Print Inspection: RL005576

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to create an environment in which residents were treated with dignity and respect and received services in a manner that protected privacy and dignity for 2 of 6 sampled residents (#s 2 and 6) and two unsampled residents who received meal services and/or ADL care from staff. Findings include, but are not limited to: Observations were conducted during lunch on 07/14/25 and 07/17/25. The following concerns were identified: 1. Staff 8 (Resident Assistant) was observed standing while providing cueing and physical feeding assistance to an unsampled resident who was seated in a wheelchair in the dining room. Staff 8 remained standing while feeding the resident, rather than positioning herself at eye level or sitting beside the resident. At the same time, Staff 8 left the resident to perform other tasks, including collecting dirty plates off the table nearby and assisting another resident back to their room, then returned to continue assisting the resident to eat. 2. Resident 6 moved into the community in 03/2025 with diagnoses including dementia, diabetes mellitus type II, and malignant neoplasm of the bronchus and lung. During lunch on 07/17/25 from 12:05 pm through 12:45 pm, Staff 8 was observed standing while assisting Resident 6, who required cueing assistance during meals. The resident was seated in a chair in the dining room, while Staff 8 remained standing beside the resident. While the resident was eating, Staff 8 was repeatedly asking, “Are you going to eat?” The resident replied, “I don’t like the food, I want mashed potatoes and gravy. Can you taste the food?” Staff 8 did not acknowledge the resident’s request and continued asking the resident if he/she was going to eat. The resident was observed to be visibly frustrated and replied to Staff 8, “I guess I have to eat, if I don’t eat, I’m going to die, right?” The need to ensure residents were treated with dignity and respect during meal service was discussed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25 at 2:30 pm and on 07/17/25 at 1:00 pm. They acknowledged the findings. 3. Resident 2 moved into the community in 06/2022 with diagnoses including dementia and seizures. During the acuity interview, Resident 2 was identified as a two-person assist for incontinence care. During an ADL observation on 07/14/25 at 2:55 pm the following was noted: * One staff was observed providing Resident 2 with incontinence care and failed to close the door to Resident 2’s room. The need to ensure residents' rights of privacy and dignity were upheld was discussed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25. They acknowledged the findings. 4. Observations of meal service were conducted at 11:45 am on 07/16/25. An unsampled resident was observed sitting in the common area, holding his/her head in his/her hands. Staff 8 (Resident Assistant) approached the resident and stated, “What’s wrong?” The unsampled resident stated s/he had a headache. Staff 8 stated, “Well, get up. It’s time to eat.” The resident stood and took a seat in the dining room. S/he ate a few bites of food but was observed grimacing and still holding his/her head in his/her hands. Staff 8 approached him/her at 12:05 and stated, “Why aren’t you eating? Are you finished?” Without waiting for an answer, Staff 8 removed the unsampled resident’s plate of food. The unsampled resident appeared frustrated and stated, “I wasn’t finished,” but the staff had walked away and didn’t hear him/her. The need to ensure residents’ right to be treated with respect and dignity was discussed with Staff 1 (ED) on 07/17/25 at 10:00 am. She acknowledged the findings.

The Cottages Senior Living will create an environment in which residents are treated with dignity and respect and receive services in a manner that protects privacy and dignity. During the Re-licensure survey, team members were educated on resident Bill of Rights that included treating residents with dignity and respect and receiving services in a manner that protects privacy and dignity. Bi-weekly audits will be completed by Executive Director (ED), Resident Services Director (RSD) and/or Designee to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Licensed nurse meeting held on July 22, 2025. Training topics included resident Bill of Rights in the areas noted above. Cottage leader meeting held on July 29, 2025. Training topics included resident Bill of Rights in the areas noted above. All staff in-service was held on August 8, 2025. Training topics included resident Bill of Rights in the areas noted above. Weekly memos posted by ED in team breakroom and cottages, an additional educational/training tool for team. ED and RSD will be responsible.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

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 ensure injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse for 1 of 5 sampled residents (#4) whose incidents were reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in 07/2024 with diagnoses including Alzheimer’s disease. Progress notes, dated 04/15/25 through 06/23/25, corresponding incident reports, and outside provider documentation, dated 04/01/25 through 07/08/25, were reviewed. The following was revealed: Resident 4 had a bruise on the “right rib area” documented by the resident’s hospice RN on 05/22/25. On 05/23/25, Staff 2 (Administrator/RN) reviewed and initialed the outside provider document. On 07/15/25 at 1:48 pm, Staff 2 confirmed she reviewed the outside provider documentation, and she acknowledged there was no investigation to rule out abuse of the injury of unknown cause. The facility failed to promptly investigate the resident's injuries of unknown cause to rule out abuse. The facility was instructed to report the injury of unknown cause to the local SPD office. Proof of reporting was received by the survey team on 07/16/25 at 8:48 am. The need to ensure all injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse was discussed with Staff 1 (ED) on 07/17/25 at 8:25 am. She acknowledged the findings.

The Cottages Senior Living will promptly investigate residents' injuries of unknown cause to rule out abuse. Community will report injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concludes and documents the injury was not the result of abuse. During the Re-licensure survey, RSD reported to the local SPD office Resident #4's bruise identified on right rib area by an outside service provider on 5/22/2025. Outside service provider documents will be reviewed daily by ED and RSD to review and investigate all resident injuries. Routine clinical meetings will be held at minimum 5 days a week with ED, RSD and charge nurse. These meetings are a double check to review and identify any new resident injuries to review and investigate. Licensed nurse meeting held on July 22, 2025. Training topics included outside service provider document forms that include sections that identify new resident concerns (i.e. bruise). Resident incident reports will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All community's licensed nurses, RN and LPNs, will be registered for the Role of the RN Class through OHCA and/or Leading Age. ED and RSD will be responsible.

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 move-in evaluation addressed all required elements for 1 of 1 sampled resident (#7) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 7 moved into the facility in 04/2025 with diagnoses including dementia and chronic atrial fibrillation. The resident’s “Pre-Move in Memory Care Assessment with Service Plan” dated 04/29/25 was reviewed, and the following required elements were not addressed: * Customary routines: sleeping, eating; * Mental health issues including presence of depression, thought disorders or behavioral or mood problems, history of treatment, and effective non-drug interventions; * Complex medication regimen; * Recent losses; * Unsuccessful prior placements; * Environmental factors that impact the resident’s behavior including but not limited to: noise, lighting, room temperature; * Gender identity; and * Preferred name. The need to address all required elements on the resident’s move-in evaluation was discussed with Staff 1 (ED) on 07/17/25 at 8:47 am. She acknowledged the findings.

The Cottages Senior Living will ensure move-in, 30-day, quarterly and as needed evaluations address all required elements. All current residents' evaluations will be updated to address all required elements. Resident #7's evaluation will be updated to address all required elements. Weekly audits will be completed by ED and RSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. Communirty RN will registered for the Role of the RN class through OHCA and/or Leading Age. ED and RSD will be responsible.

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' current care needs and preferences and provided clear direction regarding the delivery of services for 5 of 6 sampled residents (#s 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the community in 06/2022 and had diagnoses including dementia and seizures. The resident's current service plan, dated 06/05/25, was reviewed, observations were made, and interviews with staff and the resident were conducted. The service plan was not reflective of the resident's needs and preferences, and did not provide clear instruction to staff in the following areas: * Behaviors, including interventions; * Pain, including signs/symptoms; * Dressing assistance; * Communication; * Eating/Meals/Nutrition, including feeding assistance, fluids within reach and instructions for refusals; * Mobility and transfer assistance; * Assistive devices; and * Hospice services. The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED), and Staff 24 (Regional Director of Operations) on 07/16/25. They acknowledged the findings. 2. Resident 6 moved into the community in 03/2025 with diagnoses including dementia, diabetes mellitus type II, and lung cancer. The resident's service plan, dated 06/25/25, was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 07/14/25 through 07/17/25. Resident 4's service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Skin condition, regarding the right foot wound; * Hearing, related to the resident being hard of hearing; * Oral care, related to the use of dentures and assistance required; * Environmental factors related to preferred room temperature; * Weight loss; * Nutrition, concerning food preference and supplement use; and * Diet orders of mechanical soft versus regular textures. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25 at 2:05 pm. They acknowledged the findings. 3. Resident 4 moved into the community in 07/2024 with diagnoses including Alzheimer’s disease. The resident's service plan, dated 04/10/25, was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 07/14/25 and 07/16/25. Resident 4's service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Hospice services, including expectations for caregivers regarding showering; * Meal assistance required; * Behaviors and interventions related to the resident’s proximity to other residents; * Use of adaptive utensils during meals; * Diet orders of mechanical soft versus regular textures; * Use of eyeglasses; * Access to and assistance required with cell phone; * Toileting assistance required and frequency of incontinence care; * Ability to evacuation; and * Pain. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED) on 07/17/25 at 8:25 am. She acknowledged the findings. 4. Resident 3 was admitted to the facility in 02/2021 and had diagnoses which included Alzheimer’s, insulin dependent diabetes, kidney disease, chronic wounds and edema. Observations, interviews with staff, and review of the record during the survey revealed the current service plan, dated 05/07/25, was not reflective or did not provide clear direction regarding the delivery of services in the following areas: * Hospice; * Assistance with incontinence care and barrier cream, and use of incontinence briefs; * Staff assistance needed for evacuation; * Bathing assistance; * Housekeeping assistance; * Ted hose; * Dressing assistance; * Laundry assistance; * Personal hygiene; and * Mobility and transfer assistance. The need to ensure the service plan was reflective of Resident 3's current needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25 at 12:30 pm. They acknowledged the service plan was not reflective in several areas and needed to be updated. 5. Resident 5 was admitted to the MCC in 05/2021 with diagnoses which included dementia. Interviews with care staff and observations of Resident 5 during the survey revealed s/he was incontinent, dependent on staff for ADL care, and had hospice services. Resident 5's service plan and quarterly evaluation, dated 05/08/25, was reviewed and lacked clear direction regarding the delivery of services in the following areas: * Toileting; * Evacuation; * Activities; * Transfers; * Personal hygiene care; * Housekeeping; and * Laundry. The need to ensure the service plan included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED) during an interview on 07/15/25 at 2:30 pm. She acknowledged the findings.

The Cottages Senior Living will ensure all residents' service plans are reflective of residents' current care need and preferences and provides clear direction regarding the delivery of services. All resident service plans will be updated and updated as needed to include resident changes. These updates will be written to provide clear direction to team members regarding the delivery of services. Service plans for Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6 will be updated to reflect residents' current care needs and preferences and will provide clear direction regarding the delivery of services. A "Service Plan Update" form will be used to update a service plan as needed. Weekly audits will be completed by ED and RSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. Licensed nurse meeting held on July 22, 2025. Training topics included service plans. Cottage leader meeting helld on July 29, 2025. Training topic included service plans. All staff in-service held on August 8, 2025. Topic included service plans. Weekly memos posted by ED in team breakroom and cottages, an additional educational/training tool for team. All community licensed nurses (RN and LPNs) will be registered for the Role of the RN Class through OHCA and/or Leading Age. ED, RSD and licensed nurses will be responsible.

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 observation, interview, and record review, it was determined the facility failed to determine actions/interventions needed, communicate actions or interventions to staff on all shifts, and monitor changes through resolution with at least weekly documentation for 2 of 7 sampled residents (#s 4 and 6) reviewed with short-term changes of condition, and failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan for 1 of 3 sampled residents (#3) with a significant change of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2021 with diagnoses which included Alzheimer’s disease, insulin dependent diabetes, kidney disease and edema. Observations of Resident 3 and interviews with direct care staff during the survey revealed s/he required assistance with ADL care needs including dressing, bathing and toileting. During an interview on 07/14/25 at 1:40 pm, Staff 9 (Resident Assistant) stated Resident 3 had open wounds to both buttocks and staff were applying barrier cream during incontinence care. On 07/15/25 at 9:30 am, the RN surveyor obtained permission and observed Staff 12 (Resident Assistant) provide toileting assistance and incontinence care to Resident 3. During the observation, open wounds were visible to both of the resident’s buttocks near the intergluteal cleft (posterior deep midline groove in the gluteal region). During an interview on 07/15/25, Staff 18 (Resident Assistant) stated the wounds had been present for “a while.” Review of the clinical record revealed no evidence the facility evaluated the resident, referred to the facility RN, documented the change, and updated the service plan. Additional information was requested from Staff 20 (MCC Care Coordinator) on 07/15/25 at 1:15 pm. At 2:15 pm the same day, Staff 20 said she was unaware of the skin breakdown. She said staff failed to report the wounds to the nursing clinical staff. Staff 2 (RN) was interviewed on 07/15/25 at 2:45 pm. She said she had not assessed the wounds because she had not been notified. She stated she would assess the area. On 07/15/25, Staff 2 provided an assessment to the surveyor which indicated the resident had two ulcers to his/her “bilateral, middle, inner buttocks.” The wound on the right buttock measured 1.5 by 1 cm, and the wound on the left buttock measured 1 by 1 cm. Interventions were developed and the service plan was updated. The need for significant changes of condition to be evaluated, referred to the facility RN, and service plan updated was shared with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25 at 12:30 pm. They acknowledged the findings. 2. Resident 4 moved into the community in 07/2024 with diagnoses including Alzheimer’s disease. A review of Resident 4’s outside provider notes, dated 04/14/25 through 07/07/25, indicated the following short-term changes of condition were identified by the resident’s hospice provider and documented as reviewed by Staff 2 (RN/Administrator): * 04/17/25 – Diarrhea episode; * 05/13/25 – Non-productive cough; and * 05/22/25 – Bruise. The resident’s 04/15/25 through 06/23/25 progress notes and Service Plan Updates were reviewed. The resident's record lacked documentation that the short-term changes of condition were monitored until resolution. On 07/15/25 at 1:48 pm, Staff 2 confirmed she initialed and reviewed the outside provider documentation with the identified changes of condition, and she acknowledged the lack of documented monitoring. The need to ensure the facility monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED) on 07/17/25 at 8:25 am. She acknowledged the findings. 3. Resident 6 moved into the community in 03/2025 with diagnoses including dementia, diabetes mellitus type II, and lung cancer. Resident 6's progress notes and service plan updates, dated 04/14/25 through 07/14/25, outside provider notes, dated 06/23/25 through 07/08/25, and service plan, dated 06/25/25, were reviewed. a. A review of resident’s clinical record indicated the following changes of condition: * 05/21/25 Severe weight loss; * 05/22/25 Nutritional supplement (Ensure) was increased from one time daily to twice daily; * 05/27/25 Regular texture diet was changed to mechanical soft; and * 06/18/25 Resident was admitted to hospice. Although these changes were monitored by Staff 5 (LPN) and Staff 7 (LPN), there was no documented evidence these changes or interventions were communicated to staff. b. On 06/23/25 the Hospice RN documented on an outside provider note that resident’s pulse was elevated, possibly dehydrated and recommended to encourage rest and sips of water. There was no documented evidence staff were instructed to provide sips of water to the resident, or the resident had been monitored for dehydration through resolution. Interview on 07/16/25 at 11:40 am with Staff 2 (Administrator/RN) acknowledged review of outside provider’s note and stated there was no communication provided to staff. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, communicated the actions or interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25 at 2:05 pm. They acknowledged the findings. No additional documentation was provided.

The Cottages Senior Living will ensure that residents' short term and long term change of conditions are monitored appropriately. Community will determine actions/interventions needed, communicate actions or interventions to team members on all shifts, and monitor changes through resolution with weekly documentation. Resident #3's significant change of condition assessment by RN was completed on July 15, 2025. Resident # 6's significant change of condition assessment by RN was completed on July 17, 2025. RN assessments will be completed when applicable. Routine clinical meetings will be held at minimum 5 days/week with ED, RSD and charge nurse. These meetings are a double check to review and identify resident short term and long term change of conditions. Weekly high risk resident meetings will take place to assure compliance. Licensed nurse meeting held on July 22, 2025. Training topics included residents' short term and long term change of conditions. Cottage leader meeting held on July 29, 2025. Training topics included residents' short term and long term change of conditions. All staff in-service held on August 8, 2025. Training topics included residents' short term and long term change of conditions. All community licensed nurses (RN and LPNs) will be registered foir the Role of the RN Class through OHCA and/or Leading Age. ED and RSD will be responsible.

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 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and/or completed in a timely manner for 3 of 3 sampled residents (#s 2, 3 and 6) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 03/2025 with diagnoses including dementia, diabetes mellitus type II and malignant neoplasm of the bronchus and lung. Resident 6’s weight records were reviewed. The following was identified: * 03/14/25 - 116.4 pounds; * 04/07/25 - 113.2 pounds; * 05/07/25 - 105.4 pounds; * 06/07/25 – 104.2 pounds; and * 07/07/25 - 100.4 pounds. Per surveyor request, the resident was weighed on 07/16/25 and weighed 100.4 pounds. From 04/07/25 through 05/07/25, Resident 6 experienced a total body weight loss of 7.8 pounds, or 6.89% of his/her total body weight, in one month. This severe weight loss constituted a significant change of condition and required an RN assessment. On 05/21/25, 14 days after the weight loss was identified, an RN assessment was completed including findings, resident status, and interventions made as a result of the assessment. In an interview on 07/16/25 at 11:40 am, Staff 2 (Administrator/RN), acknowledged the RN assessment was not completed timely. The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25 at 2:05 pm. They acknowledged the findings. 2. Resident 2 moved into the community in 06/2022 with diagnoses including dementia and seizures. Observations of the resident, interviews with staff, and review of the resident's 06/05/25 service plan and progress notes were completed. The following was identified: A progress note dated 04/14/25 noted a significant change of condition by Staff 5 (LPN) and indicated Resident 2 was dependent with all cares due to significant weakness. There was no documented evidence the facility RN had completed an assessment to include findings, resident status and interventions. The need to ensure the facility RN performed timely assessments, and developed interventions was reviewed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 02/2021 with diagnoses which included Alzheimer’s, insulin dependent diabetes, kidney disease and edema. Observations of Resident 3 and interviews with direct care staff during the survey revealed s/he required assistance with ADL care needs including dressing, bathing and toileting. Observations and staff interviews revealed the resident had skin breakdown on his/her buttocks. There was no documented facility RN assessment. Staff 2 (RN) was interviewed on 07/15/25 at 2:45 pm. She said she was unaware of the skin breakdown and therefore an assessment had not been done. Refer to C270, example 1.

The Cottages Senior Living will ensure RN assessments are completed in a timely manner. Resident #2's significant change of condition RN assessment was completed on 7/16/2025. Resident #3's significant change of condition RN assessment completed on 7/15/2025. Resident #6's significant change of condition RN assessment was completed on 7/17/2025. Routine clinical meetings will be held with ED, RSD and charge nurse. These meetings are a double check to review RN assessments. Licensed nurse meeting held on July 22, 2025. Training topics included timeliness of RN assessments. Weekly high risk meetings will be held to also review RN assessments. Internal tracker developed to assure compliance. RN assessments will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All community nurses (RN and LPNs) will be registered for the Role of the RN Class through OHCA and/or Leading Age ED and RSD will be responsible.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. 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 implement effective methods of infection control for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control. 1. Resident 3 was admitted to the facility in 02/2021 with diagnoses which included Alzheimer’s, insulin dependent diabetes, kidney disease, chronic wounds and edema. Observations and interviews with staff during the survey revealed s/he had a catheter, was incontinent of bowel, relied on staff for incontinence care needs, and had open sores on his/her bottom. On 07/15/25 at 9:30 am, the surveyor obtained permission and observed Staff 12 (Resident Assistant) provide toileting assistance and incontinence care to Resident 3. During the observation, Staff 12 donned gloves, assisted the resident onto the toilet, and emptied urine from the resident’s catheter bag. Wearing the same gloves, Staff 12 wiped fecal matter from the resident’s perineum, then proceeded to apply barrier cream to his/her bottom and open wounds. The surveyor intervened and asked Staff 12 to don clean gloves prior to application of the barrier cream. Per the surveyor's request, Staff 12 donned clean gloves before applying the barrier cream to the resident's bottom. The above observation was discussed with Staff 1 (ED) and Staff 24 (Regional Director of operations) on 07/16/25 at 12:30 pm. They acknowledged appropriate infection control practices were not implemented. 2. Resident 2 moved into the community in 06/2022 with diagnoses including dementia and seizures. The current service plan, dated 06/05/25, noted the resident was dependent on staff for toileting activities, including changing incontinent products and assistance with perineal care. During an ADL observation on 07/14/25 at 2:55 pm, the following was noted: * Staff 23 provided incontinence care for Resident 2; * Staff 23 removed Resident 2's soiled incontinence product and placed it in the garbage can; * Staff 23 put on a new incontinence product using the same soiled gloves; and * Staff 23 assisted with the resident’s blanket and handed the resident her/his water bottle using the same soiled gloves. The observation was discussed with Staff 1 (ED), and Staff 24 (Regional Director of Operations) on 07/16/25. No additional information was provided.

The Cottages Senior Living will implement effective methods of infection control. During the Re-licensure survey, team members were educated on infection control. Licensed nurses meeting held July 22, 2025. Training topics included infection control. Cottage leader meeting held on July 29, 2025. Training topics included infection control. All staff in-service held on August 8, 2025. Training topics included infection control. Bi-weekly audits will be completed by RSD and/or Designee to ensure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Weekly memos posted by ED in team breakroom and cottages, an additional educational/training tool for team. ED, RSD and Maintenance Director will be responsible.

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 resident (# 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 moved into the community in 06/2022 with diagnoses including dementia and seizures. The current written prescriber orders and MARs dated 07/01/25 through 07/14/25 were reviewed during the survey. Resident 2 had a physician order for lorazepam 0.5 MG, give one tablet by mouth every eight hours for agitation. Review of the MAR and Controlled Substance Disposition Log revealed the following discrepancies: There were 12 times a facility staff signed the Controlled Substance Disposition log indicating the lorazepam was removed from locked storage but did not document on the MAR that the medication was administered. In interviews on 07/16/25 with Staff 25 (MT) at 8:45 am and Staff 2 (RN) at 1:35 pm, both confirmed the missed documentation on the MAR for the lorazepam. Neither Staff 25 or Staff 2 could explain the missed documentation. The need to ensure the tracking of controlled substances was accurate was reviewed with Staff 2, Staff 1 (ED), Staff 24 (Regional Director of Operations). They acknowledged the findings.

The Cottages Senior Living will have a system in place to accurately track controlled substances. WeeklyPointClick Care audits will be completed by RSD, charge nurse and/or Designee to assure compliance. Licensed nurse meeting held on July 22, 2025. Training topics included controllled substances. Cottage leader meeting held on July 29, 2025. Training topics included controlled substances. All staff in-service meeting held on August 8, 2025. Training topics included controlled substances. Weekly memos posted by ED in team breakroom and cottages, an additional educational/training tool for team. ED, RSD, charge nurses and/or Designee will be responsible.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 6 sampled residents (#3) whose medications were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 02/2021 with diagnoses which included Alzheimer’s, insulin dependent diabetes, kidney disease, chronic wounds and edema. Residents 3's MARs were reviewed from 07/01/25 through 07/14/25. According to the MAR, staff failed to administer the following medications: * Tylenol (for pain) 325 mg two tablets three times a day was not administered on two occasions; * Ammonium Lactate cream (used for skin care on the lower extremities) was not applied on two occasions; * Eliquis (for atrial fibrillation) 5 mg one tablet twice a day was not administered on one occasion; *Levothyroxine (for thyroid) 150 mcg one tablet daily was not administered on one occasion; * Melatonin (for sleep) 3 mg one tablet at bedtime was not administered on one occasion; * Metformin (for diabetes) ER 500 mg two tablets twice daily was not administered on one occasion; * Metoprolol (for atrial fibrillation) 50 mg one tablet twice daily was not administered on one occasion; * Quetiapine (for agitation) 50 mg one tablet at bedtime was not administered on one occasion; * Quetiapine (for agitation) 50 mg 1/2 tablet at bedtime was not administered on one occasion; and * Tamsulosin (for urinary retention) HCL 0.4 mg two tablets nightly was not administered on one occasion. On 07/15/25 at 1:35 pm, the surveyor and Staff 9 (Resident Assistant) observed/checked the MARs and medication supply. Staff 9 verified that the medications had been given, but staff failed to document. The need for the facility to ensure MARs were accurate was discussed with Staff 20 (MCC Care Coordinator) on 07/15/25, and Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25. They acknowledged the findings.

The Cottages Senior Living will ensure Medication Administration Records (MARs) will be accurate. Daily audits will be completed by RSD, charge nurse and/or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Licensed nurse meeting held on July 22, 2025. Training topics included accuracy of MARs. Cottage leader meeting held on July 29, 2025. Training topics included accuracy of MARs. All staff in-service held on August 8, 2025. Training topics included accuracy of MARs. Weekly memos posted by ED in team breakroom and cottages, an additional educational/training tool for team. ED, RSD, charge nurse and/or Designee will be responsible.

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 accurately capture care time and care elements staff were providing to residents for 2 of 6 sampled residents (#s 2 and 4). Findings include, but are not limited to: 1. Resident 4 moved into the community in 07/2024 with diagnoses including Alzheimer’s disease. The service plan, dated 04/10/25, Service Plan Updates, and the resident's corresponding ABST evaluation were reviewed. The resident was observed, and interviews were conducted with staff. The resident's care time and care elements were found to be not reflective in the following areas: * Assisting with communication, assistive devices for hearing, vision, and speech; * Supervising, cueing, or supporting while eating; * Bathing; and * Bowel and bladder management. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (ED) on 07/17/25 at 8:25 am. She acknowledged the findings. 2. Resident 2 moved into the community in 06/2022 with diagnoses including dementia and seizures. The service plan, dated 06/05/25, temporary service plans, and the resident's corresponding ABST evaluation were reviewed. The resident was observed, and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas: * Leisure activities; * Supervising, cueing or supporting while eating; and * Repositioning in bed. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25. They acknowledged the findings.

The Cottages Senor Living will accurately capture care time and care elements team members provide to residents. Resident #2's and Resident #4's ABST evaluations were updated on 7/21/2025. Residents' corresponding ABST evaluations will be updated and updated as needed. Weekly audits will be completed by ED and RSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and RSD will be responsible.

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 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean, in good repair, and free from unpleasant odors. Findings include, but are not limited to: 1. Observations of Cottage 5 on 07/14/25 revealed the following: * Rooms 502, 504, 506 and 507 had scraped doors and/or jambs; * Entrance door to cottage had scraped paint on the door jamb; * Baseboards, walls and corners, and handrails throughout the cottage had scraped paint in several areas; * Paint was coming off around the left side of the door frame of Rooms 509 and 510; * Several doors had broken plastic door hooks which created a sharp, pointed end; * The dining area had an accumulation of dried food matter on table bases, scrapes on the chair rail, and peeling paint by the light switch; * The three-season porch had broken screens, an accumulation of dead bugs and cobwebs, trash and debris on the shelves, and sharp gardening tools. Additionally, wheelchairs and an overbed table were stored in the area; * The laundry room had an accumulation of dirt and debris on the floor, sink, and in the water collection pan underneath the washer; * Room 501 was missing a section of baseboard next to the bathroom and had brown smears on the bathroom door; * Room 505 had broken blinds; * Room 503 had an approximate 1X1 inch hole in the bathroom door, and an approximate 3X2 inch hole in the wall behind the entrance door; and * Unpleasant odors were noted throughout. The surveyor toured the environment with Staff 1 (ED) and Staff 6 (Maintenance Director) on 07/14/25 at 5:00 pm. They acknowledged the findings. 2. During a tour of the Cottage 1 on 07/14/25 at 1:45 pm the following was identified: * Handrails had exposed wood, gouges, and splinters; * Light fixtures in main hallway were dusty and contained dead insects; * Door to the laundry room had black wear marks and scratches; * Dust and dirt accumulated behind a dryer; * Multiple ceiling tiles with water damage and stains above the fireplace; and * Torn baseboard molding next to Room 104. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 07/16/25 at 9:28 am. She acknowledged the findings. 3. Cottage 2 was observed at 11:31 am on 07/14/25. The following was identified: * A build-up of dust, dirt, splashes, paint chips, and black scuffs was observed on the walls, baseboards, doors, and trim in common areas, and the floors and walls in the laundry room; and * The carpet in Room 207 had several large stains. The environment was toured and areas above were shown to and discussed with Staff 1 (ED) at 11:35 on 07/16/25. She acknowledged the findings. 4. Observations of Cottage 7 on 07/14/25 through 7/16/25 revealed the following: * Baseboards, walls, doors, and corners throughout the cottage had scraped paint in several areas; * The three-season porch had plexiglass on exterior windows, which was not secured, and one was broken. Also, an accumulation of dust, dead bugs, and cobwebs in the lighting and windowsills; and * Torn baseboard molding next to Room 703. The environment was toured and areas above were shown to and discussed with Staff 1 (ED) on 07/16/25 at 2:30 pm. She acknowledged the findings. 5. Observations of Cottage 4 on 07/14/25 revealed the following: * Several doors had broken plastic door hooks which created a sharp, pointed end; and * Room 408 was missing a window screen. The window in room 408 was observed open and two flies were in the room. The findings were reviewed with Staff 1 (ED) and Staff 24 (Regional Director of Operations) on 07/16/25. They acknowledged the areas needing repair. The environment was toured and areas above were shown to and discussed with Staff 6 (Maintenance Director) at 10:25 am on 07/17/25. 6. The interior of the Cottage 8 was toured on 05/14/25. The following issues were noted: * The baseboards throughout the cottage were missing paint and had exposed wood; * The banisters surrounding the kitchenette were missing paint and had exposed wood; * The wall between room 813 and 812 was missing paint and had exposed holes in the drywall; * Multiple door frames were scraped and missing paint; * There were several areas on the walls in living room and hallway missing paint; and * The laundry room floor had cracked and missing linoleum and had debris build up around washing machine and dryer and in the utility sink. The facility was toured, and the findings were reviewed with Staff 1 (ED) and Staff 6 (Maintenance Director) on 07/15/25. They acknowledged the areas needing cleaning and repair. 7. Cottage 6 was observed at 11:25 am on 07/14/25. The following was identified: * A build-up of dust, dirt, white residue, paint chips, and drywall gouges was observed on the walls, baseboards, doors, and trim in common areas; * The three-season porch had broken screens and an accumulation of cobwebs; * Fabric armchairs in the living room had staining; and * The bathroom door, door frame, and baseboard in Room 604 had paint chips and gouges. The environment was toured and the areas above were shown to and discussed with Staff 1 (ED) at 8:47 am on 07/17/25. She acknowledged the findings.

The Cottages will ensure community's environment is kept clean, in good repair, and free from unpleasant odors. Weekly audits will be completed by Maintenance Director to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurment meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. Licensed nurse meeting held on July 22, 2025. Training topics included community's environment. Cottage leader meeting held on July 29, 2025. Topics included community's environment. All staff in-service held on August 8, 2025. Training topics included community's environment. All enviromental items identified during survey to not be in compliance will be corrected. ED and Maintenance Director will be responsible.

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 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees F when they were installed in locations that were subject to incidental contact by people. Findings include, but are not limited to: Observations of Cottage 2 were made at 11:31 am on 07/14/25. The following was identified: Several resident bathrooms had wall heaters situated approximately four inches from the floor and unobstructed, controlled by a knob on the wall. The wall heater in Room 207 reached a temperature of 160 degrees F when the knob was turned all the way on. In an interview at 11:40 am on 07/14/25, Staff 22 (Resident Assistant) confirmed the heater was frequently used for the residents who occupied Room 207. The environment was toured with Staff 1 (ED) at 10:58 am on 07/15/25 and the heater was discussed with her at that time. She acknowledged the temperature of the heater exceeded 120 degrees F and confirmed the lack of a system to monitor the temperatures of the wall heaters in use in the MCC. The heater was confirmed disconnected at 10:02 am on 07/16/25.

The Cottages Senior Living will ensure covers, grates, or screens of wall heaters and associated heating elements do not exceed 120 degrees F. Weekly audits will be completed to assure compliance. Audits will be reviewed in Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. ED and Maintenance Director will be responsible.

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by:

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' apartments were maintained within a range of 110 - 120 degrees F. Findings include, but are not limited to: On 07/14/25 and 07/15/25, resident apartments were toured, and water temperatures were taken throughout the building’s eight cottages. Water temperatures were higher than 120 degrees F in Cottage 6 in the following apartments: * Room 603 – 140.9 degrees F; and * Room 609 – 140.6 degrees F. The need to adjust the water temperatures between 110 degrees and 120 degrees F was discussed with Staff 1 (ED) on 07/14/25 at 1:10 pm. Water temperatures were re-taken on 07/14/25 at 3:07 pm, and Room 603 was measured at 122.5 degrees F. At that time, Staff 1 was instructed to re-adjust the temperature to meet the regulation. On 07/15/25 at 8:45 am, water temperatures were measured in Room 603 at 115.1 degrees F. On 07/16/25 at 9:57 am, Staff 6 (Maintenance Director) and this surveyor reviewed the facility’s monthly water temperature monitoring system. There was no documented evidence of monitoring Cottage 6’s water temperatures after 04/30/25. The need to ensure water temperatures in residents' apartments were maintained within a range of 110 to 120 degrees F was discussed with Staff 1 at 8:47 am on 07/17/25. She acknowledged the findings.

The Cottages Senior Living will ensure hot water temperatures in residents' rooms are maintained within a range of 110-120 degrees F. Weekly audits will be completed to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Licensed nurse meeting held July 22, 2025, Training topics included hot water temperatures in resident rooms. Cottage leader meeting held July 29, 2025. Topics included hot water temperatures in resident rooms. All staff in-service meeting held August 8, 2025. Training topics included hot water temperatures in resident rooms. ED and Maintenance Director will be responsible.

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide each individual privacy in his or her own unit for multiple sampled and unsampled residents who resided in shared units. Findings include, but are not limited to: During the acuity interview on 07/14/25, the survey team was provided with a resident roster which indicated there were 15 double occupancy rooms in the facility. Eight of the double occupancy rooms had two residents sharing one unit. Large studio-like rooms that were shared between two residents had no means to provide privacy for one of the two residents when the unit was entered, when ADL cares were provided outside of the bathroom, or when a resident walked to the bathroom. The tour of the double occupancy rooms also revealed the bathroom doors did not have a lock to allow privacy. The need to ensure residents’ right to be afforded privacy was discussed with Staff 1 on 07/16/25 at 10:27 am. She acknowledged the findings.

The Cottages Senior Living will ensure residents' right to privacy in shared units. Privacy curtains have been purchased and will be installed to be in compliance. Licensed nurse meeting held on Jul 22, 2025. Training topics included privacy curtains. Cottage leader meeting held on July 29, 2025. Training topic included privacy curtains. All staff in-service held on August 8, 2025. Topics included privacy curtains. ED and Maintenance Director will be responsible.

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 411-054-0034 (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 sampled resident (#7) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C252.

Refer to Plan of Correction for 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. Findings include, but are not limited to: Refer to C 200, C 231, C 362, C 513, C 540, C 545

Refer to Plan of Correction for C200, C231, C362, C513, C540 and C545.

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 interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 270, C 280, C 295, C 302, C 310

Refer to C252, C260, C270, C280, C295, C302 and C310.

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: