Print Inspection: CHOW009247

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear instruction to staff, and/or were readily available to staff for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the memory care community in 03/2025 with diagnoses including Alzheimer’s disease, rheumatoid arthritis, and anxiety disorder. On 02/03/26 it was observed that the resident’s most recent service plan, dated 01/25/26, was not available to care staff in the service plan binder. In an interview on 02/03/26 at 2:30 pm, Staff 1 (Memory Care Director) acknowledged that the service plan available to staff, dated 12/18/25, was not reflective of Resident 1’s care needs, based on the most recent evaluation completed 01/25/26. The need to ensure service plans were readily available to staff was discussed with Staff 1 (Memory Care Director), Staff 3 (RN), and Staff 5 (Campus ED) on 02/04/26 at 1:45 pm. They acknowledged the findings.? 2. Resident 2 was admitted to the facility in 12/2025, with diagnoses of dementia, depression, and urinary tract infection (UTI). Review of Resident 2’s service plan, dated 01/14/26, interim service plans (ISPs), interviews with staff, and observations during survey revealed the service plan was not reflective or did not provide clear direction to staff in the following areas: * Meals, nutrition, and food/fluid preferences; * Use of “scoop plate” for eating; * Adaptations and strategies for activities; and * Proper cleaning and use of CPAP machine. On 02/04/26 at 11:50 am, the need to ensure service plans were reflective and provided clear instructions to staff was discussed with Staff 1 (Memory Care Director) and staff 5 (Campus ED). They acknowledged the findings.

1.What actions will be taken to correct the rule/violation for each example/resident? Resident #1: -The most current service plan dated 1/25/26 was immediately place in the service plan binder in the memory care area. -The service plan was reviewed by the LN(s) and Memory Care Director to ensure all elements from the most recent evaluation were incorporated and clearly outlined what services are provided, by whom, when, how, and how often. -All care staff were notified of the updated service plan during shift change meetings. -A copy of the updated service plan was offered to the resident's legal representative. Resident #2: -The service plan was revised to clearly reflect: *Meal preferences and nutritional needs *Use of scoop plate during meals that has since been discontinued *Specific activity adaptations and engagement strategies *Detailed CPAP cleaning instructions, includes who provides the service, frequency, and procedure steps. -The updated service plan was placed in care staff binder and reviewed with direct care staff. -A copy of the updated service plan was offered to the resident and/or legal representative. 2. How will the system be corrected so this violation will not happen again? -Systemic changes to ensure deficient practice does not occur The facility has implemented the following system changes: (A) service plan availability process -A standarized process was implemented requiring: 1. Immediate replacement of outdated service plans in the care binder upon completion of any update 2. A "Service Plan Update Checklist" to be completed by Memory Care Director or designee verifying: -Binder copy updated -Electronic copy updated -ABST elements updated -Staff notified -Copy offered to resident/legal representative 3. The Memory Care Director or designee will verify completion within 24 hours of update. (B) Quarterly and Significant Change Tracking -A service plan tracking log has been implemented to monitor: *Move-in service plans *30 and 60 day reviews *Quarterly reviews *Significant change updates -The Memory Care Director will review the tracking log weekly (C) Staff Education -The Memory Care Director and LN(s) will provide in-service training to all care leadership on: *OAR 411-054-0036 requirements *Incorporation of person-centered service plans *Clear service direction (who, what, when, how, and how often) *Readily available plans *ABST alignment requirements -Direct Care Staff were educated on accessing and following current service plans -New hires will receive training on service plan requirements during orientation. (D) Administrator Oversight -The Administrator has reaffirmed responsibility under OAR 411-054-0036(2)(g) for ensuring implementations of services -Monthly QA review of 5 randomly selected service plans will be conducted to verify compliance. 3. How often will the area needing correction be evaluated? -The LN(s) or desginee will conduct: *Weekly audits of newly updated service plans for 30 days. *Monthly random audits of at least 5 resident service plans thereafter for 3 months -Audit results will be reviewed in the facility's QA meetings -Any identified concerns will result in immediate correction and re-education -Monitoring will continue at admission, 30 days, 60 days, Quarterly and longer if compliance is not sustained. 4. Who will be responsible for seeing that the corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey or Designee.

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

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician/ or other legally recognized practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 2) who had documented medication refusals. Findings include, but are not limited to: The 01/01/26 through 01/31/26 MARs for Residents 1 and 2 were reviewed. Both residents’ records showed multiple medication refusals. There was no documented evidence the facility notified the prescriber when the residents refused to consent to the orders. In interviews on 02/03/26, Staff 1 (Memory Care Director) and Staff 2 (Memory Care Manager) acknowledged the refusals had not been reported to the residents’ physicians. On 02/04/26 at 11:50 am, the need to ensure the facility notified the physician when a resident refused medication was discussed with Staff 1 and Staff 5 (Campus ED). They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -The LN(s)/Memory Care Direcor reviewed all documented medication refusals for January 2026. -The prescribing practictioners for both residents were notified on 2/4/26 of the documented refusals, including frequency and pattern of refusals -Documentation of practictioner notification was entered into the residents’ clinical records, including date, time and method of communication -Each resident’s service plan was reviewed and updated as appropriate to reflect: *History of medication refusals *Interventions to address refusals *Clear instructions to staff regarding documentation and notification requirements 2. How will the system be corrected so this violation will not happen again? -The facility has implemented the following corrective systems: (A) Medication refusal reporting protocol A written “Medication Refusal Notification Protocol” was implemented requiring: 1. All medication refusals to be documented on MAR at time of occurrence 2. The medication coordinator to notify the prescriber: a. For ongoing refusals per prescriber direction 3. Documentation in the progress notes to include: a. Date/time of refusal b. Medication refused c. Interventions attempted d. Date/time and method of prescriber notification e. Prescriber instructions or follow up when received (B) Shift to shift communication -Medication refusals will be reviewed during weekly clinical stand up or shift report to ensure timely follow up. -Memory Care Director or designee will review 24-hour reports daily for documented refusals (C) Staff Education -Medication Coordinators receive in-service education on *OAR 411-054-0055 (1) (j-k) requirements *Residents’ right to refuse medications and treatments *Mandatory prescriber notification requirements *Proper documentation standards -Education will be incorporated into new hire orientation for all Clinical Managers and Medication Coordinators. (D) Leadership Oversight -The LN(s) or designee will conduct weekly MAR audits for 30 days to ensure: *Refusals are documented *Prescriber notifications occur timely as directed by provider *Documentation is complete -The Administrator (Campus ED) will review audit findings monthly through QA meetings for 3 months. 3. How often will the area needing correction be evaluated? -Weekly MAR audits -Monthly random audits of 5 resident MARs for 3 months -Findings will be reviewed in IDT meetings -Additional training will be provided immediately if non-compliance is identified -Monitoring will continue until substantial compliance is sustained. 4. Who will be responsible to see that corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey Or designee

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions were attempted, with ineffective results, prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 2) who had documented administrations of PRN psychotropics. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2025, with diagnoses including dementia, depression, and urinary tract infection (UTI). Review of Resident 2’s MAR, dated 01/01/26 through 01/31/26, revealed the resident was prescribed two PRN psychotropic medications. These were: * Haloperidol 2mg/ml, for “nausea, restlessness, agitation”; and * Lorazepam 0.5 mg, for “anxiety.” The MAR revealed multiple administrations of PRN Lorazepam. There was no documented evidence that non-pharmacological interventions were attempted with ineffective results, prior to administering the psychotropic. In an interview on 02/03/26 at 12:55 pm, Staff 10 (Lead Med Tech) showed the surveyor the electronic record of PRN psychotropic administrations for Resident 2. Staff 10 acknowledged the lack of documentation of non-drug interventions attempted. On 02/04/26 at 11:50 am, the need to document non-pharmacological interventions tried without effective results prior to administration of a PRN psychotropic medication of a PRN psychotropic medication was discussed with Staff 1 (Memory Care Director) and Staff 5 (Campus ED). They acknowledged the findings. 2. Resident 1 moved into the memory care community in 03/2025 with diagnoses including Alzheimer’s disease, rheumatoid arthritis, and anxiety disorder. Review of Resident 1's 01/01/26 through 01/31/26 MAR and corresponding physician orders showed the following: * Haloperidol 2 mg/ml solution take 1 ml (2mg) by mouth every 6 hours as needed for agitation/hallucinations; and * Lorazepam 0.5 mg tablet give 1tablet every 2 hours as needed for anxiety/dyspnea. Between 01/01/26 and 01/31/26, the resident was administered the PRN haloperidol two times and the PRN lorazepam 17 times. There was no documented evidence non-pharmacological interventions had been attempted with ineffective results prior to administering the PRN psychotropic medications. There were no written resident-specific parameters to instruct staff as to how the resident displayed agitation, anxiety, or hallucinations. The need to ensure documentation of resident-specific parameters and non-pharmacological interventions attempted with ineffective results prior to administering a PRN psychotropic medication was discussed with Staff 1 (Memory Care Director) and Staff 3 (RN) on 02/04/26 at 1:45 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -The MARs, Progress Notes, and Service Plans for Residents #1 and #2 were immediately reviewed by LN and Memory Care Director -Resident specific parameters for PRN Psychotropic medications were obtained from the prescribing provider and added to the physician orders for both residents -The LN updated each resident’s service plan to include: *Clear behavioral descriptions that warrant PRN use *Required non-pharmacological interventions to attempt prior to administration *Documentation requirements -All medication staff will be re-educated regarding: *Documentation of non-pharmacological interventions attempted prior to PRN administration *Documentation of ineffective results before administering PRN psychotropics *Proper documentation in electronic record. -A medication documentation audit was completed for January to February 2026 to ensure no additonal undocumented PRN psychotropic administration occurred. Residents #1 and #2 are now compliant with OAR 411-054-0055 (6). 2. How will the system be corrected so this violation will not happen again? The facility has implemented the following systemic corrections: (A) Policy Revision -The Psychotropic Medication policy was revised to: *Require documented non-pharmacological interventions prior to PRN administration *Resident specific parameters for all PRN psychotropics used for behavior. *Clarify that PRN psychotropics may not be used for staff convenience. *Include documentation standards consistent with OAR 411-054-0055 (6) (c) and (f). (B) Documentation Protocol -A mandatory electronic documentation field has been added reequring staff to document: *Specific behaviors observed *Non-pharmacological interventions attempted *Resident response *Rationale for medication administration -PRN psychotropic medication cannot be signed off in MAR until documentation is completed (C) Staff Education All direct care staff, medication coordinators, nurses and leadership reeceived in-service training on: *OAR 411-054-0055 (6) requirements *Use of non-pharmacological interventions *Appropriate PRN psychotropic use *Side effects and when to notify a healthcare professional *Resident specific parameters New hires will receive this training during orientation before being authorized to administer medications. 3. How often will the area needing correction be evaluated? -The LN(s) or designee will conduct: *Weekly audits of all PRN psychotropic administations for 30 days *Monthly audits thereafter for 3 months -Audit results will be reviewed in IDT meetings -Any variances will result in immediate retraining and corrective action 4. Who will be responsible to see that the corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey Or Designee

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and recorded according to the Oregon Fire Code (OFC) and to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Upon survey’s entrance to the facility on 02/02/26, fire and life safety records for the past six months were requested. The following was determined: a. The facility lacked documented evidence unannounced fire drills were conducted and recorded at least every other month. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. On 2/04/26 at 10:30 am, Staff 1 (Memory Care Director) and Staff 6 (Building Services Director) confirmed the facility’s lack of documentation of fire drills and fire and life safety training for staff. The need to ensure fire drills were conducted every other month according to the OFC and staff were provided fire and life safety instruction on alternate months was discussed with Staff 1 and Staff 6 on 02/04/26 at 10:40 am. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -Immediate Correction *A fire drill was conducted on 2/5/26 with full activation of the alarm system and documentation meeting OAR 411-054-0090 requirements. *Fire and Life Safety in-service training conducted for all current staff. *Any staff not present received 1:1 make-up training. 2. How will the system be corrected so this violation will not happen again? -A standardized Fire Drill Report Form has been implemented to ensure that all required elements are documented: *Date and time *Location of simulated fire *Escape route used *Problems encountered *Evacuation time *Staff on duty and participating *Number of occupants evacuated -A Fire and Life Safety Training Attendance Log has been implemented for alternate month instruction. 3. How often will the area needing correction be evaluated? -Fire Drill Schedule -A 12 month fire drill calendar has been developed to ensure: *Unannounced drills are conducted every other month *Drills occur at varying times (day, evening, night shifts) *Alternate exit routes are used -Alarm activation will occur during each drill unless otherwise directed by the Fire Authority. -Alternate-Month Training -Fire and Life safety instruction will be provided during months when drills are not conducted. -Training will include: *Evacuation procedures *Staff roles and assingments *Use of alternate routes *Resident evacuation assistance *Review of designated points of safety 4. Who will be responsible to see that the corrections are completed/monitored? -Designation of Responsible Party -The Building Services Director (Ty Von Bargen) is responsible for scheduling and conducting fire drills. -The Memory Care Director (Christina Sexton) is responsible for ensuring alternate-month fire and life safety instruction is completed. -The Administrator (Melissa Kozey) has ultimate oversight responsibility.

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 411-057-0140(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 C420.

1. What actions will be taken to correct the rule violation for each example/resident? -A fire drill compliant with OAR 411-054-0090 was conducted on 2/5/26, including activation of the fire alarm system and full documentation of required elements. -Fire and life safety instruction was provided to all current staff. -Any staff not present received make-up training. -All documentation has been reviewed and organized to ensure accessibility and completeness. 2. How will the system be corrected so this violation will not occur again? To ensure compliance with both Division 54 and Division 57 rules: (A) Compliance Tracking System -A 12-month regulatory compliance calendar has been implemented to track: *Every other month unannounced fire drills *Alternate-month fire and life safety instruction *Required documentation elements -The calendar includes assigned responsibility and due dates. 3. How often will the area needing correction be evaluated? -Fire drill and training compliance will be reviewed monthly for 6 months -After 6 months of sustained compliance, monitoring will occur quarterly though QA program -Any missed or incomplete requirement will be corrected immediately, and retraining provided as necessary. 4. Who will be responsible to see that the corrections are completed/monitored? Building Services Director: Ty Von Bargen Memory Care Director: Christina Sexton Administrator: Melissa Kozey

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C305, C310, and C330.

1. What actions will be taken to correct the rule violation for each cexample/resident? -All ressidents’ records were reviewed by LN(s) and Memory Care Director to ensure: *Assessments are current *Service Plans reflect resident needs *Physician Orders are current and accurately transcribed *Monitoring documentation is complete -Any identified discrepancies were corrected immediately. -Staff directly involved received 1:1 retraining regarding: *Assessment updates *Service Plan implementation *Documentation standards *Health status monitoring and reporting -The LN(s) conducted a focused review of residents with higher acuity needs to ensure appropriate heatlh care services are being delivered. 2. How will the system be corrected so this violation will not happen? To ensure compliance with OAR 411-057-0160 (2) (b) and Division 54 health care requirements: (A) Clinical Oversight Strengthened -The LN(s) will conduct a weekly review of: *New move ins *Residents with condition changes *Incident Reports *High-risk residents -Monthly comprehensive chart audits will be completed for a minimum of 10% residents (or at least 5 charts) (B) Assessment & Service Plan Monitoring -A tracking log has been implemented to monitor: *30 and 60 day reviews *Quarterly updates *Significant change assessments (C) Medication and Treatment Oversight -Monthly MAR audits will be completed by LN(s) or designee -Any discrepancies will result in immediate correction and retraining. (D) Staff Education -All care staff will receive refresher training on: *Health status monitoring and reporting *Documentation requirements *Scope of practice *Following physician orders -All new hires will receive reinforced training during orientation regarding Division 54 health care service requirements. 3. How often will the area needing correction be evaluated? -The Memory Care Director will review clinical audit findings once monthly for 6 months -Findings will be discussed during IDT meetings -Patterns or repeat concerns will result in correction action plans. 4. Who will be responsible to see that the corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey

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

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and included in the service plans, for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: Current service plans for Residents 1, 2, and 3 were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. On 02/04/26 at 11:50 am, the need to develop individualized service plans which addressed residents' nutrition and hydration needs was discussed with Staff 1 (Memory Care Director) and Staff 5 (Campus ED). They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -The LN(s) and Memory Care Director reviewed Residents #1, #2, and #3 -Individualized nutrition and hydration interventions were added to each resident’s service plan, including: *Dietary preferenes *Texture modifications (if applicable) *Hydration supports and monitoring *Cueing or assistance level required *Adaptive utensils (if applicable) -A full audit of current resident service plans was completed to ensure nutrition and hydration needs are individualized and documented. -Any identified gaps were correcteed immediately -Staff were educated on updated service plans and individualized supports. 2. How will the system be corrected so this violation will not happen again? (A) Standardized Assessment Process -Service Plan(s) were updated with Nutrition and Hydration information to ensure the following are addressed: *Resident food preferences *Cultural considerations *Assistance level *Swallowing or chewing concerns *Hydration risk factors *Weight monitoring needs *Adaptive equipment needs *Environmental supports (visual contrast) (B) Visual Contrast Requirement (OAR 411-057-0160 (2)(c)(A)) -The facility reviewed dining settings to ensure: *Plates contrast with table surfaces *Utensils contrast with plates when possible -Dining room setup will be monitored daily by the Memory Care Director or desginee. (C) Adaptive Equipment (OAR 411-057-0160(2)(c)(B)) -Residents are evaluated for adaptive utensils upon move-in and with any significant change. -Adaptive equipment needs are documented in the service plan -Adaptive utensils are readily available during meal times. 3. How often will the area needing correction be evaluated? -The LN(s) will conduct monthly weight reviews -Residents at nutritional risk will be reviewed weekly during IDT. -Service plans will be reviewed 30 and 60 days, Quarterly and with any significant change. -The Memory Care Director or designee will audit 10% of service plans monthly for 3 months to ensure nutrition and hydration needs are individualized and documented. -Findings will be reviewed in IDT meetings. -Any identified deficiency will result in immediate correction and retraining. 4. Who will be responsible to see that the corrections are completed/monitored? Memory Care Director: Christina Sexton Licensed Nurse(s): Brie Mendoza RN, Lesli Allen LPN Administrator: Melissa Kozey Or designee

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

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate the residents for activities and develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to: On 02/03/26 at 1:30 pm, Staff 13 (Life Enrichment Coordinator) reported she did not have activity evaluations for Residents 1 and 2 that included all of the following required components: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. 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 develop individualized activity plans which were based on an evaluation of the resident's interests, abilities, and needs was discussed with Staff 13 on 02/03/25 at 1:30 pm and with Staff 1 (Memory Care Director) on 02/04/25 at 1:45 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each cexample/resident? -Residents received comprehensive activity evaluations that include: *Past and current interests *Current abilities and skills *Emotional and social needs and patterns *Physical abilities and limitations *Adaptations necessary for participation *Identification of activities for behavioral interventions. -Individualized activity plans were developed for each resident based on their evaluation. *Plans specify what activities will be offered. *When and how often activities will occur *Level of assistance or cueing required *Behavioral interventions supported through activities. -A full audit of all current resident records was completed to ensure: \ *Activity evaluations are complete *Individualized activity plans are developed and reflect evaluation findings. -Any missing components are corrected immediately. 2. How will the system be corrected so this violation will not happen again? A revised Activity Evaluation Form has been implemented that requires documentation of all regulatory components under OAR 411-057-0160 (2)(d)(A), including: *Interests (past and present) *Skills and abilities *Emotional and social patterns *Physical capabilities and limitations *Necessary adaptations *Activities for behavioral support 3. How often will the area needing correction be evaluated? -Evaluations will be completed: *Upon move-in *Within 30 and 60 days * With significant change *At least Quarterly -The Memory Care Director will audit 10% of activity evaluations and plans monthly for 3 months -The administrator will review compliance during IDT meetings. -After 3 months of sustained compliance, monitoring will occur quarterly. -Any identified deficiency will result in immediate correction and retraining. 4. Who will be responsible to see that the corrections are completed/monitored? Life Enrichment Coordinator: Alieah Stinson Memory Care Director: Christina Sexton Administrator: Melissa Kozey

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: