Print Inspection: CHOW008841

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to make staff instructions part of the resident record for a short term change of condition and failed to evaluate the resident, refer to the facility nurse and update the service plan as needed for significant changes of condition, for 1 of 3 sampled residents (#3) with short term or significant changes of condition. Findings include, but are not limited to: Resident 3 was admitted to the facility in 09/2020 with diagnoses including dementia with behavioral disturbance and chronic pain. Review of Resident 3’s clinical record indicated the following: a. The resident had a non-injury fall on 11/17/25. Through its investigation of the fall, the facility determined a new intervention was to have the resident wear non-skid socks when in bed to try to reduce falls if the resident exited the bed during the night without staff present. The new intervention regarding non-skid socks was not added to the resident’s service plan. b. The resident had a fall on 10/26/25 and was diagnosed on 11/05/25 with a fracture to the humeral head (shoulder joint). The fracture represented a significant change of condition for which an RN assessment was required along with changes to the resident’s service plan, if necessary, based on the assessment. Staff 6 (LPN) completed an evaluation of the fracture on 11/13/25 – six days after the diagnosis – and no new interventions were noted. In an interview on 01/15/26, Staff 2 (RN) stated she had not been informed of the fracture and had not conducted an assessment. She also acknowledged instructions for how to assist with ADLs to protect the resident’s arm/shoulder should have been developed, added to the service plan and communicated to staff. The facility failed to refer the significant change of condition to the facility RN for an assessment and failed to update the resident’s service plan as needed. c. On 12/19/25, staff documented the discovery a “dime size open area” on the resident’s buttock. An open area on an area of the body exposed to pressure could represent a significant change of condition for which an RN assessment would be required. A nurse, Staff 6 (LPN), did not evaluate the wound until 12/24/25 – five days after it was discovered – and documented the wound as “superficial skin breakdown” at that time. In an interview on 01/15/26, Staff 2 (RN) stated she had not been informed of the wound. She stated she could not say for certain what level of severity the wound was without seeing it immediately when it was discovered. She further stated she expects to be informed of all significant injuries so that she can assess them as needed. She acknowledged the wound could have improved over the five days between when it was first identified and when it was seen by Staff 6. The need to ensure new interventions were added to the resident’s service plan and significant changes of condition were evaluated, referred to the facility nurse and the service plan was updated, was discussed with Staff 1 (ED), Staff 4 (Resident Services Director) and Staff 12 (Senior General Manager) on 01/15/26 at 1:10 pm. They acknowledged the findings. Staff 12 confirmed that wounds should be referred to the facility RN for assessment.

1. Resident 3's service plan was updated to include the intervention regarding non-skid socks while in bed. RN performed change of condition assessment on 01/13/2026 for fracture and evaluated/updated the service plan to include current needs for Resident 3. The example for Resident 3 of the open area has since healed. 2. Training provided to LPN and direct care staff on change of condition interpretive guidelines including when to report to RN. Implemented nurse communication log for staff to communicate and/or refer to RN for any changes of conditions to result in a timely RN assessment. Moving forward when any change of condition occurs resulting in interventions being implemented, the interventions will be added to the service plan and scheduled accordingly per regulation and policy. This will be corrected as part of the service planning that occurs immediately following an evaluation. 3. This system and correction(s) will be evaluated and monitored during each change of condition evaluation and quarterly evaluation. 4. The Administrator and community RN will oversee and monitor this to ensure compliance. The RN will be responsible to complete change of condition assessments and ensure ongoing monitoring.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to prevent the development and transmission of communicable diseases. Findings include, but are not limited to: Meal service was observed in the MCC dining room on 01/12/26 between 11:30 am and approximately 12:20 pm. Food was prepared and provided by the main facility kitchen and placed in a steam table in the MCC kitchenette. Caregivers, who had assisted residents with basic ADL care earlier in the day, plated and served the food. The following was observed: * The caregivers did not don any kind of protective covering to prevent cross contamination from their clothing which may have been contaminated during the provision of ADL care. * Multiple caregivers failed to change gloves or wash hands after contact with residents’ clothing, hair or wheelchair handles, or after clearing used dinnerware from the tables, and before serving food to other residents. The need to ensure all staff followed infection control protocols to prevent the development and transmission of communicable diseases was discussed with Staff 12 (Senior General Manager) on 01/15/26 at 3:00 pm. She acknowledged the findings.

1. Inservice to all staff to follow infection control protocols to include washing their hands before serving food and/or after they touch residents' clothing, wheelchairs, dirty dishes, etc. All direct care staff serving will don aprons to prevent cross contamination from their clothing before serving food. 2. This has been corrected through the purchase of aprons, followed by training to staff members on these expectations moving forward. Trianing included following infection control policies on appropriate glove changes in between touching "dirty" to "clean" and appropriate hand washing. 3. This will be evaluated daily when the Administrator is present and the manager on duty will evaluate this when the Administrator is not present. 4. This process will be evaluated daily at each meal time by the Memory Care Administrator and then the manager on duty when the Administrator is not present. The General Manager will evaluate this to ensure compliance weekly.

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

OAR 411-054-0055 (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 included resident-specific parameters for PRN medications and medication-specific instruction to instruct non-licensed staff for 2 of 3 sampled residents (#s 2 and 3) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2025 with diagnoses including dementia and anxiety. a. Resident 2's 12/18/25 through 01/12/26 MARs were reviewed and identified the following as needed bowel medications lacked resident specific parameters and clear instructions for unlicensed staff: • Polyethylene Glycol 17 gram; • Milk of magnesia 30 ml; • Bisacodyl tablet 5mg; and • Bisacodyl suppository. In interview on 1/15/26 at 1:00 pm, Staff 11 (Resident Care Coordinator acknowledged the instructions required clarification. There were not clear instructions or parameters for the sequence of use, and/or if there was a time frame in which staff should wait before administering the other PRN bowel medications. b. The MAR lacked specific instructions for which to use first for the following psychotropic prn medications: • Hydroxyzine 25 mg; and • Quetiapine Fumarate 12.5 mg The indicators for use in the orders were exactly the same for both medications: “As evidenced by pacing, insomnia, clenching hands, talking fast, calling staff frequently or restlessness.” In an interview on 01/14/26, Staff 1 (Executive Director) and Staff 12 (Senior General Manager) acknowledged the current indicators for use did not provide unlicensed staff adequate direction regarding which medication to administer if the resident was exhibiting those behaviors. The need to ensure the MAR included parameters and clear instructions for unlicensed staff to follow was reviewed with Staff 1 (ED) and Staff 12 (SGM) on 01/15/25 at 3:15 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 09/2020 with diagnoses including dementia with behavioral disturbance and chronic pain. Review of the resident’s most recent signed physician order summary, dated 01/02/26, and the 12/01/25 through 01/11/26 MAR indicated the following: a. Resident 3 was prescribed three PRN medications to address pain: * Acetaminophen 500 mg as needed for pain rated 1 – 5 on a 10-point scale; * Morphine sulfate 0.25 ml as needed for moderate pain rated 4 – 6 on a 10-point scale; and * Oxycodone 5 mg as needed for moderate to severe pain not controlled with acetaminophen. In an interview on 01/14/26, Staff 6 (LPN) acknowledged the instructions for when to administer each medication were unclear because a pain rating of “4” or “5” would fall under both acetaminophen and morphine, and “severe pain” noted on the oxycodone order was not defined. b. The 01/02/26 physician order list included a change to the orders for the administration of PRN trazodone (used to treat dementia). The new order was not transcribed to the 01/2026 MAR. c. Resident 3 was prescribed two PRN psychotropic medications to address anxiety or agitation: * Lorazepam 0.25 ml for nausea/agitation or anxiety; and * Trazodone 50 mg for dementia. The indicators for use in the orders were exactly the same for both medications: “As evidenced by restlessness, calling out, fearful, inconsolable yelling, pacing and/or physical aggression toward self or others.” In an interview on 01/14/26, Staff 6 (LPN) acknowledged the current indicators for use did not provide unlicensed staff adequate direction regarding which medication to administer if the resident was exhibiting those behaviors. The need to ensure the facility kept an accurate MAR, including parameters and instructions for PRN medications, was reviewed with Staff 1 (ED), Staff 4 (Resident Services Director) and Staff 12 (Senior General Manager) on 01/15/26 at 1:10 pm. They acknowledged the findings.

1. Resident 2's medications were updated to include resident specific specific parameters for when to use and clear instructions to include sequence of use. Resident 3's instructions for pain medications were updated to be clear. Resident 3's psychotropic medication's indicators for use were updated to be clear and different. Resident 3's orders were reviewed to ensure all medication orders were transcribed appropriately. 2. All resident MAR's will be audited to ensure that all orders have been transcribed so ensure accuracy. Audit will also include that all medications, including pain, psychotropic, bowel medications, include appropriate and clear instructions, parameters, and indicators for use. Training will occur with Administrator, med techs, and nurses to inform and explain this regulation as well as the importance. Training to include to notify nursing, Administrator, and/or fax the doctor for clarification when and if orders are not clear. System and training implemented of a triple check system of all medication orders to ensure that orders have been transcribed and clear instructions and/or parameters have been given. 3. This will be evaluated with any order changes through the triple check system among med techs and nurses. This will also be evaluated through our pharmacy audit and by our Administrator at the time of the quarterly evaluations. 4. The Administrator will be responsible to ensure completion and ongoiing monitoring.

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 included resident-specific parameters for PRN medications and medication-specific instruction to instruct non-licensed staff for 2 of 3 sampled residents (#s 2 and 3) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2025 with diagnoses including dementia and anxiety. a. Resident 2's 12/18/25 through 01/12/26 MARs were reviewed and identified the following as-needed bowel medications lacked resident-specific parameters for when to use and clear instructions for unlicensed staff: * Polyethylene Glycol 17 gram; * Milk of magnesia 30 ml; * Bisacodyl tablet 5mg; and * Bisacodyl suppository. There were not clear instructions or parameters for the sequence of use and/or if there was a specific amount of time staff should wait before administering the other PRN bowel medications. In interview on 1/15/26 at 1:00 pm, Staff 11 (Resident Care Coordinator) acknowledged the instructions required clarification. b. The MAR lacked specific instructions for which to use first for the following psychotropic prn medications: * Hydroxyzine 25 mg; and * Quetiapine fumarate 12.5 mg. The indicators for use in the orders were exactly the same for both medications: “As evidenced by pacing, insomnia, clenching hands, talking fast, calling staff frequently or restlessness.” In an interview on 01/14/26, Staff 1 (Executive Director) and Staff 12 (Senior General Manager) acknowledged the current indicators for use did not provide unlicensed staff adequate direction regarding which medication to administer if the resident was exhibiting those behaviors. The need to ensure the MAR included parameters and clear instructions for unlicensed staff to follow was reviewed with Staff 1 (ED) and Staff 12 (SGM) on 01/15/25 at 3:15 pm. They acknowledged the findings. F 2. Resident 3 was admitted to the facility in 09/2020 with diagnoses including dementia with behavioral disturbance and chronic pain. Review of the resident’s most recent signed physician order summary, dated 01/02/26, and the 12/01/25 through 01/11/26 MAR indicated the following: a. Resident 3 was prescribed three PRN medications to address pain: * Acetaminophen 500 mg as needed for pain rated 1 – 5 on a 10-point scale; * Morphine sulfate 0.25 ml as needed for moderate pain rated 4 – 6 on a 10-point scale; and * Oxycodone 5 mg as needed for moderate to severe pain not controlled with acetaminophen. In an interview on 01/14/26, Staff 6 (LPN) acknowledged the instructions for when to administer each medication were unclear because a pain rating of “4” or “5” would fall under both acetaminophen and morphine, and “severe pain” noted on the oxycodone order was not defined. b. The 01/02/26 physician order list included a change to the orders for the administration of PRN trazodone (used to treat dementia). The new order was not transcribed to the 01/2026 MAR. c. Resident 3 was prescribed two PRN psychotropic medications to address anxiety or agitation: * Lorazepam 0.25 ml for nausea/agitation or anxiety; and * Trazodone 50 mg for dementia. The indicators for use in the orders were exactly the same for both medications: “As evidenced by restlessness, calling out, fearful, inconsolable yelling, pacing and/or physical aggression toward self or others.” In an interview on 01/14/26, Staff 6 (LPN) acknowledged the current indicators for use did not provide unlicensed staff adequate direction regarding which medication to administer if the resident was exhibiting those behaviors. The need to ensure the facility kept an accurate MAR, including parameters and instructions for PRN medications, was reviewed with Staff 1 (ED), Staff 4 (Resident Services Director), and Staff 12 (Senior General Manager) on 01/15/26 at 1:10 pm. They acknowledged the findings.

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 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to document the use of supportive devices with restraining qualities, for 1 of 1 sampled resident (#3) who utilized side rails. Findings include, but are not limited to: Resident 3 was admitted to the facility in 09/2020 with diagnoses including dementia with behavioral disturbance and chronic pain. During a tour of the resident’s room on 01/12/26 at 3:15 pm, bilateral half-length side rails were observed on the resident’s bed in the up position. The side rails were attached firmly to the bed and there were no gaps between the rails and the mattress. In an interview on 01/12/26, Staff 16 (CG) reported the side rails were always kept in the up position and the resident used them to hold onto when s/he repositioned in bed or transferred in and out of the bed. Resident 3’s service plan indicated the resident was independent with transfers and ambulation; this was confirmed by observations during the survey. Records included an order dated 11/07/25 for the use of side rails and a progress note indicated the side rails were received and installed on 11/17/25. There was no documented evidence of the following: * The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; * The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and * Documentation of the use of supportive devices with restraining qualities was included in Resident 3’s service plan. In an interview on 01/15/26, Staff 2 (RN) stated she had not conducted an assessment of the use of the side rails because she had not been informed they had been installed. The need to ensure the facility documented the use of supportive devices with restraining qualities was reviewed with Staff 1 (ED), Staff 4 (Resident Services Director) and Staff 12 (Senior General Manager) on 01/15/26 at 1:10 pm. They acknowledged the findings.

1. RN completed side rail assessment for Resident 3. 2. Inservice completed for staff education on regulation for restraints and supportive devices to include reporting to community RN if devices containing a restraining quality arrive in the community. Community RN to complete an audit to ensure all assessments, if applicable, have been completed for any residents with supportive devices with restraining qualities. When a new order is received, this will be triple checked and then referred to RN for assessment. 3. This will be evaluated on a quarterly basis with resident service plan updates and/or with change of condition evualation. 4. Administrator will be responsible for tracking devices requiring RN assessment and follow up with RN on completion of assessments. RN will be responsible for completing appropriate assessments.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0065 (1-3) Administrator Qualification and Requirements (1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below: Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to ensure a full-time administrator was scheduled to be on site in the facility at least 40 hours per week for each licensed care setting. Findings include, but are not limited to: Survey entered the facility on 01/12/26 at 9:00 am and requested to speak with the administrator of the Memory Care Community. Staff stated there was not an administrator for the MCC, but the Executive Director was an administrator. On 01/12/26 at 11:30 am, Staff 1 (Executive Director) stated there was not a licensed administrator for the MCC, but she had an approved exception to work as ALF administrator also administrator of the MCC. Review of the waiver showed it had expired on 08/31/25. The need to employ a full-time licensed administrator for each separately licensed care setting was reviewed with Staff 1 and Staff 12 (Senior General Manager) at 2:45pm on 1/15/26. They acknowledged the findings.

1. An Administrator was hired and is in place. An admininstrator's reference summary was submitted to the licensing policy analyst per requirement. 2. Community management will ensure any exceptions are more carefully noted to ensure compliance. Community management will also identify current staff members who we can assist in getting their Administrator's licenses for back up scenarios of needed coverage. 3. This will be evaluated on a quarterly basis to ensure ongoing compliance. 4. The General Manager will be responsible for ensuring compliance.

OAR 411-054-0065 (1-3) Administrator Qualification and Requirements (1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below: Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0070 (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 qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On 04/08/26, the posted staffing plan and the 03/29/26 through 04/04/26 staffing schedule were reviewed. The facility’s posted staffing plan, based on a proprietary Acuity-Based Staffing Tool, indicated the following: * Four direct care staff were scheduled for the day shift, 6:00 am to 2:00 pm; * Four direct care staff were scheduled for the swing shift, 2:00 pm to 10:00 pm; and * Three direct care staff were scheduled for the overnight shift, 10:00 pm to 6:00 am. Review of the 03/29/26 through 04/04/26 staffing schedule identified the facility did not meet the posted staffing plan on nine of 21 shifts, including overnight shifts on six occasions that were staffed at two, instead of the required three. Staff 11 (Garden House Coordinator) stated in an interview on 04/08/26 at 1:25 pm that he would often come in to cover a shift if staffing was insufficient. No further documentation of staffing for the week of 03/29/26 through 04/04/26 was provided. The facility's staffing schedule was reviewed with Staff 1 (General Manager), Staff 6 (Garden House Director), Staff 4 (Resident Care Director), and?Staff 12 (Senior General Manager) on 04/08/26 at 2:50 pm. They acknowledged the findings and no further documentation was provided.

1. Proprietary ABST tool was run to determine number of staff needed per shift. Management reviewed current need, scheduled staff accordingly and hired additional staff needed to fill in staffing deficiencies. 2. This system has been corrected by training current staff on frequency of running the ABST and then updating the staffing plan to meet necessary staffing requirements. Furthermore, additional staff have been hired to fill in staffing holes to ensure coverage in the event of unexpected employee absences. Also, Agency contracts in place to ensure appropriate minimum staffing. 3. The Administrator will evaluate this correction each time they run the ABST on a weekly basis. The General Manager will oversee that posted staffing plan is meeting ABST needs and will work in conjunction with the Business Office Manager to ensure timely hiring of new employees. 4. The Administrator and the General Manager will be responsible to ensure ongoing compliance and monitoring.

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 interview and record review, it was determined the facility failed to ensure their posted staffing plan included time for unscheduled needs and was updated to match the staffing plan generated by their Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to. The facility’s ABST and posted staffing plan were reviewed 01/14/26 at 11:30 am with Staff 1 (Executive Director) and Staff 5 (Business Office Director). Staff 1 and 2 stated the facility was in transition to using the state ABST, however, were also using the proprietary Eldermark ABST which had been submitted for approval with the state. Review of the ABST showed: • At the time of review, Staff 1 stated technical difficulties with the Eldermark ABST prevented the facility from demonstrating how the tool was used to generate a staffing plan; • There was not a system to provide time for unscheduled care needs; and • At the time of the review, staff were unable to confirm the posted staffing plan was generated by the ABST, or had been updated as residents admitted to the facility. Staff 1 stated the posted staffing was based on what had been generated approximately two months prior, and the plan had not been updated since. On 1/15/26 at 2:30 pm the need to use the ABST to create a staffing plan was reviewed with Staff 1 (ED) and Staff 12 (Senior General Manager). They acknowledged the findings

1. Training was performed with community staff of how to use the proprietary staffing tool to run the ABST to generate the posted staffing plan. Training included Merrill Gardens policy on Oregon ABST tools including the frequency of which to run the ABST and how the system provides time for unscheduled care needs. The proprietary tool was used to run ABST and the posted staffing tool was updated accordingly. 2. This system has been corrected by thorough training of community staff on how to use the system, it's frequency, explanation of how unscheduled needs are addressed, and to update the staffing plan accordingly. The system of the proprietary tool has since passed subsequent surveys of sister communities under Merrill Gardens but additional training needed to occur and has now. 3. The Administrator will evaluate this correction each time they run the ABST: twice weekly, with quarterly evaluations, changes of conditions, and upon new move ins. The General Manager will also oversee that this is occurring on a monthly basis. 4. The Administrator and the General Manager will be responsible to ensure ongoing compliance and monitoring.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure their posted staffing plan included time for unscheduled needs and was updated to match the staffing plan generated by their Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to: The facility’s ABST and posted staffing plan were reviewed on 01/14/26 at 11:30 am with Staff 1 (Executive Director) and Staff 5 (Business Office Director). Staff 1 and 2 stated the facility was in transition to using the state ABST, however, they were also using a proprietary ABST which had been submitted for approval with the state. Review of the ABST showed: * At the time of review, Staff 1 stated technical difficulties with the proprietary ABST prevented the facility from demonstrating how the tool was used to generate a staffing plan; * There was not a system to provide time for unscheduled care needs; and * At the time of the review, staff were unable to confirm the posted staffing plan was generated by the ABST or had been updated as residents admitted to the facility. Staff 1 stated the posted staffing was based on what had been generated approximately two months prior, and the plan had not been updated since. On 1/15/26 at 2:30 pm the need to use the ABST to create a staffing plan was reviewed with Staff 1 (ED) and Staff 12 (Senior General Manager). They acknowledged the findings.

1. Training was performed with community staff of how to use the proprietary staffing tool to run the ABST to generate the posted staffing plan. Training included Merrill Gardens policy on Oregon ABST tools including the frequency of which to run the ABST and how the system provides time for unscheduled care needs. The proprietary tool was used to run ABST and the posted staffing tool was updated accordingly. 2. This system has been corrected by thorough training of community staff on how to use the system, it's frequency, explanation of how unscheduled needs are addressed, and to update the staffing plan accordingly. The system of the proprietary tool has since passed subsequent surveys of sister communities under Merrill Gardens but additional training needed to occur and has now. 3. The Administrator will evaluate this correction each time they run the ABST: twice weekly, with quarterly evaluations, changes of conditions, and upon new move ins. The General Manager will also oversee that this is occurring on a monthly basis. 4. The Administrator and the General Manager will be responsible to ensure ongoing compliance and monitoring.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were trained in the use of abdominal thrust and First Aid within 30 days of hire, for 2 of 3 sampled newly-hired direct care staff (#s 13 and 14) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed with Staff 5 (Business Office Director) on 01/13/26 at 12:00 pm. Staff 13 (MT) was hired 11/05/25 and Staff 14 (CG) was hired 10/21/25. The facility could not produce documented evidence Staff 13 and Staff 14 had completed First Aid and abdominal thrust training. The need to ensure all newly-hired staff completed all required training was reviewed with Staff 1 (ED), Staff 4 (Resident Services Director), Staff 5 and Staff 12 (Senior General Manager) on 01/15/26 at 1:10 pm. They acknowledged the findings. No additional information was provided.

1. The two employees that were identified to not have training completed for first aid and abdominal thrust within 30 days of hire have now been trained and documentation of such is in their employee file. 2. An audit will be completed within the compliance date to ensure that all direct care staff have completed training in first aid and abdominal thrust. 3. First Aid course, to include abdominal thrust, has been added to their New Employee Checklist requirements to be completed within the first 30 days. 3. This will be evaluated weekly by the Business Office Director, and Memory Care Administrator. The General Manager will evaluate compliance monthly. 4. The Administrator will be responsible for ensure the corrections are completed and monitored for compliance.

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

OAR 411-054-0090 (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 conduct and record fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records were reviewed on 01/13/26 at 3:10 pm. The following was identified: a. The written fire drill records did not include: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. In an interview on 01/14/26, Staff 3 (Garden House Supervisor) reported the facility did not relocate MCC residents to a point of safety during fire drills. b. There was no documented evidence alternate exit routes were used during fire drills to react to varying potential fire origin points. The need to ensure fire drills were conducted and documented as required was reviewed with Staff 1 (ED), Staff 8 (Maintenance Assistant) and Staff 12 (Senior General Manager) on 01/15/26 at 2:00 pm. They acknowledged the findings.

1. The Fire Drill form for Merrill Gardens includes all required components and has been given to staff and training has been provided to the Maintenance Team and management team members. A Fire Drill was completed with this new form to include the evacuation of residents to beyond a point of fire safe doors. 2. The new form, containing all required components was given to staff and training was completed. Training included the evacuation of residents and that this needed to occur each time, every other month, at alternating times and alternating exit points. Fire Drill was then practiced as described above to ensure competency. 3. The system will be evaluated routinely (monthly) during fire drill training where fire drill documentation will be reviewed to ensure compliance. 4. The Maintenance Director, Maintenance Assistant, Administrator, and General Manager will be responsible to ensure all corrections are completed and monitored.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview, it was determined the facility failed to ensure each resident was instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: In an interview on 01/14/26 at 11:35 am, Staff 3 (Garden House Supervisor) stated she did not provide fire and life safety instruction to residents upon admission. In an interview on 01/15/26 at 2:00 pm with Staff 1 (ED), Staff 8 (Maintenance Assistant) and Staff 12 (Senior General Manager), Staff 1 reported the facility provided each new resident with the Resident Handbook which included fire and life safety information. They acknowledged they did not have a consistent system for providing and documenting annual re-instruction to residents. At 3:15 pm, Staff 12 reported that upon further review the facility was having the resident’s guardian or power of attorney review the Resident Handbook and were not ensuring the resident received instruction. Staff 12 acknowledged the facility needed to develop a consistent system for providing and documenting fire and life safety instruction to residents.

1. All residents have now received fire and life safety education and instructions. 2. Power of attorney and/or resident signs the Resident Handbook upon or prior to move in that includes Resident Fire Life and Safety instructions and education. Resident Fire Safety and Evacuation Instructions Form, showing date and signature of trainer, has been implemented to show/proof of annual training and initial training has been completed. The initial training will be done within 24 hours of move in and the annual training will occur with each resident as the form is resident specific. 3. and 4. This will be evaluated by General Manager to ensure completion of Resident Handbook Acknowledgment signature page at time of move in. The Resident Fire Safety and Evacuations instructions form will also be turned in to the Administrator each at time of move in and annually to ensure compliance as well. Administrator will perform audit annually to ensure compliance. The Maintenance Department will evaluate quarterly to ensure compliance.

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

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for multiple sampled and unsampled residents who shared bathrooms. Findings include, but are not limited to: Observations of the MCC were conducted during survey on 01/12/26. Eight resident room had shared bathrooms with sliding pocket doors. The pocket doors did not have the capability to lock from inside the bathroom. Therefore, each individual was not ensured privacy when using his/her shared restroom. During an environment walkthrough with Staff 1 (Executive Director) and Staff 3 (Garden House Supervisor), it was confirmed eight resident rooms had bathrooms with pocket doors and did not have a locking mechanism for privacy when using the shared bathroom. The need to ensure privacy in individual resident units was reviewed with Staff 1(ED) and Staff 12 (Senior General Manager) at 2:30 pm on 1/15/26. They acknowledged the findings.

1. Locks will be installed in the 8 shared memory care apartments where residents share a single bathroom. 2. Once locks are installed, the violation will be corrected and resident privacy regs will be met. 3. Locks will be evaluated routinely by all staff members of memory are to ensure they are in working order. 4. The facilities maintenance director will install locks and repair as needed. The Administrator will evaluate and audit this quarterly to ensure compliance.

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

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C350, C362, C372, C420, C422, and H1517.

Refer to plan of correction for C350, C362, C372, C420, C422, and H1517.

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 C360.

Refer to plan of correction for C360.

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 staff completed all required training and all training was documented, for 4 of 4 sampled newly-hired staff (#s 7, 9, 13 and 14) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed with Staff 5 (Business Office Director) on 01/13/26 at 12:00 pm. Staff 7 (Activities Director) was promoted to that position 11/02/25, Staff 9 (MT) was hired 11/23/25, Staff 13 (MT) was hired 11/05/25 and Staff 14 (CG) was hired 10/21/25. The following was identified: a. There was no documented evidence Staff 7 completed pre-service dementia training on the following required topics: * Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * 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; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including how to: identify and address pain, provide food and fluids, and prevent wandering and elopement. In an interview on 01/13/26, Staff 7 stated he did not remember taking the pre-service dementia course that the facility assigned as part of its new-hire training curriculum. b. Staff 5 confirmed the facility did not provide training to Staff 9, 13 and 14 on the topic of the use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 14 completed pre-service training on the following topics: * Infectious disease prevention; * Home and community-based services; * Inclusive care (LGBTQIA2S+); * Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * 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; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; * Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including how to: identify and address pain, provide food and fluids, and prevent wandering and elopement; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and * How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan. d. There was no documented evidence Staff 9, 13 and 14 demonstrated knowledge and satisfactory performance in the duties to which they were assigned. In an interview on 01/13/26, Staff 3 (Garden House Supervisor) stated she had not been documenting new direct care staff competencies as required. In an interview on 01/14/26, Staff 11 (Resident care Coordinator) stated he had not been provided the competency form the facility utilized, and had not documented new direct care staff competencies. The need to ensure staff completed all required training, and the training was documented, was reviewed with Staff 1 (ED), Staff 4 (Resident Services Director), Staff 5 and Staff 12 (Senior General Manager) on 01/15/26 at 1:10 pm. They acknowledged the findings. No additional information was provided.

1. Facility ensured missing training components were completed with Staff 7, Staff 9, Staff 13, and Staff 14. Competency training was completed on 01/15/2026 with Staff 9,13, and 14 as well. 2. An audit will be completed to ensure all memory care employees have completed all required training as well as all competencies. If any employee is found to be out of compliance, this will be corrected within the compliance date. All required training to meet the regulation is assigned to each employee with the appropriate due dates. Moving forward, weekly reports will be automaically sent to the Administrator and department heads on a weekly basis of which they will evaluate, follow up immediately, and assist the employee to complete any training needed. 3. This will be evaluated and monitored weekly by sending training reports weekly. 4. The Administrator will be responsible to ensure this is monitored and completed.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow the health care licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C270, C295, C310, and C340.

Refer to plan of correction for C270, C295, C310, and C340.

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

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements and to develop an individualized activity plan based on their activity evaluation for 3 of 3 sampled residents (#s 1, 2, and 3) whose evaluations and services plans were reviewed. The most recent evaluations and current service plans were reviewed for Residents 1, 2, 3 and 4. The following was identified: a. There was no documented evidence an activity evaluation had been completed for sampled residents that addressed the following: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no documented evidence an individualized plan was developed for the sampled residents. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (Executive Director) and Staff 12 (Senior General Manager) on 01/15/26 at 2:30 pm. They acknowledged the findings.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements and to develop an individualized activity plan based on their activity evaluation for 3 of 3 sampled residents (#s 1, 2, and 3) whose evaluations and services plans were reviewed. Findings include, but are not limited to: The most recent evaluations and current service plans were reviewed for Residents 1, 2, and 3. The following was identified: a. There was no documented evidence an activity evaluation had been completed for sampled residents that addressed the following: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no individualized activity plan developed for each resident based on his/her activity evaluation which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (Executive Director) and Staff 12 (Senior General Manager) on 01/15/26 at 2:30 pm. They acknowledged the findings.

1. Activity evaluations and plans to include the missing components were completed for Resident's 1, 2, and 3. 2. During the move in process, management will work with residents and family members to obtain a resident interest sheet that includes the missing evaluation components at time of move in. This information will then be provided to the memory care team of which an activity plan based on current needs and how often staff should offer and assist with resident with individualized activities. 3. The memory care activity team and the Administrator will complete these activity evaluations quarterly and with change of conditions. Based on the evaluations, the activity plan will then be updated accordingly. 4. The Administrator will be responsible to ensure all evaluations and plans are updated.

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