon activation of the fire alarm or sprinkler system; (B) Power failure to the facility; or (C) By activating a key button or keypad located at exits for routine use by staff. (b) If the memory care community uses keypads to lock and unlock exits, then directions for the keypad code and their operation must be posted on the outside of the door to allow access to the unit. However, if all of the community is endorsed, then directions for the operation of the locks need not be posted on the outside of the door. (c) Memory care communities may not have entrance and exit doors that are closed with non-electronic keyed locks. A door with a keyed lock may not be placed between a resident and the exit. (d) If the memory care community does not post the code, the community must develop a policy or a system that allows for visitor entry. This Rule is not met as evidenced by: