Print Inspection: RL005275

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, 06/30/25 through 07/02/25, observations of the memory care units showed minimal group activities. The television was on throughout the day. One to two residents were observed to color intermittently during the observations. One resident played a game with staff in Cottage C. Additional residents were observed sleeping in their chairs, in their rooms or wandering the common area, dining room and halls, throughout the rest of the day. Care staff were not observed to initiate any additional large or small group activities or offer the residents other things to do. Interviews were conducted on 07/01/25 with Staff 9 (MT) and Staff 17 (CG). Staff 17 indicated she was in to help with activities today. She normally was a caregiver, but activity staff was out sick. Staff 9 indicated the facility normally had an activity staff Monday through Friday that worked in all three units. Activities were done in each unit and some activities like bingo would be done in one cottage and interested residents would go to the one house. The residents who remained in their own cottages would have a group activity done by staff. The need to ensure a daily activity program was provided for residents to address their mental, physical, and psychosocial needs was reviewed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. Staff 1 stated they had extra staff in to cover for activities this week. She was unsure why activities were lacking. The staff acknowledged the findings.

1. Community has daily, scheduled program of social/recreational activities planned and posted as "Activities Calendar" ongoing. Community identified 17 residents that do not often prefer or routinely participate in activites, community developed new "Moments Together." program to engage them. Community has additionally implemented individual totes in B, C, D Cottages with pre-planned, prepared activities for care staff to resource in down times or as needed. Community hired an Activities Assistant for weekends and as needed to ensure 7 days per week, activity engagement for residents. 2. Community will work with Activities Director and Assitant to ensure that daily activities program schedule is being met, Administrator and IDT will ensure activities are occuring through performing spot checks and random audits. Administrator will meet with Activities Director weekly for 1:1 to review and ensure schedule effectiveness and new program implementatation is effective. 3. Weekly. 4. Activities Director and Adminstrator.

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

OAR 411-054-0036 (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 reflected the residents’ needs and preferences, gave clear direction to staff with a written description of who should provide the services and what, when, how, and how often the services should be provided, handwritten changes were dated and initialed, and were implemented for 4 of 5 sampled residents (#s 1, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 09/2021 with diagnoses including Alzheimer’s disease and depression. The resident's service plan available to staff, dated 04/14/25, Resident 3’s service plan located in the facility’s electronic system, also dated 04/14/25, and progress notes, dated 04/05/25 through 06/25/25, were reviewed. Staff were interviewed and Resident 3 was observed. The service plan available to staff lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided, and/or was not being implemented in the following areas: * Resident-specific direction to staff on how to get the best participation with meal assistance; * Cleaning under arms and left hand, then placing a cloth when caring for the resident's contractures and reducing the risk of skin issues; * Hospice providing scheduled showers and facility staff providing PRN bed baths; * One to two staff members needed for repositioning, bed baths, dressing, and incontinence care; * Preference of having the apartment door open; * Checking on the resident at least three times an hour, and repositioning every two hours; * Pureed foods; * Thin liquids with the use of a straw; * What to read to Resident 3 and where the reading material was located; * How to ensure the resident got to listen to his/her calming music of choice; * How Resident 3 showed signs or symptoms of depression; * Use of sertraline for depression; * Resident-centered ways s/he communicates his/her needs (e.g., fidgeting when wanting to get up, holding arms close to the body when cold, whimpering when s/he is uncomfortable, etc.); * The use of a high back, tilt-in-space wheelchair with footrests; and * No longer requiring a soft brace on the dependent arm. There were handwritten changes on the service plan available to staff pertaining to the number of staff needed for dressing, grooming, and oral hygiene that were not dated and initialed. The service plan located in the facility’s electronic system was more reflective of the resident’s care needs but was not available to caregivers, as they did not have access to the electronic system. The need to ensure service plans provided clear caregiving instruction, handwritten changes were dated and initialed, and the service plan was being implemented was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), and Staff 25 (RN) on 07/02/25 at 4:58 pm. They acknowledged the findings. 2. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan, dated 06/06/25, revealed the service plan was not reflective of the resident's current care needs and preferences, did not provide clear direction to staff, and/or was not consistently implemented in the following areas: * Prescribed diet of pureed textures; * Food preferences reflective of the resident’s pureed diet; * Settings related to the resident’s air mattress; * Location of toileting assistance; * Shower days; and * Shaving. The need to ensure resident service plans were reflective of current care needs and preferences, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings. 3. Resident 1 moved into the facility in 05/2022 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the service plan, dated 05/22/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented, and/or did not provide clear direction to staff in the following areas: * Gait belt use; * Fall mat placement; * Snacks and hydration throughout the day; * Activities; and * Behaviors, including verbal aggression. The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. They acknowledged the findings. 4. Resident 5 moved into the facility in 11/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan, dated 05/22/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented, and/or did not provide clear direction to staff in the following areas: * Hallucinations, anxiety about the “man upstairs,” and fear of poisoned food/fluids; * Activities; * Crying and yelling; * Agitation with roommate and claims of theft; * Toileting and incontinence care; and * Safety interventions, including non-skid footwear. The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. They acknowledged the findings.

1. Service plans for residents 1, 3, 4, 5 have been updated with required information to ensure that resident needs and preferences clear instructions for staff for providing resident specific care. 2. Administrator will work with clinical team to ensure all resident service plans are detailed with resident specific information and provide clear instructions for staff to ensure resident preferences are honored. Administrator is working with families/POA/Guardians to obtain more resident specific information to make the service plans more individualized 3. Daily, weekly, monthly, quarterly. 4. Administrator.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who had changes of condition had resident-specific instructions or interventions developed and communicated to staff, and weekly progress documented until resolution for 3 of 5 sampled residents (#s 1, 4, and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 05/2022 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the resident's 05/22/25 service plan, 04/01/25 through 06/29/25 Interim Service Plans, progress notes, dated 04/07/25 through 06/30/25, physician communications, and incident investigations were completed. Multiple observations of the resident were made between 06/30/25 and 07/02/25. The resident was observed while in bed, in the common areas, and in the dining room at meals. The resident moved around the facility in his/her wheelchair and in/out of other residents’ apartments. The resident experienced multiple short-term changes without resident-specific directions communicated to staff and/or progress noted at least weekly until resolution in the following areas: * Behaviors, including resident-to-resident altercations; * Medication changes; * Skin injury; * Falls and safety interventions; and * Cough/sickness. The need to ensure short-term changes of condition had documentation of resident-specific directions communicated to staff and weekly progress was noted through resolution was discussed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. The staff acknowledged the findings. 2. Resident 5 moved into the facility in 11/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 05/22/25 service plan, 04/03/25 through 06/29/25 Interim Service Plans, progress notes, dated 04/01/25 through 06/30/25, physician communications, and incident investigations were completed. Multiple observations of the resident were made between 06/30/25 and 07/02/25. The resident was observed while in bed, in the common areas, and in the dining room at meals. The resident moved around the facility with his/her walker and stand-by assistance from staff. The resident moved very slowly but appeared steady on his/her feet. The resident experienced multiple short-term changes without resident-specific directions communicated to staff and/or progress noted at least weekly until resolution in the following areas: * Falls and safety interventions; * Foot pain; * Resident-to-resident altercations; * Anxiety and paranoia around roommate and potential theft; and * Left hip/thigh pain, increases in pain complaints, and hip x-ray. The need to ensure short-term changes of condition had documentation of resident-specific directions communicated to staff and weekly progress was noted through resolution was discussed with Staff 1 (ED) and Staff 3 (Resident Care Manager) on 07/02/25. The staff acknowledged the findings. 3. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 06/06/25 service plan, 04/02/25 through 06/29/25 Interim Service Plans, 04/01/25 through 06/29/25 progress notes, and corresponding incident investigations were completed. The facility failed to determine resident-specific actions or interventions needed for the resident, communicate the actions or interventions to staff on each shift, and/or document weekly progress until the condition resolved for the following short-term changes of condition: * 05/12/25 – Cut to the nose; * 05/23/25 – Change to morphine dosing (for pain); * 05/23/25 – New Debrox treatment for ear wax; * 05/30/25 – Fall; * 05/30/25 – Abrasion to forehead; * 05/30/25 – Increased lorazepam dosing (for anxiety); * 05/30/25 – New acetaminophen (for pain); * 05/30/25 – New morphine (for pain); * 05/31/25 – New haloperidol (for anxiety); * 06/04/25 – New cyclobenzaprine (muscle relaxant); * 06/27/25 – Fall; and * 06/27/25 – Skin tear. The need to ensure the facility determined and documented what resident-specific actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. For residents 1,4, and 5 the RN assessed each resident, a review was completed of progress notes for changes of condition and alert charting was completed through resolution. Changes/updates were made as needed. 2. Community holds a clinical meeting each business day that reviews progress notes, alert charting notes, and TSPs. Any changes of condition will be reviewed for all required elements and determine need for change of condition monitoring including through resolution. Follow up action to be implemented as appropriate at that time. 3. Daily, weekly. 4. The Licensed Nurse and Administrator.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services and for 2 of 3 sampled residents (#s 3 and 4) dependent on staff for ADL care. Findings include, but are not limited to: 1. Lunch service was observed in Cottages B and C on 06/30/25 - 07/02/25. a. Staff were observed serving meals and beverages, touching residents ,and assisting residents with feeding without changing their gloves or performing hand hygiene. b. Direct care staff were observed serving food to residents without donning a protective barrier over potentially contaminated clothing. The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during meal service was reviewed on 07/03/25 at 10:24 am with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN). They acknowledged the findings. 2. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Observations of the resident and interviews with staff from 06/30/25 through 07/03/25 revealed Resident 4 relied on staff for incontinence care. On 07/01/25 at 1:18 pm, Staff 15 (CG) and Staff 17 (CG) donned gloves to provide ADL care for Resident 4. The resident's incontinence brief was unfastened, the resident was physically repositioned to determine whether his/her brief was dry, s/he was determined to be clean and dry, and then his/her brief was re-fastened. Staff 15 and Staff 17 doffed their soiled gloves and donned new gloves without completing hand hygiene between tasks. Then Staff 15 and 17 assisted the resident by adjusting the bed, pillows, and blankets. Following cares, Staff 15 and 17 doffed the soiled gloves. Staff 17 failed to complete hand hygiene prior to leaving the room and then the cottage. The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings. 3. Resident 3 moved into the facility in 09/2021 with diagnoses including Alzheimer’s disease. Observations of the resident and interviews with staff from 06/30/25 through 07/03/25 revealed the resident relied on staff for incontinence care. On 07/01/25 at 10:27 am, Staff 19 (CG) and Staff 29 (CG) donned gloves to provide ADL care for Resident 3. The resident's incontinence brief was unfastened and removed, staff turned Resident 3, wiped his/her bottom, applied barrier cream, put a clean brief on, changed the resident’s clothes, and got the resident ready for a hoyer lift transfer. Resident 3’s wheelchair handles, the hoyer including the sling and controls, a blanket, and the resident’s hair were all touched without doffing gloves and without performing hand hygiene. Following cares, Staff 19 and 29 doffed the soiled gloves and both staff members failed to complete hand hygiene prior to leaving Resident 3’s apartment. The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), and Staff 25 (RN) on 07/02/25 at 4:58 pm. They acknowledged the findings.

1. Staff were provided infection control education during the survey on the need for aprons and hand hygeine during meal service and the need for hand hygeine and the use of gloves during personal care. 2.Staff Training was provided on 07/30/25 that covered the importance of hand hygiene, how to perform assisted dining with dignity and staff apron use. Community purchased new aprons for each cottage on 7/15/25. The management team will monitor compliance through observations and audits during meal times and when staff are providing personal care. A new observation checklist was developed. 3.Weekly, monthly. 4. Administrator.

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

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. The resident's physician orders, the Controlled Substance Disposition logs, and the MAR, dated 06/01/25 through 06/29/25, were reviewed. Resident 4 had the following physician’s orders: * Lorazepam 1 mg – one tablet by mouth every six hours for anxiety; and * Lorazepam 1 mg – one tablet by mouth every two hours as needed for anxiety. a. The following doses of scheduled lorazepam were documented in the MAR but were not documented in the Controlled Substance Disposition log: * 06/04/25 – 8:00 am dose; * 06/11/25 – 8:00 am dose; * 06/13/25 – 2:00 am dose; * 06/15/25 – 2:00 pm dose; * 06/27/25 – 8:00 pm dose; and * 06/28/25 – 2:00 am dose. b. The following doses of scheduled lorazepam were documented in the Controlled Substance Disposition log but not documented in the MAR: * 06/12/25 – 8:00 am and 2:00 pm doses; and * 06/27/25 – 2:00 pm dose. c. The following doses of scheduled lorazepam were not documented in either the MAR or the Controlled Substance Disposition log: * 06/11/25 – 8:00 pm dose; and * 06/12/25 – 2:00 am dose. d. The following dose of PRN lorazepam was not documented in the MAR: * 06/27/25 – 4:30 pm dose. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Resident #4 no longer resides in the facility. His MAR and controlled substance logs were reviewed for discepancies at the time of the survey. 2. Medication Techs were educated on the controlled substance protocol on 7/23 and 7/24. Administrator and clinical team will review controlled substance count records against the MAR administration and missed medication reporting with followup. The Missed Medication report will be reviewed daily during clinical meeting for any issues, with follow up as needed. A controlled substance record and count review will occur weekly. An audit tool was developed for use during observation of counts. 3. Weekly. 4. Licensed Nurse and Administrator.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, including medication-specific instructions, and provided resident-specific parameters and instructions for PRN medications for 3 of 4 sampled residents (#s 2, 3, and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 03/2022 with diagnoses including frontotemporal dementia and anxiety disorder. Resident 2's current physician's orders, MAR, dated 06/01/25 through 06/30/25, and progress notes, dated 05/01/25 through 06/30/25, were reviewed. The following medications lacked medication-specific instruction: * Quetiapine (for bipolar disorder/ mood) 100 mg tablet did not have side effects listed; and * Gabapentin (for pain) 100 mg capsule did not specify the route of delivery. The need to ensure MARs were accurate and provided medication-specific instruction was reviewed on 07/03/25 at 10:24 am with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN). They acknowledged the findings. 2. Resident 3 moved into the facility in 09/2021 with diagnoses including Alzheimer’s disease. The resident’s current physician’s orders, MAR, dated 06/01/25 through 06/30/25, and progress notes, dated 04/05/25 through 06/25/25, were reviewed. The following inaccuracies were identified: a. There was no documentation if the resident's scheduled lactulose (for bowel management) was administered on 06/20/25 or his/her scheduled health shake (for a nutritional supplement) was provided on 06/02/25 at 5:00 pm, as the MAR was blank on those dates. b. There were blanks relating to monitoring Resident 3's bowel movements six times from 06/01/25 through 06/30/25. In addition, staff documented "NA [not applicable]" 21 times. The options for staff to document were: "S = Small," "M = Medium," and "L = Large." "NA" was not an option provided for staff to document relating to monitoring the resident's bowels. c. Staff were directed to document a number relating to the resident's pain prior to administrating scheduled acetaminophen. Staff documented "NA" six times instead of a number. d. Staff were directed to monitor the percentage of meal consumed by the resident. There were seven blanks in which staff did not document anything between 06/02/25 and 06/25/25. e. Resident 3 had two PRN medications prescribed for pain. There was no direction to staff on which sequential order to administer the medication. f. The resident had three PRN medications prescribed for constipation. Although the Milk of Magnesia directed staff to administer the medication first, and directed staff to administer two doses, there was no direction on how much time to allow between the first and second dose. In addition, the other two bowel medications lacked the sequential order for administration if there was no result from the two Milk of Magnesia doses. The need to ensure MARs were accurate, and included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), and Staff 25 (RN) on 07/02/25 at 4:58 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Resident 4's physician orders and MAR, dated 06/01/25 through 06/29/25, were reviewed during survey. The following PRN pain medications lacked resident-specific parameters or instructions to staff: * Acetaminophen 325 mg tablet; * Acetaminophen 650 mg suppository; and * Morphine sulfate 0.75 ml by mouth or sublingually. During an interview with Staff 14 (MT) on 07/01/25 at 2:54 pm, she confirmed the PRN pain medications lacked resident-specific parameters or instructions for unlicensed staff. The need to ensure PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Residents 2,3,4 will have orders reviewed for accuracy, completeness, resident-specific instructions, and parameters with updates to orders as needed. 2. An audit will be conducted of resident records for accuracy, instructions, and parameters of medication orders. Any noted issues will be addressed when found. Med techs will be educated on medication administration and documentation.The missed medication report will be reviewed during daily clinical meeting to identify missed charting. Follow up will be completed. Community has implemented a triple check process for orders to assure accuracy, instructions and parameters are in place. 3. Daily, weekly. 4. Licensed Nurse and Administrator.

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

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to their administration for 2 of 4 sampled residents (#s 2 and 4) who were prescribed psychotropic medications. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 03/2022 with diagnoses including frontotemporal dementia and anxiety disorder. The resident's 06/01/25 through 06/30/25 MAR and prescriber orders were reviewed, and staff were interviewed. Resident 2 had orders for clonazepam 0.5 mg tablet: take one tablet by mouth every eight hours as needed for anxiety. The MAR indicated the PRN medication was administered on 06/01/25, 06/11/25, and 06/28/25. The resident's record lacked evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication. The record also lacked instruction to staff on when to contact a health professional regarding side effects. Staff 9 (MT) was interviewed on 07/02/25 at 11:20 am, and Resident 2’s MAR was reviewed. She acknowledged not all MTs have documented non-pharmaceutical interventions attempted prior to administration of PRN psychotropic medication. The need to document attempted and ineffective non-pharmacological interventions prior to administering PRN psychotropic medications was reviewed on 07/03/25 at 10:24 am with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN). They acknowledged the findings. 2. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. The resident's 06/01/25 through 06/29/25 MAR and prescriber orders were reviewed, and caregivers were interviewed. a. The resident’s PRN haloperidol and lorazepam medications, both used for agitation and anxiety, lacked resident-specific parameters or instructions to staff. This was confirmed during an interview with Staff 11 (MT) on 07/02/25 at 11:48 am. b. Resident 4 had a physician order for lorazepam 1.0 mg - take one tablet by mouth every two hours for anxiety. The MAR indicated the resident received the PRN medication seven times between 06/03/25 and 06/23/25. The resident's record lacked evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication in six of the seven administrations. Resident 4 also had a physician order for haloperidol 0.5 mg – take one tablet by mouth/sublingual every four hours as needed for agitation/nausea. The MAR indicated the resident received the PRN medication once on 06/13/25. The resident’s record lacked evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication. On 07/03/25 at 8:44 am, Staff 1 (ED) confirmed non-pharmacological interventions attempted prior to the administration of the resident's PRN lorazepam or haloperidol were not documented in seven of the eight administrations reviewed. The need to ensure PRN medications administered to treat a resident’s behavior had resident-specific parameters and non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Residents #2 and #4 have had their orders reviewed and updated with resident specific instructions and parameters. 2. Med techs have been educated on the need to document all non-pharm interventions prior to administering the PRN psychotripc meds. The revised triple check order protocol includes checking for staff instructions, resident specific interventions and parameters for administration. The LN will be the 3rd check in the process and will address any missing items. 3. Weekly. 4. Licensed Nurse and Administrator.

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident who required two-person transfer assistance during the night shift. Findings include, but are not limited to the following: The acuity interview was completed on 06/30/25 at 1:21 pm with Staff 3 (Resident Care Manager) and Staff 9 (MT), and the “ABST Facility Entrance Questionnaire,” dated 06/30/25, was reviewed. The following was identified: * The MCC was home to 40 residents who resided in cottages B, C, and D. Cottage A was empty at the time of survey; * Four residents required two-person assist for transfers. At least one resident who required two-person assist resided in each of the three cottages in use; * Four residents required assistance with eating; * Eight residents had support for behavioral symptoms; and * Multiple other residents were reported to require high levels of caregiving assistance due to hospice status, need for one-person transfer assistance, need for frequent checks, and/or due to fall risk. The facility's posted staffing plan for each cottage and the staffing schedule from 06/23/25 through 06/29/25 were reviewed. The facility's posted staffing plan for the 6:00 pm to 6:00 am shift was as follows: * Cottage A – “Clear”; * Cottage B – one MT and one CG; * Cottage C – one MT and two CGs; and * Cottage D – one MT and one CG. The staffing plan was confirmed in an interview with Staff 1 (ED) on 07/01/25 at 3:55 pm. When Staff 1 was asked how the unscheduled needs of residents requiring two-person assist with transfers were met when staff took breaks, she acknowledged the facility was not currently in compliance. Staff 1 reported she would change the NOC schedule immediately. The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs of the multiple residents who required the assist of two care staff for transfers, had high levels of care needs, had behaviors (including resident-to-resident altercations), and resided in three distinct cottages. On 07/01/25 at 4:46 pm, Staff 1 provided an updated schedule which included a float to relieve staff during their breaks for 07/01/25 and 07/02/25. From 07/03/25, the facility’s plan included staffing two CGs and one MT in each cottage. This updated schedule accounted for the scheduled and unscheduled needs of the residents. The need to have a sufficient number of staff in to meet all scheduled and unscheduled needs of residents on the overnight shift was discussed with Staff 1, Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. The community updated the schedule which includes a float to relieve staff during their breaks to meet scheduled and unscheduled needs of the residents. 2. The plan includes staffing two CGs and one MT in cottage C, one MT and 1 CG in the other two cottages during night shift. The Administrator completes ABST review multiple times per week with updates from daily clinical meeting and makes adjustments to the schedule as needed to meet resident care needs. 3. With changes and weekly. 4. Administrator.

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

OAR 411-054-0037 (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 accurately capture care time and care elements staff were providing to residents for 3 of 4 sampled residents (#s 2, 3, and 4). Findings include but are not limited to: Observations of Resident 2, 3, and 4 and interviews with direct care staff were conducted from 06/30/25 through 07/03/25. Review of Resident 2, 3, and 4’s current service plans and acuity-based staffing tool (ABST) evaluations were reviewed and revealed the residents’ allotted care minutes were not reflective of current needs in one or more of the 22 care areas of the ABST. The need to ensure the ABST accurately captured the care time and care elements for all residents in each of the 22 ADL areas was discussed with Staff 1, Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Administrator reviewed the ABST for residents 2, 3 & 4 and after verifying residents care needs made neccesary adjustments in service plans and to the ABST to ensure congruency. The ABST was reviewed to include meal preparation and unscheduled resident needs. 2. Administrator is updating ABST multiple times per week after daily clinical meeting to ensure all resident change of condition or service plan updates are reflected. The staffing plan is adjusted by scheduler/Administrator to ensure the community is able to meet ongoing and changing resident needs. 3. With changes of condition and weekly. 4. 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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted every other month which included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to: Facility fire drill records, dated 12/2024 through 06/2025, were reviewed and the following was identified: a. The fire drill documentation lacked one or more of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills; * Evacuation time; and * Number of residents evacuated. On 07/02/25 at 8:35 am, Staff 7 (Environmental Services Director) confirmed residents were not being evacuated. Due to the facility not evacuating residents during fire drills, there was no evidence alternate routes were used nor was there documentation on problems encountered. The facility would not be able to make the changes needed to ensure the evacuation standard was being met. b. The facility was not providing fire and life safety instruction to staff on alternating months from fire drills. The need to ensure unannounced fire drills were conducted every other month and included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills, was discussed with Staff 1 (ED) and Staff 7 on 07/02/25 at 8:40 am.

1. Community has updated the Fire Drill Evacuation checklist form to include all required componants for OFC life safety. 2. Training was provided to the Environmental Services Director and the Environmental Services assistant to ensure aknowledgment and understanding of Fire Drill Checklist additions. Additions on Community Fire Drill checklist: -Required listing of individuals who participated in the drill both staff and residents. * Including to note the residents who refused or failed to participate in the drill. -Required listing of the Escape route and/or alternate route that was used in evacuation drill. -Required listing of the time it takes to successfully complete the drill. -Required listing of the area in which the residents were evacuated to. Administrator and ESD developed semi-monthly training schedule for alternative, life safety training for the year. Training will include presentation/training for emergency procedures in the community. Training will be provided at monthly required staff meetings. 3. Monthly. 4. Administrator and Environmental Services Director.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 07/01/25. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods, and responsibilities within 24 hours of admission and annually. On 07/02/25 at 8:35 am, Staff 7 (Environmental Services Director) confirmed annual re-instruction had not been done with the residents. The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (ED) and Staff 7 on 07/02/25 at 8:40 am. No additional information was provided.

1. Residents have received Fire and Life Safety (FLS) education. 2. Residents will be educated on Fire Life and Safety information anually and at the time of move in with resident and POA/Guardian. Administrator acknowledges that some residents may require individual training based on resident- specific needs. Administrator will review resident FLS education documentation for completeness 3. Monthly. 4. Environmental Services Director and Administrator.

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior of the building was maintained clean and in good repair. Findings include, but are not limited to: The facility was toured on 07/02/25 at 8:45 am with Staff 1 (ED) and Staff 7 (Environmental Services Director). The following was observed: Cottage B * Stains were observed on the carpet in the television area; * Vinyl was coming off from a black recliner located in the television area; * Multiple resident rooms were missing closet doors; * The laundry closet was observed to have holes in the wall, chipped paint, and there was missing flooring; * The cupboard underneath the kitchenette sink had brown- and rust-colored marks and the linoleum was pealing off; * The common use bathroom had areas in need of painting on the walls, door, and door jamb; * Dining room chairs were missing vinyl on the seats and/or the legs were scuffed with exposed wood; * Staff made comments about the dryer being very loud when in operation; * There was a door located across from room B7 that had a hole above the lever handle; and * Walls throughout the dining room were in need of painting due to chipped paint and/or gray scuff marks. Cottage C * Walls throughout the dining room, outside of the medication room, and in the laundry closet had chipped paint observed; * The laundry closet was observed to have flooring missing; * Multiple resident rooms were missing closet doors; * The skinny door and door jamb behind the kitchenette was observed to have drips down the left side by where the aprons were hanging; * The cupboard under the kitchenette's sink and the cupboard to the left of the stove had brown- and rust-colored stains observed; * Dining room chairs were missing vinyl on the seats and/or the legs were scuffed with exposed wood; * There were stains observed on the carpet in the television area; * The community bathroom had chipped paint observed on the walls and the inside of the door; and * The bathroom door had a hole above the lever handle. Cottage D * Multiple resident rooms were missing closet doors; * There was chipped paint observed on walls in the laundry closet, community bathroom, and dining room; * The windowsill on the outside of the medication room had chipped paint present; * The toilet in the community bathroom had rust coloring around the base on the floor; * The skinny door behind the kitchenette had chipped paint observed; * There was approximately two and a half inches of linoleum trim missing from the side of the countertop in the kitchenette, to the right of the refrigerator; * Doors and door jambs were observed to have gray or brown streaks or gouged/exposed wood with missing paint pertaining to room D3, the closet across the hall from room D7, the common use bathroom, where the "Sheets/Shower Towels" were stored, and the medication room; * Dining room chairs were missing vinyl on the seats and/or the legs were scuffed with exposed wood; and * The walls to the right of the laundry closet and in the dining room had scuffed and/or gouged wood observed. Common Area Outside the Cottages * All cottage doors had chipped paint both inside and outside present; * Both the kitchen’s entrance and exit doors had scuffs, scrapes, and chipped paint observed; and * The exit door that led into the reception area had chipped paint present. The above identified findings were acknowledged by Staff 1 and Staff 7 on 07/02/25.

1. Items in Cottage B have been addressed. -Carpet was shampooed 7/15/25 -Community plans to replace recliner in television area. -Community plans to repair or replace all missing closet doors. -Laundry closet was repaired and painted on 7/9/25, Community to get quotes on repair of laundry closet flooring. -Cupboard under the kitchen sink painted 7/9/25 community plans to replace the linoleum. -Common use bathroom painting planned for 8/6/25. -Community plans to replace dining room chairs. -Clothing dryer service, scheduled 8/7/25. -Community plans to repair any holes near door handles. -Community plans to complete dining wall painting. Items in Cottage C have been addressed. -Community has painted all white surfaces on 7/9/25 ; areas/walls of color are planned to be completed. -Laundry closet was painted on 7/9/25, Community to get quotes on repair of laundry closet flooring. -Community plans to repair or replace all missing closet doors. -Skinny kitchen door and jamb has been cleaned and painted on 7/9/25. -Cupboards in dining area and under sink painted 7/9/25, community plans to add linoleum. -Community plan to replace dining room chairs. -Carpet was shampooed on 7/15/25 -Common use bathroom painting planned for 8/6/25. -Community plans to repair holes above door handles. Items in Cottage D have been addressed. -Community plans to repair or replace all missing closet doors. -Laundry closet was painted on 7/9/25, community painted all the “White” areas on 7/9/25. All remaining areas of color and dining room to be painted. Common use bathroom painting planned for 8/6/25, medication room windowsill was painted on 7/9/25. -Community ordered supplies to remove the rust from near the toilet on the floor in the bathroom. -Skinny kitchen door has been cleaned and painted on 7/9/25. -Linoleum trim has been temporarily repaired until matching trim can be replaced. -Community has cleaned all doors and door jambs; white areas have been painted as of 7/9/25. All remaining doors, closets and trim to be repaired and painted. -Community plans to replace dining room chairs. -Community plan to paint and repair any scuffed/gouged wood. Common Areas Outside the Cottages -Community to paint all cottage doors both internally and externally. -Community plans to repair and paint both Kitchen entrance and exit doors on inside and outside. -Community plans to paint the exit doors to the lobby on both sides. 2. Environmental Services Director (ESD) will work with Administrator to develop a schedule for routine painting and repair. Community will use TELS to monitor community needed repairs. The Administrator and ESD will do weekly walk-throughs to identify needs. 3. Weekly. 4. Environmental Services Director and Administrator.

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:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents received services in a manner that protected dignity and respect. Findings include, but are not limited to: The following observations were made between 06/30/25 and 07/03/25: * Multiple staff members were observed referring to Resident 1 as “grandma”; * Multiple staff members were observed referring to Resident 3 as “momma”; * A staff member was observed referring to Resident 4 by an abbreviation of the resident’s name. The resident’s service plan, dated 06/06/25, did not indicate the resident preferred to be addressed as such; * A staff member was observed referring to Resident 4 and Resident 4’s roommate as “the boys”; * A staff member was observed referring to an unsampled resident as “sweetheart” and “sugar sugar”; and * Staff members were observed standing over residents as they assisted the residents with eating their meals. The need to ensure residents received services in a manner that protected dignity and respect was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 10:35 am. They acknowledged the findings.

1. Staff education regarding resident rights to dignity was provided to staff during survey. 2. Administrator provided training to all staff during 7/16/25 all staff meeting. Training provided was a reminder of resident rights, in depth training on privacy and dignity and the use of terms of endearment. Management will conduct walking rounds randomly throughout the day observing for continued care practices with dignity. Corrections to be made as they events occur. 3. Daily, weekly. 4. Administrator.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to ensure each individual had privacy in his/her own unit for 2 of 3 sampled residents (#s 3 and 4) who required staff assistance for all ADLs. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 09/2021 with diagnoses including Alzheimer's disease. Observations of the resident and interviews with staff from 06/30/25 through 07/03/25 revealed the resident relied on staff for all ADLs and care. On 07/01/25 at 10:27 am, Staff 19 (CG) and Staff 29 (CG) were observed to provide incontinence care and dressing for Resident 3 in the resident's bed. The bed was located just below the windows in Resident 3's unit. The blinds were open, and the resident was visible to people passing by outside of the facility. Staff provided incontinence care and changed Resident 3's clothes with the blinds open. The need to ensure privacy in resident's units was discussed with Staff 1 (ED), Staff 3 (Resident Care Manager), Staff 4 (Resident Care Manager), Staff 24 (Regional Director of Operations), and Staff 25 (RN) on 07/02/25 at 4:58 pm. They acknowledged the findings. 2. Resident 4 moved into the facility in 09/2022 with diagnoses including dementia. Observations of the resident and interviews with staff from 06/30/25 through 07/03/25 revealed the resident relied on staff for all ADLs and care. On 07/01/25 at 1:18 pm, Staff 15 (CG) and Staff 17 (CG) were observed to provide incontinence care for Resident 4 while s/he remained in bed. Resident 4 shared the room with an unsampled resident. The room was observed to have a privacy curtain situated between the two beds. However, Staff 15 and Staff 17 failed to draw the privacy curtain when Resident 4 received incontinence care, and the unsampled resident remained in the room and in the line of sight of the ADL cares provided. The need to ensure privacy in residents’ units was discussed with Staff 1, Staff 3 (Resident Care Manager), Staff 24 (Regional Director of Operations), Staff 25 (RN), and Witness 3 (Consultant RN) on 07/03/25 at 9:43 am. They acknowledged the findings.

1. Staff education regarding resident rights to privacy was completed during survey. 2. Administrator provided staff training related to resident privacy on 7/16/25 during an all staff meeting. Adminstrator/designee will continue to provide training to staff to ensure that residents right to dignity and privacy are respected and upheld. Administrator/designee will be performing spot and random checks on each shift while care is being performed to ensure community ongoing compliance with the rule. 3. Weekly. 4. Administrator.

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

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C295, C360, C362, C420, C422, and C513.

Refer to C295, C360, C362, C420, C422, C513

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C302, C310, and C330.

Refer to C260, C270, C302, and C330.

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: