Print Inspection: CHOW009503

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report a physical injury of unknown cause to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to immediately notify the local Department office of any incident of suspected abuse, investigate all reports of abuse or suspected abuse, and document the investigation as required for 2 of 4 sampled residents (#s 1 and 5) with an injury of unknown cause and elopement. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2024 with diagnoses including Lewy Body Dementia. During the acuity interview on 02/17/26, Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) reported Resident 5 had recently eloped from the facility and was outside in front of the building for approximately ten minutes before an unsampled resident’s visitor noticed him/her and brought him/her back into the building. On 02/17/26 at 2:15 pm, the surveyor met with Staff 1 and 2 and requested documentation of this incident. They stated the incident occurred on 01/16/26. They were not able to provide any documentation about the incident. An elopement from an endorsed memory care community, which is intended to be locked and secure, represents an incident of suspected abuse that must be immediately reported to the local Department office and investigated. The facility failed to report the incident to the local Department office and failed to document an investigation that included: * Time, date, place, and individuals present; * Description of the event as reported; * Response of staff at the time of the event; * Follow-up action; and * Administrator’s review. The incident was reviewed with Staff 3, Staff 5, and Staff 4 (Assistant ED/Marketing Director) on 02/18/26 at 2:10 pm. They acknowledged the facility failed to report the incident to the local office and failed to document an investigation as required. The surveyor directed the facility to report the incident to the local Department office as suspected abuse. Confirmation the facility reported as directed was received on 02/19/26 at 8:35 am. 2. Resident 1 was admitted into the facility in 10/2025 with diagnoses including severe dementia. The resident’s 11/19/25 to 02/16/26 clinical record was reviewed. The following was identified: Staff documented on 01/05/26 a two-inch by three-inch “dark purple” bruise to Resident 1’s “lower left calf” was discovered while assisting the resident to the bathroom. When asking Resident 1 about how s/he obtained the bruise, staff documented, “Resident was not able to recall.” An incident report, dated 01/05/26, was reviewed. There was no documented evidence the facility was able to reasonably conclude that the physical injury was not the result of abuse. On 02/18/26, Staff 5 (RN) reported the facility was not able to determine how the bruise occurred, and the local Department office had not been notified of the injury of unknown cause. Survey requested the facility report the incident, and confirmation that the facility reported the injury of unknown cause to the local Department office was received on 02/19/26 at 11:29 am. The need to ensure the local Department office was notified if the facility’s investigation of an injury of unknown cause could not reasonably conclude and document that the physical injury was not the result of abuse was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5, and Staff 6 (Lead MT) on 02/19/26 at 3:53 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0028 (1–3) Reporting and Investigating Abuse – Other Action, the facility immediately reviewed the incident involving the identified resident(s) and ensured appropriate reporting to the required authorities in accordance with mandatory reporting requirements. The resident(s) involved were assessed to ensure their safety and well-being, and care plans were reviewed and updated as needed. Staff involved in the incident received immediate re-education regarding abuse recognition, mandatory reporting requirements, and investigation procedures. To determine if other residents may have been affected, the Executive Director conducted a review of recent incident reports, abuse logs, and investigation documentation, and staff interviews were completed as appropriate. No additional concerns were identified, and any potential reportable events would be reported immediately according to rule. To prevent recurrence, the facility provided mandatory training for all staff on abuse prevention, recognition, and reporting requirements, and reinforced facility policy outlining the steps for timely reporting and documentation. A standardized abuse reporting and investigation process has been implemented, and the Executive Director or designee will review all incident reports daily to ensure reportable events are identified promptly. Ongoing compliance will be monitored through weekly audits of incident reports and abuse logs for 90 days, after which monitoring will transition to routine quality assurance reviews. Any IMMEDIATLEY Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No Page 2 | 27 identified concerns will result in immediate corrective action and staff re-education.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements for 1 of 1 sampled resident (#4) whose initial evaluation was reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 02/2026 with diagnoses including dementia with behaviors. The resident’s move-in evaluation was reviewed, and the following elements were not addressed: * Name, preferred pronouns, and gender identity; * Customary routines for eating and bathing; * Cultural preferences and traditions; * Cognition: memory and decision-making abilities; * How the person copes with change or challenging situations; * Vision ability; * ADLs, including toileting and transfer ability; and * Dental status. The need to ensure all elements were addressed in the initial evaluation was reviewed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:20 pm. They acknowledged the information that was lacking.

Upon identification of the deficiency related to OAR 411-054-0034 (1–6) Resident Move-in and Evaluation, The facility immediately reviewed the resident evaluation for the identified resident(s) to ensure that required assessments and documentation were completed and accurately reflected the resident’s current needs. Any missing or incomplete information was updated in the resident record, and care plans were reviewed to ensure services and supports were appropriate. The Executive Director and nursing staff conducted a review of current resident files to determine if other residents may have been affected by incomplete or untimely evaluations. Any discrepancies identified were corrected promptly to ensure compliance with evaluation requirements. To prevent recurrence, the facility provided re-education to nursing and administrative staff responsible for admissions and evaluations regarding the required components and timelines for completing resident move-in evaluations in accordance with OAR 411-054-0034. The facility also implemented a standardized admission and evaluation checklist to ensure all required documentation is completed prior to or at move-in and reviewed within required timeframes. The Executive Director or designee will monitor compliance by auditing new admission files weekly for 90 days to verify that resident evaluations are completed accurately and timely. After 90 days, audits will transition to routine quality assurance monitoring. Any variances identified will result in immediate correction and additional staff education.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of service, and/or were implemented for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 admitted to the facility in 10/2025 with diagnoses including severe dementia. The resident’s service plan, dated 02/16/26, and temporary service plans, dated 11/12/25 through 02/07/26, were reviewed, and interviews were conducted with staff. The following was not reflective of Resident 1’s needs or lacked clear direction to staff: * Current incontinent status and brief use; * How the resident participated in dressing; * The use of a shower bench; * Person-centered behavioral interventions; and * Current elopement status. On 02/18/26 at 2:06 pm, Staff 11 (MT/CG) confirmed the resident’s incontinent status and brief use. He addressed how Resident 1 assisted in the dressing process and the use of a shower bench for safety. Staff 11 was aware of person-centered behavioral interventions and confirmed they were not reflected on the resident’s service plan. The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 and Staff 6 (Lead MT) on 02/19/26 at 3:53 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2025 with diagnoses including dementia. The resident’s clinical record, dated 11/15/25 through 02/17/26, was reviewed, observations were made, and interviews were conducted with staff. The 02/16/26 service plan and 11/15/25 to 02/16/26 temporary service plans (TSPs) were not reflective of the resident’s current status, lacked clear instructions for staff, or were not implemented in the following areas: * Swallowing precautions; * Level of assistance for personal hygiene; * Assistance with activities; and * Fall precautions. During the acuity interview on 02/17/26, the resident was noted to have difficulty swallowing which resulted in the resident being sent to the hospital and had a history of falls. The service plan indicated the resident’s wheelchair should be kept out of the resident’s reach while in bed to prevent falls. The 02/09/26 TSP indicated the resident should be kept upright for 30 minutes following meals. During an observation on 02/18/26, staff assisted the resident to lie down in bed immediately following lunch. On 02/18/26 and 02/19/26, the wheelchair was placed next to the bed, allowing the resident to reach it while in bed. The need to ensure service plans were reflective of the resident’s status, provided clear direction to staff regarding the delivery of services, and were implemented was reviewed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources) and Staff 5 (RN) on 02/19/26 at 11:52 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia and depression. The resident’s clinical record from 11/18/25 to 02/16/26 was reviewed, observations were made, and interviews were conducted with staff. The following was identified: The service plan dated 02/16/26 was not reflective or lacked a description of how staff should provide the care and services in the following areas: * Toileting; * Transfers; * Pain; and * Speech. During an observation of personal care on 02/19/26 at 1:10pm, staff escorted the resident to the toilet. Staff 7 (CG) and Staff 9 (CG) confirmed they always offered to escort the resident to the toilet. The service plan did not include instructions for staff to escort the resident to the toilet. During the survey, staff were observed to have the resident use a walker for stability during transfers. In an interview on 02/19/26 at 1:20 pm, Staff 7 and Staff 9 confirmed they always used the walker during transfers. The service plan did not include instructions for staff to utilize the walker. The service plan indicated the resident’s speech was clear and understandable. Multiple interviews with the resident and observations during the survey indicated the resident was sometimes difficult to understand. The need to ensure service plan was reflective of the resident’s status and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:45 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0036 (1–4) Service Plan: General, the facility immediately reviewed the service plan for the identified resident(s) to ensure that the plan accurately reflected the resident’s current needs, preferences, and required services. Any missing or incomplete information was corrected, and the service plan was updated to ensure it provided clear direction to staff regarding the care and support required. The resident’s record and care plan were reviewed with relevant staff to ensure understanding and consistent implementation of the updated service plan. To determine if other residents may have been affected, the Executive Director and nursing staff conducted a review of current resident service plans to verify that plans were completed, current, and reflective of each resident’s assessed needs. Any discrepancies identified during the review were corrected promptly. To prevent recurrence, the facility provided re-education to staff responsible for completing and updating service plans regarding required components, documentation standards, and timelines in accordance with OAR 411-054-0036. The facility also implemented a standardized service plan review checklist to ensure all required elements are included and updated as residents’ needs change. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of resident service plans for 90 days to verify accuracy, completeness, and timeliness. After 90 days, monitoring will transition to routine quality assurance reviews. Any identified concerns will result in immediate correction and additional staff training.

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)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2025 with diagnoses including depression, insomnia, and dementia. Resident 2's 11/06/25 and 02/16/26 physician’s orders and 02/01/26 through 02/17/26 MAR/TARs were reviewed. The following prescribed medications were not transcribed, or were incorrectly transcribed, on the MAR: * Quetiapine fumirate, for agitation; * Trazadone, for sleep; and * Hyoscyamine, for secretions. The need to ensure all medications were carried out as prescribed was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources) and Staff 5 (RN) on 02/19/26 at 11:52 am. They acknowledged the findings. On 02/19/26 at 12:58 pm, Staff 5 confirmed the orders had not been carried out as prescribed. 2. Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia, depression, hypertension and hypoxemia. On 02/19/26 at 11:00 am, the resident's 02/01/26 through 02/16/26 and current signed physician orders were reviewed. Resident 3 was prescribed metoprolol succinate 50 mg, 1 tablet every day, for hypertension with instructions to hold for systolic blood pressure (SBP) less than 100 and/or pulse less than 55. The MAR indicated the resident’s SBP was less than 100 on 02/09/26 and the resident’s pulse was less than 55 on 02/01/26, 02/02/26, 02/07/26 and 02/10/26, but the medication was administered on each of these days. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:40 pm. During this interview, Staff 5 requested an opportunity to review the MAR. On 02/19/26 at 5:30 pm, Staff 5 reviewed Resident 3’s electronic MAR with the surveyor and acknowledged the metoprolol was not held per physician’s orders.

Upon identification of the deficiency related to OAR 411-054-0055 (1)(f–h) Systems: Treatment Orders, the facility immediately reviewed the treatment orders for the identified resident(s) to ensure all physician or licensed practitioner orders were accurately documented, current, and properly implemented. Any missing, unclear, or outdated treatment orders were clarified with the appropriate licensed practitioner and updated in the resident record to ensure staff had clear direction for implementation. The resident’s care documentation and service plan were reviewed with staff to ensure treatments were being completed as ordered. To determine if other residents may have been affected, the Executive Director and nursing staff conducted a review of resident records to verify that all treatment orders were present, current, and consistently followed. Any discrepancies identified during the review were corrected promptly. To prevent recurrence, the facility provided re-education to staff responsible for receiving, documenting, and implementing treatment orders regarding proper documentation procedures, verification of practitioner orders, and ensuring treatments are completed as directed. The facility also implemented a standardized process for reviewing and verifying treatment orders upon receipt and during routine chart reviews. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of resident records and treatment orders for 90 days to ensure accuracy, completeness, and implementation of orders as required. After 90 days, monitoring will transition to routine quality assurance reviews. Any identified concerns will result in immediate corrective action and additional staff education

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and instructions for PRN medications for 1 of 1 sampled resident (#3) who was prescribed multiple PRN medications for shortness of breath. Findings include, but are not limited to: Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia, depression, hypertension and hypoxemia. Resident 3's MAR from 02/01/26 through 02/16/26 was reviewed during the survey, and the following was identified: The resident was prescribed the following four PRN medications for shortness of breath/respiratory distress: * Albuterol inhaler; * Ipratropium and albuterol nebulizer; * Hydromorphone; and * Oxygen (administered via concentrator or portable tank). The MAR lacked resident-specific parameters and instructions for these PRN medications, including which intervention to attempt first and what to do if ineffective. The need for resident-specific parameters and clear instructions for PRN medications was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:40pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0055 (1)(f–h) Systems: Treatment Orders, the facility immediately reviewed the treatment orders for the identified resident(s) to ensure all physician or licensed practitioner orders were accurately documented, current, and properly implemented. Any missing, unclear, or outdated treatment orders were clarified with the appropriate licensed practitioner and updated in the resident record to ensure staff had clear direction for implementation. The resident’s care documentation and service plan were reviewed with staff to ensure treatments were being completed as ordered. To determine if other residents may have been affected, the Executive Director and nursing staff conducted a review of resident records to verify that all treatment orders were present, current, and consistently followed. Any discrepancies identified during the review were corrected promptly. To prevent recurrence, the facility provided re-education to staff responsible for receiving, documenting, and implementing treatment orders regarding proper documentation procedures, verification of practitioner orders, and ensuring treatments are completed as directed. The facility also implemented a standardized process for reviewing and verifying treatment orders upon receipt and during routine chart reviews. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of resident records and treatment orders for 90 days to ensure accuracy, completeness, and implementation of orders as required. After 90 days, monitoring will transition to routine quality assurance reviews. Any identified concerns will result in immediate corrective action and additional staff education Addendum on 04/01/26, submitted by Ericka Forman : Inaccurate or unclear documentation on the MAR, including lack of defined parameters for PRN medications (e.g., sequencing when multiple PRNs are ordered for the same condition). 2. Corrective Actions Taken for Affected Residents All current physician orders were reviewed for accuracy and completeness. PRN medication orders were clarified with prescribing providers to ensure: Clear indications for use, Defined administration parameters Explicit sequencing instructions when multiple PRNs exist for the same symptoms. MARs were immediately updated to reflect clarified orders. Staff re-educated on any updated or corrected orders prior to next medication pass. 3. Systemic Changes to Prevent Recurrence Physician Order Process Improvements: All new and revised orders will be reviewed by a licensed nurse prior to transcription onto the MAR. Any PRN order lacking specificity will be clarified with the provider before implementation. MAR Accuracy Protocol: Standardized process implemented requiring: Documentation of indication, Clear frequency and timing, Step-by-step PRN hierarchy (e.g., “Administer Medication A first; if ineffective after X time, administer Medication B”). PRN Medication Guidelines: A facility-wide guideline for PRN medications has been developed and implemented. Includes required elements: Symptom identification First-line vs. second-line medication use. Documentation of effectiveness 4. Staff Education - All medication staff (RNs, LPNs, and caregivers involved in medication administration) received training on: Following physician orders precisely, Proper MAR documentation, PRN medication protocols and sequencing, New hires will receive this training during orientation. Competency validation completed post-training. 5. Monitoring and Quality Assurance - RN Oversight: The RN will conduct: Weekly scheduled audits of MARs and physician orders for 4 weeks. Random audits thereafter on an ongoing basis (minimum monthly). Audit Focus Areas: Accuracy of transcription from physician order to MAR Presence of clear PRN parameters and sequencing Documentation of medication effectiveness. Corrective Action: Any discrepancies identified will be corrected immediately. Staff involved will receive re-education and, if necessary, progressive discipline per policy. QA Review: Audit findings will be reviewed in Quality Assurance/Performance Improvement (QAPI) meetings. Trends will be tracked and addressed. 6. Completion Date Full compliance expected by: April 10,2026 7. Responsible Party Administrator / RN Designee 1. What happened? The facility failed to consistently ensure physician orders were followed as prescribed, specifically related to PRN medications lacking clear administration parameters and sequencing when multiple PRNs were ordered for the same symptoms. 2. How was the problem corrected for affected residents? All current physician orders were reviewed. PRN orders were clarified with providers to include: Indications for use. Frequency and timing. Clear sequencing when multiple PRNs are ordered MARs were updated immediately to reflect clarified orders. Staff were re-educated prior to next medication administration. 3. How will the system be corrected? All new and revised physician orders are reviewed by a licensed nurse prior to MAR transcription. PRN medications must include clear parameters before implementation. A standardized PRN protocol has been implemented defining first-line and alternative interventions. 4. How will the facility monitor to ensure compliance? RN will conduct: Weekly scheduled and random audits

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 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured the care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 3 sampled residents (#s 1, 2 and 3) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2025 with diagnoses including severe dementia. The service plan, dated 02/16/26, temporary service plans, charting notes, and the resident's corresponding ABST evaluation were reviewed. Resident 1 was observed, and interviews were conducted with staff. The resident's care time and care elements were not reflective in the following areas: * Monitoring physical conditions or symptoms; * Providing treatments; * Bowel and bladder management; and * Supervising, cueing, or supporting while eating. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN) and Staff 6 (Lead MT) on 02/19/26 at 3:53 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2025 with diagnoses including dementia. During the acuity interview on 02/17/26, the resident was identified as having a hospital stay and experienced a significant change of condition upon returning to the facility. During the survey, the resident was observed to be dependent on staff for all ADL care. The 02/16/26 service plan, temporary service plans, charting notes, and the resident's corresponding ABST evaluation were reviewed. Resident 2 was observed, and interviews were conducted with staff. The resident's care time and care elements were not reflective in the following areas: * Monitoring physical conditions or symptoms; * Assisting with leisure activities; and *Ambulation, escorting to and from meals or activities. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), and Staff 5 (RN) on 02/19/26 at 11:52 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia. The 02/16/26 service plan, temporary service plans, charting notes, and the resident's corresponding ABST evaluation were reviewed. Resident 3 was observed, and interviews were conducted with staff. The resident's care time and care elements were not reflective in the following areas: * Monitoring physical conditions or symptoms; * Assisting with leisure activities; * Monitoring behavioral conditions or symptoms; and * Ensuring non-drug interventions for behaviors. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:45 pm. They acknowledged the findings.

Upon identification of deficiency the administrator and RN immediatley conducted a full reassessment of all urrent residents ABST evaluations to ensure accurate capture of providing non drug intervwentions, monitoring physical conditions and symptoms, assisting and leisure activities, cueing aor redirecting due to cognitive impaired, providing non drug interventions for pain amanagement, supervising, cueing, or supporting while eating, assissting with ambulation, escorting to and from meals or activities, To prevent recurrence, the facility provided re-education to all staff responsible for completing and updating the ABST and staffing plan, including proper documentation, timeliness of updates, and ensuring staffing assignments match resident care needs. The facility also implemented a standardized procedure for regular review and updating of the ABST and staffing plan, ensuring adjustments are made whenever resident needs change. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of the ABST and staffing plan for 90 days to verify accuracy and alignment with resident acuity. After 90 days, monitoring will transition to routine quality assurance review through the facility’s QAPI program. Any variances identified will result in immediate correction and additional staff training weekly ABST auditis will be completed by the RN and Administrator

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated whenever there was a significant change of condition and no less than quarterly, at the same time the resident’s service plan was updated, for 4 of 4 sampled residents (#s 1, 2, 3, and 6) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2025 with diagnoses including severe dementia. The resident’s quarterly service plan was updated on 02/16/26 but the resident’s ABST evaluation was last updated on 01/19/26. Resident 1’s ABST evaluation was not updated at the same time as his/her service plan. The need to ensure residents’ ABST evaluation was updated at the same time as the service plan was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 06/2025 with diagnoses including dementia. The resident’s quarterly service plan was updated on 02/16/26 but the resident’s ABST evaluation was last updated on 01/19/26. Resident 6’s ABST evaluation was not updated at the same time as his/her service plan. The need to ensure residents’ ABST evaluation was updated at the same time as the service plan was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN) and Staff 6 (Lead MT) on 02/19/26. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 06/2025 with diagnoses including dementia. During the acuity interview, the resident was identified as having returned to the facility the previous week and having experienced a significant change in condition. The resident’s quarterly and significant change of condition evaluation and service plan were updated on 02/16/26. The resident’s ABST evaluation was last updated on 01/19/26. The resident's ABST evaluation was not updated following a significant change of condition. The need to ensure residents’ ABST evaluations were updated following a significant change in condition was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), and Staff 5 (RN) on 02/19/26 at 11:52 am. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia. The resident’s quarterly service plan was updated on 02/16/26, but the resident’s ABST evaluation was last updated on 01/19/26. Resident 3’s ABST evaluation was not updated at the same time as his/her service plan. The need to ensure residents’ ABST evaluations were updated at the same time as the service plan was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:45 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0037 (4–6) Acuity Based Staffing Tool – Updates and Staffing Plan, the facility immediately reviewed the staffing plan and Acuity Based Staffing Tool (ABST) to ensure that it accurately reflected resident needs and was updated according to current resident acuity. Any discrepancies or outdated information were corrected, and the staffing assignments were adjusted to ensure adequate coverage based on resident care requirements. The Executive Director and nursing leadership reviewed all resident acuity assessments to determine if other residents may have been affected by incomplete or outdated staffing data, and any necessary updates were completed promptly. To prevent recurrence, the facility provided re-education to all staff responsible for completing and updating the ABST and staffing plan, including proper documentation, timeliness of updates, and ensuring staffing assignments match resident care needs. The facility also implemented a standardized procedure for regular review and updating of the ABST and staffing plan, ensuring adjustments are made whenever resident needs change. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of the ABST and staffing plan for 90 days to verify accuracy and alignment with resident acuity. After 90 days, monitoring will transition to routine quality assurance review through the facility’s QAPI program. Any variances identified will result in immediate correction and additional staff training

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills at different times of the day, evening, and night shifts, provide fire and life safety instruction to staff on alternate months, and address problems encountered relating to residents who resisted or failed to participate in the drills. Findings include, but are not limited to: Fire drill and staff training records were reviewed on 02/18/26. The following was identified: a. The facility provided fire drill records for the last six months, from 08/2025 through 02/2026. A fire drill was conducted in five of the six months. Four fire drills were conducted on swing shift (2:00 pm to 10:00 pm) and one fire drill was conducted on night shift (10:00 pm to 6:00 am). No fire drills were conducted on day shift (6:00 am to 2:00 pm). The facility failed to conduct fire drills at different times of the day, evening, and night shifts as required. b. In an interview on 02/19/26 at 12:33 pm, Staff 3 (ED/Human Resources) explained fire and life safety instruction was provided to staff during all-staff meetings. Review of the staff meeting records indicated instruction on fire drill procedures was presented on 05/22/25 and 11/12/25. The facility failed to provide fire and life safety instruction to staff on alternate months. c. Records for fire drills conducted on 09/29/25, 11/12/25, and 01/21/26 noted that between three and 12 residents did not participate in the fire drills for various reasons. The facility failed to address strategies for improving those residents’ participation in future fire drills. The need to ensure the facility conducted fire drills at different times of the day, evening, and night shifts, provided fire and life safety instruction to staff on alternate months, and addressed problems encountered relating to residents who resisted or failed to participate in the drills was reviewed with Staff 3 on 02/19/26 at 12:33 pm. She acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0090 (1–2) Fire and Life Safety: Safety, The facility immediately conducted a review of the identified fire and life safety concern and ensured corrective action was taken to eliminate any immediate hazards. Safety checks were performed to verify that fire exits, alarms, sprinkler systems, extinguishers, and other life safety equipment were in proper working order, and any deficiencies were corrected promptly. The Executive Director and maintenance staff conducted a facility-wide review to determine if other areas or systems may have been affected, and all issues identified during this review were addressed to ensure resident safety. During each fire drill, staff will now complete forms that mark which residents did not participate, and corrective action will be taken to ensure those residents receive individualized support or retraining as needed. In addition, the facility will conduct safety training for all staff every other month during all-staff meetings, in addition to the planned fire drills, which will occur at random times and on random shifts to reinforce preparedness. Staff have also received re-education on fire and life safety policies, including proper use of safety equipment, emergency procedures, and routine safety checks. A standardized fire and life safety inspection checklist has been implemented to ensure ongoing compliance with all safety requirements. Ongoing monitoring will be conducted by the Executive Director or designee through weekly safety audits for 90 days, with any identified concerns corrected immediately and additional staff education provided as needed.

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

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exterior pathways located in the facility’s secured courtyards were maintained in good repair, the grounds were free of litter and refuse. and ensure there was locked storage for all poisons, chemicals, rodenticides, and other toxic materials. Findings include but are not limited to: The exterior of the facility was toured on 02/17/26. a. The following was identified in the secured courtyards located on the East and West Wings: * There were exterior pathways that had drop-offs in multiple areas, which created a potential tripping and fall hazard for residents; * There was refuse in each courtyard, including wipes, gloves, deflated balloons, cigarette butts, leaves, and weeds; * Cleaning equipment, and tools were stored in two of the three courtyards; and * An outside mat located in the secured courtyard across the hall from Unit 201 was not flush to the concrete patio, which created a potential tripping and fall hazard for residents. b. Chemicals were accessible to residents in the following unlocked areas: * The East Wing laundry room; * A restroom located across the hall from Unit 108; * The buffet located in the large dining room; * A storage room on the Open Wing; and * A cabinet located in the beauty salon. The areas where unsecured chemicals were identified was toured with Staff 3 (ED/Human Resources) and Staff 6 (Lead MT) on 02/17/26 at approximately 1:45 pm. Staff 3 and 6 ensured all chemicals were in locked storage during the tour. A tour of the exterior environment was completed with Staff 2 (Co-owner), Staff 3, and Staff 4 (Assistant ED) on 02/18/26 at 11:04 am. They acknowledged the potential tripping hazards and the presence of litter and refuse. The rooms identified as storage for the chemicals had coded locks observed during the tour on 02/18/26.

Upon identification of the deficiency related to OAR 411-054-0200 (3) General Building Exterior, The facility immediately conducted a review of the building exterior, including walkways, handrails, lighting, entrances, and other accessible areas, and addressed any immediate safety hazards to ensure resident, staff, and visitor safety. Maintenance staff corrected identified issues promptly by cleaning debris, repairing or removing broken lights, and ensuring that dirt and ground surfaces are level with the edges of sidewalks. The Executive Director and maintenance team conducted a facility-wide inspection to determine if other areas of the exterior were affected and completed all necessary corrections. To prevent recurrence, staff were re-educated on routine exterior safety inspections, hazard reporting procedures, and the importance of ongoing preventive maintenance. A standardized exterior inspection checklist has been implemented, with inspections conducted weekly by the Executive Director or designee. Any hazards identified during inspections will be corrected immediately by maintenance staff, and staff will be informed of findings during team meetings. Ongoing compliance will be monitored through weekly audits for 90 days, after which monitoring will transition to routine quality assurance review

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility's environment was toured on 02/17/26, and the following was observed: 1. East Wing: * There was black and brown debris in the ceiling light fixtures; * Multiple doors and door frames were scuffed with paint chipping off, including resident unit doors, doors leading inside staff use areas, and doors leading into the wing; * A transition strip was missing in Unit 101 and 106; * Every other light fixture was not able to turn on in the common use area and down the hallway; * The seating located in front of the common use television had torn and peeling upholstery; * The baseboards located between Unit 104 and the courtyard’s doors had spills and drips; * There was splintering wood on the double doors located across from Unit 101 and a bathroom/shower room door located across Unit 106 and 107; * Both cupboards in the shower rooms had handles in disrepair, rusted locking mechanisms, and there was exposed wood which deemed them to be uncleanable surfaces; * The ceiling and ceiling vent in the bathroom/shower room across from Unit 108 had dust accumulation and the vent was coming away from the ceiling; * The “Sprinkler Control” door was unlocked, and there were multiple tripping hazards identified inside the area; and * The door leading out to the secured courtyard was unlocked to get outside, but it locked from the outside and prevented re-entry into the wing. 2. Open Wing: * There was black and brown debris in the ceiling light fixtures; * Multiple doors and door frames were scuffed with paint chipping off, including resident unit doors and doors leading inside staff use areas; * Transition strips were missing in the hallway and the beauty shop; * The buffet had knobs in disrepair and chipped varnish; and * The thermostat casing (labeled “#9”) was in disrepair. 3. West Wing: * Multiple doors and door frames were scuffed with paint chipping off, including resident unit doors, doors leading inside staff use areas and doors leading into the wing’s hall; * There were loose tacks located in a drawer underneath the television, in a common area; * The double doors leading out to the secured courtyard were easily opened to go outside, but were difficult to open to re-enter the wing; * There were multiple paint chips and scrapes in the two common use areas that residents were observed watching television and doing activities in; and * The linoleum was missing and peeling away from the backsplash located to the left of the sink where water and snacks were stored. A tour of the environment was completed with Staff 2 (Co-owner), Staff 3 (ED/Human Resources) and Staff 4 (Assistant ED) on 02/18/26 at 11:04 am. They acknowledged the areas in need of cleaning and repair.

Upon identification of the deficiency related to OAR 411-054-0200 (4)(d–i) Doors, Walls, Elevators, Odors, The facility immediately conducted a review of all doors, walls, handrails, elevators, and areas where odors were identified. Maintenance staff corrected identified issues promptly by repairing or replacing missing door strips, ensuring all doors are properly locked, correcting paint chips on walls and handrails, cleaning walls, and addressing any sources of odors. In addition, chemicals and cleaning supplies were secured and stored out of reach of residents. The Executive Director and maintenance team conducted a facility-wide inspection to determine if other areas were affected and completed all necessary corrections. To prevent recurrence, staff were re-educated on routine inspections, reporting hazards, and maintaining environmental safety, including monitoring doors, walls, elevators, and odors. A standardized environmental inspection checklist has been implemented, with weekly inspections conducted by the Executive Director or designee. Any hazards identified during inspections will be corrected immediately by maintenance staff, and staff will be informed of findings during team meetings. Ongoing compliance will be monitored through weekly audits for 90 days, after which monitoring will transition to routine quality assurance review

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

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with operational alarming devices or another acceptable system to alert staff when residents exited. Findings include, but are not limited to: A tour of the facility on 02/17/26 revealed exit doors leading into three secured courtyards located on the East and West Wings were not equipped with operational alarming devices or another acceptable system to alert staff when residents opened the doors. A tour of the environment was completed with Staff 2 (Co-owner), Staff 3 (ED/Human Resources), and Staff 4 (Assistant ED) on 02/18/26 at 11:04 am. They acknowledged the door alarms were not functioning.

Upon identification of the deficiency related to OAR 411-054-0200 (11–13) Call System, Exit Door Alarm, Phones, TV, or Cable, The facility immediately reviewed the resident call system, exit door alarms, and communication devices to ensure all were functional and accessible. Maintenance staff corrected identified issues promptly, including repairing or replacing call system devices, phones, and televisions as needed. To enhance resident safety, the facility will be installing door alarms on all doors that residents can exit through, ensuring staff are immediately alerted if a resident leaves an area and can confirm their safety when outside. The Executive Director and maintenance team conducted a facility-wide inspection to determine if other systems were affected and completed all necessary corrections. To prevent recurrence, staff were re-educated on the proper use of the call system, monitoring of exit doors, and environmental safety. A standardized communication and safety device checklist has been implemented, with weekly inspections conducted by the Executive Director or designee. Any issues identified during inspections will be corrected immediately by maintenance staff, and staff will be informed of findings during team meetings. Ongoing compliance will be monitored through weekly audits for 90 days, after which monitoring will transition to routine quality assurance review.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents who resided in the facility. Findings include, but are not limited to: In interviews on 02/18/26 with Staff 3 (ED/Human Resources) at approximately 12:15 pm and with Staff 11 (MT/CG) at 2:06 pm, both confirmed that no residents had keys to their units. The need to ensure the individual and only appropriate staff had a key to access resident units was discussed with Staff 2 (Co-owner) and Staff 3 on 02/18/26. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-004-0020 (2)(e) Individual Door Locks: Key Access, the facility immediately reviewed resident room door locks and corrected any deficiencies to ensure residents have secure and functional access to their personal rooms. Maintenance staff to ensure that keys are made and provided to each resident for their room, and that locks are functioning properly. To prevent recurrence, staff were r

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

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

Refer to C252

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

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Refer to C231, C362, C363, C420, C510, C513, and C555.

Refer to C231, C362, C363, C420, C510, C513, and C555.

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 2 of 2 sampled newly-hired staff (#s 10 and 12) completed all required orientation and pre-service training before performing any job duties and 1 of 1 sampled newly-hired direct care staff (#10) completed pre-service training in all required training areas, and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 3 (ED/Human Resources) on 02/19/26 at 1:00 pm. The following was identified: Staff 10 (MT/CG) was hired 06/06/25 and Staff 12 (Activities Director) was hired 01/06/26. a. There was no documented evidence Staff 10 and Staff 12 completed orientation in: * Residents' rights and the values of community-based care; * Abuse and reporting requirements; and * Fire safety and emergency procedures. b. There was no documented evidence Staff 10 completed pre-service training in: * Environmental factors that are important to resident’s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); * Family support and the role the family may have in the care of the resident; * How to provide personal care to a resident with dementia, including an orientation to the resident and the resident’s service plan; and * The use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 10 had demonstrated competency in the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to ensure newly hired staff completed all required training was reviewed with Staff 3 on 02/19/26 at 1:00 pm, and with Staff 1 (Co-owner), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:20 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-057-0155 (1–6) Staff Training Requirements, The facility immediately reviewed staff training records and corrected any gaps to ensure all staff had received required training. All new staff will receive mandatory trainings at the time of hire, and the Administrator and nursing leadership will ensure ongoing compliance by reviewing and verifying staff training completion at 30 days, 6 months, and annually. To prevent recurrence, staff were re-educated on training requirements, documentation standards, and timelines. The facility implemented a standardized staff training tracking system to ensure trainings are completed, documented, and updated timely. Ongoing compliance will be monitored through weekly audits of training records for 90 days, with any discrepancies corrected immediately, and after 90 days, monitoring will transition to routine quality assurance review.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Refer to C252, C260, C303, and C310.

Upon identification of the deficiency related to OAR 411-057-0160 (2)(b) Compliance with Rules – Health Care, The facility immediately reviewed current practices and resident health care documentation to ensure compliance with all applicable rules and regulations. Any deficiencies identified in care delivery, documentation, or policy adherence were corrected promptly, including updating care plans, verifying physician orders, and ensuring staff followed proper procedures. To prevent recurrence, staff were re educated on facility policies, OAR requirements, and proper documentation standards related to health care delivery. The facility implemented a standardized health care compliance checklist to monitor ongoing adherence to rules and regulations. The Executive Director or designee will audit resident records, care plans, and related health care documentation weekly for 90 days to ensure compliance, with any discrepancies corrected immediately and documented. After 90 days, monitoring will transition to routine quality assurance review.

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 observation, interview, and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2, and 3) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, many sampled and unsampled residents were observed needing assistance and encouragement from staff to initiate, attend, and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms, sat in the common areas watching TV or falling asleep, or walked around the facility. All residents were diagnosed with some type of dementia. Resident 1, 2, and 3’s “90 Day Activity Evaluations” and current service plans were reviewed, and observations were made of the residents. The following was identified: Though the evaluations included some information about activity preferences, cognitive abilities and needs, and social interactions, the evaluations lacked a thorough evaluation of: * Past 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. The facility did not use the information gathered in the activity evaluation to develop an individualized activity plan 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 that were based on a thorough evaluation of the resident's activity interests, abilities, and needs was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), and Staff 5 (RN) on 02/19/26 at 11:52 am and with Staff 1, Staff 3, Staff 5, and Staff 6 (Lead MT) 3:40 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-057-0160 (2)(d) Activities, The facility immediately reviewed the activities plans for the identified resident(s) and corrected any deficiencies to ensure resident needs were addressed. Activities staff and nursing leadership ensured that meaningful activities are planned and documented for each resident at move-in and during the 90-day evaluation, reflecting individual preferences, abilities, and interests. The activities calendar was reviewed, updated, and will be maintained to ensure all planned activities are offered and followed consistently. To prevent recurrence, staff were re-educated on the requirements for documenting and implementing resident activities and on maintaining a current and accurate activities calendar. The Executive Director or designee will monitor compliance by auditing resident activities plans and the activities calendar weekly for 90 days to ensure that meaningful, resident-centered activities are occurring as planned. Any discrepancies identified will be corrected immediately and documented. After 90 days, monitoring will transition to routine quality assurance review.

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: