Print Inspection: RL005578

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors. Findings include but are not limited to: On 07/17/25 at 9:56 am, a tour of the facility was conducted and was noted to have three separate buildings identified as Broken Top, Bachelor, and Washington, each with two separate areas noted as A and B. The following required postings were not observed to be posted: * LGBTQIA2S+ protections; and * LGBTQIA2S+ non-discrimination notice. Additionally, Bachelor side B was noted to lack the required Ombudsman poster. The need to ensure all required postings were displayed was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings.

Deficiency: Facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors. Plan of Correction 1. Correction of Deficiency (Immediate Action Taken): As of 07/28/2025, all required postings were reviewed and updated. Missing postings were printed and placed in a conspicuous and routinely accessible area within each of the six facility wings: Broken Top A and B, Bachelor A and B, and Washington A and B. Postings now include: Current facility license Name of administrator and designee per shift Facility staffing plan Most recent re-licensure survey and applicable plans of correction Ombudsman Notification Poster Resident Rights and Protections including LGBTQIA2S+ Rights LGBTQIA2S+ Nondiscrimination Notice Any other legally required resident/visitor notices 2. Systemic Change (How We Will Prevent Reoccurrence): Each building now has a visible, locked display case located in the common dining area, ensuring that all residents can easily view the required postings. These display cases are secured to prevent the removal or tampering of posted documents. The Administrator is responsible for maintaining the accuracy of these postings and updating documents promptly to reflect any changes in state rules or requirements. 3. Monitoring (How Compliance Will Be Sustained): The administrator or designee will conduct monthly audits to confirm that postings remain accurate, up to date, and are in the correct, visible locations. Any discrepancies will be addressed within 24 hours. Staff will be educated to notify Administrator or Assistant Administrator if the case has been tampered with or broken. 4. Person Responsible: The Administrator is responsible for overall compliance. 5. Completion Date: 8/5/25

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by:

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 provide a homelike environment for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) and multiple unsampled residents. Findings include, but are not limited to: During the survey from 07/14/25 through 07/17/25, observations were made of residents eating their meals with plastic utensils. 1. On 07/15/25 at 11:44 am, an unsampled resident was observed setting the tables in the dining room in preparation for the noon time meal in the Broken Top building. S/he had gloves donned, a roll of paper towels, and plastic utensils, which included forks and knives. The unsampled resident set all of the tables up with a paper towel, plastic fork, and plastic knife. On 04/18/25, staff documented in a progress note that Resident 4 refused to take “25%” of his/her medications “because [s/he] was upset as there were no silver [forks] to eat with but plastic utensils were provided to the resident.” The need to provide a homelike environment for residents was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25. They acknowledged the findings. 2. On 07/15/25, interviews with staff and observations of food service were conducted in the Washington building. The following was identified: Throughout food service, staff were observed to serve residents with plastic utensils. At 12:33 pm, Staff 5 (Culinary Director) reported the facility used plastic utensils for “safety reasons.” The need to ensure residents’ right to a homelike environment was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings.

Tag: C0200 Regulation: OAR 411-054-0027(1) – Resident Rights and Protections (page 5) Deficiency: Failure to provide a homelike dining experience, as evidenced by consistent use of plastic utensils for all residents, which contributed to resident dissatisfaction and impacted their rights under the Residents’ Bill of Rights. Plan of Correction 1. Immediate Corrective Action: As of July 18, 2025, the facility discontinued the routine use of plastic utensils during regular meal service in all buildings (Broken Top, Bachelor, and Washington). Stainless steel flatware was purchased in sufficient quantities to accommodate all residents and has been distributed to each dining area. Staff were directed to immediately begin using stainless steel utensils for all meals unless clinically indicated otherwise for individual resident safety or if disaster plan is implemented. 2. Systemic Changes: The Culinary Director conducted a full review of meal service procedures with dietary and caregiving staff, emphasizing the importance of fostering a homelike dining experience in alignment with resident rights. Use of stainless steel utensils as the default for all residents was implemented on July 22, 2025. 3. Monitoring (Ongoing Compliance Plan): The Culinary Director will conduct a monthly audit of dining supplies in all buildings to ensure the consistent use of appropriate utensils and to support a home-like dining environment. Supplies will be reordered as necessary based on audit findings. 4. Responsible Party: The Executive Director (ED) and Culinary Director are jointly responsible for ensuring full compliance with the regulation and the continued implementation of this plan. 5. Completion Date: July 22, 2025

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 immediately report abuse relating to resident- to-resident altercations, ensure incidents including injuries of unknown cause were immediately investigated to rule out abuse or suspected abuse, and report to the local Seniors and People with Disabilities (SPD) office when abuse could not be reasonably ruled out for 4 of 4 sampled residents (#s 2, 4, 5, and 6) who had documented incidents. Findings include, but are not limited to: 1. Resident 5 moved into the community in 02/2022 with diagnoses including bipolar disorder and traumatic brain injury. The resident’s 04/01/25 through 07/11/25 progress notes and incident reports were reviewed. The following was identified: A 04/10/25 progress note documented, “Resident bullying another resident by calling them [two obscenities and a pejorative].” There was no documented evidence the above incident of verbal abuse was immediately reported to the local SPD office. The survey team requested the incident be reported to the local SPD office, and confirmation was received on 07/16/25 at 12:29 pm. The need to ensure incidents of abuse were immediately reported to the local SPD office was discussed with Staff 1 (ED), Staff 2 (Director of Nursing), Staff 3 (RN), and Staff 4 (Lead RCC) on 07/16/25 at 10:15 am. They acknowledged the findings. 2. Resident 6 moved into the facility in 10/2023 with diagnoses including schizophrenia and auditory hallucinations. The resident’s record was reviewed, including the resident’s service plan, temporary service plans, dated 05/02/25 through 07/10/25, progress notes, dated 04/15/25 through 07/14/25, and outside provider documentation. Interviews with staff were conducted and the following was identified: a. On 04/23/25, there was a witnessed resident-to-resident verbal altercation that noted “[Resident 6] was accused of being gay and allegedly engaging in sexual acts with other residents…behind closed doors” by another resident, who was also reported to threaten to physically harm Resident 6 when staff were not present. There was no documented evidence the altercation was immediately reported to local SPD. On 07/16/25 at 12:32 pm, Staff 3 (RN) and Staff 4 (Lead RCC) confirmed the altercation had not been reported to local SPD. Survey requested the facility report the altercation to local SPD. Confirmation of the report was received on 07/17/25 at 9:49 am. b. On 05/20/25, an outside provider “found open sore on [Resident 6’s] left shin”. The resident was not a reliable historian. There was no documented evidence the facility completed an immediate investigation to reasonably rule out abuse or that the injury of unknown cause was reported to local SPD. On 07/16/25 at 12:32 pm, Staff 3 (RN) and Staff 4 (Lead RCC) confirmed there was no additional documentation relating to the open sore. Survey requested the facility report the injury of unknown cause to local SPD. Confirmation of the report was received on 07/17/25 at 11:54 am. The need to ensure resident-to-resident altercations were immediately reported to local SPD and injuries of unknown cause were reported to the local SPD office if the facility could not immediately investigate to reasonably rule out abuse, was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings. 3. Resident 2 moved into the facility in 08/2023 with diagnoses including schizoaffective disorder. The resident’s progress notes, dated 04/01/25 through 07/14/25, and a Resident Incident Report, dated 05/01/25, were reviewed. The following was identified: Resident 2 was involved in an altercation with another resident. The other resident was trying to pull Resident 2’s wheelchair which resulted in the resident falling out of his/her wheelchair. An interview with Staff 1 (ED) on 07/15/25 at approximately 2:30 pm confirmed the facility had not reported the incident to the local SPD office. On 07/16/25 at 9:00 am, the facility provided documentation they reported the incident to the local SPD office. The need to ensure all resident-to-resident altercations were immediately reported to the local SPD office was discussed with Staff 1 and Staff 7 (Assistant Administrator) at 2:26 pm on 07/17/25. They acknowledged the findings. 4. Resident 4 moved into the facility in 06/2024 with diagnoses including a traumatic brain injury. The resident’s progress notes, dated 04/14/25 through 07/13/25, and a Resident Incident Report, dated 05/01/25, were reviewed and the following was noted: * 05/01/25: Resident-to-resident altercation; and * 05/20/25: The Behavioral Support Specialist documented that he spoke to Resident 4 about "bullying" another resident, in which the resident stated, "[s/he] deserved it." Staff 1 (ED) confirmed the facility had not reported either incident to the local SPD office. Documentation that both of the above incidents were reported to the local SPD office was received prior to exit. The need to ensure all resident-to-resident altercations were immediately reported to the local SPD office was discussed with Staff 1 and Staff 7 (Assistant Administrator) at 2:26 pm on 07/17/25. They acknowledged the findings.

Tag: C0231 Regulation: OAR 411-054-0028 (1–3) – Reporting and Investigating Abuse (page 12) Deficiency: The facility failed to immediately report multiple incidents of abuse and injuries of unknown cause to the local SPD office, failed to promptly investigate such incidents, and failed to implement adequate systems to ensure compliance with Oregon abuse reporting requirements. Plan of Correction 1. Immediate Correction: As of July 17, 2025, all incidents identified by the survey team involving Residents #2, #4, #5, and #6 were reported to the local Seniors and People with Disabilities (SPD) office. Confirmation of reports was received and documented. 2. Systemic Changes: A. Policy and Procedure Review for Abuse Reporting and Investigation policies that reflect current OAR 411-054-0028 Mandatory Staff Training (Completed ): 8/6/25 All staff, including leadership and direct care staff, received mandatory in-service training on: Mandatory abuse reporting responsibilities Timelines and procedures for reporting to APD Recognizing abuse vs. non-abuse incidents Documentation standards for internal investigations B. On-Call Reporting Protocols Implemented: An Abuse Reporting Flowchart and APD contact information sheet were posted in every staff work area across all buildings to ensure that abuse reports can be made immediately, regardless of shift or staff role 3. Monitoring and Oversight: The Executive Director, or designee will review all incident reports to ensure appropriate incidents are investigated and reported to APS in a timely manner. 4. Person(s) Responsible: Executive Director (ED) Director of Nursing (DON)

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 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to: On 07/15/25, interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Food trap under the three compartment sink; * Floor under/behind refrigerator and three compartment sink; * Floor to wall transition throughout kitchen; * Industrial can opener and housing; * Interior and exterior of microwave; * Interior and exterior of cabinetry throughout kitchen; * Exterior siding of both ovens, including in between the oven and cabinetry; * Meat slicer; * Walk-in refrigerator – sheet pan on the bottom shelf of the meat storage rack; * Food cart to the left of the refrigerator that stored a small ice machine; and * Wall around and below the three-compartment sink. b. The following areas were noted in need of repair: * The cabinet below the “prep sink” had a plastic basin partially filled with a clear substance with floating grey sediment and had black piping below to the “prep sink” with an orange substance that was identified to be the reason the sink was out of order; * Small grease trap in flooring near the three-compartment sink was unsealed and would sink into the floor when stepped on; * Large grease trap in the flooring near the three-compartment sink was found unsealed; * Cabinetry to the right of the refrigerator had multiple broken areas with exposed material; * Cabinetry near/next to both ovens had missing and exposed material; * Cabinetry throughout the kitchen had broken, chipped, and/or missing material; * The second cabinet from the left was missing hardware; * The industrial can openers blade had worn off finish and housing had missing hardware; * The flooring had four tiles near the three-compartment sink that were cracked/broken; * There was a partial hole in the ceiling near a fire sprinkler head; and * Caulking near the three-compartment sink was broken and missing sections. c. The facility lacked use of an approved sanitizing solution for use in the kitchen. The Safety Data Sheet for the solution identified in the kitchen as the “disinfectant” was reviewed and determined the solution was not prepared with an adequate percentage of sanitizer and lacked information related to use of product in a kitchen. d. There were no observations of staff sanitizing food prep surfaces before or after use. e. Multiple direct care staff were observed to enter and exit the kitchen without practicing proper hand hygiene and noted to touch multiple surfaces within the kitchen including larger equipment, food and beverage containers, and resident use glass and flatware, and were observed to prepare sandwiches without practicing hand hygiene in-between touching dirty/clean surfaces and resident food. f. The walk-in refrigerator (located in another building) was identified to have thawing meat improperly stored to limit the potential of cross-contamination and/or food borne illness. g. The walk-in refrigerator was identified to have an open bag of raw meat product and an unlabeled, undated, open container of a prepared meat product. h. Multiple dry foods stored in the kitchen were found open and/or uncovered including an uncovered container of slivered almonds found stored under a meat preparation area exposed to cross-contamination. i. Three garbage cans were observed uncovered throughout meal service. j. The facility served eggs to order including eggs with soft yolk and did not have pasteurized eggs. k. The kitchen was observed to have significant clutter on prep surfaces. On 07/15/25 at 3:06 pm, Staff 5 (Culinary Director) toured the facility kitchen and food storage areas with this surveyor and acknowledged areas identified above. The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings.

Tag: C0240 Regulation: OAR 411-054-0030(1)(a) – Resident Services: Meals and Food Sanitation (Page 23) Deficiency: The facility failed to maintain the kitchen in a sanitary manner, ensure appropriate food safety practices, use approved sanitizing products, and follow OAR 333-150-0000 (Oregon Food Sanitation Rules), which resulted in unsanitary kitchen conditions, cross-contamination risks, improper food storage, and food handling violations. Plan of Correction 1.Immediate Correction (Completed by 7/22/25): All identified unsanitary conditions were immediately addressed: 2.Deep cleaning of kitchen, prep areas, and equipment (can opener, microwave, ovens, walls, cabinets, grease traps, floors, sinks). Discarded open, uncovered, or undated food items, including raw and prepared meats. Reorganized and decluttered all food prep surfaces. 2. Systemic Changes (Completed by 9/15/25 ): A. Kitchen Cleaning & Maintenance Schedule was created with daily, weekly, and monthly assignments to ensure consistent sanitation. B. Signed logs for all tasks are maintained by the Culinary Director. C. Cleaning tasks include under/behind equipment, food contact surfaces, grease traps, walls, and floors. 3. New "Sanitation Station" installed with: A. Approved sanitizing solution & mixing instructions B. Disposable gloves, hand hygiene signage, food thermometer, and SDS binder 4.. Hand Hygiene Protocols were re-educated to all staff, including: A. Washing hands between tasks B. Wearing gloves and changing between clean/dirty tasks C. Avoiding bare-hand contact with ready-to-eat food 4. Revised Food Storage that includes: Date labeling of all opened/prepared food Separate shelving and containers for raw vs. cooked food Proper thawing techniques Discarding any unlabeled or improperly stored items Eggs prepared with soft yolks will now only be made from pasteurized eggs or offered in fully cooked forms. 4. Monitoring and Oversight (Ongoing): The Culinary Director or designee will perform daily inspections of kitchen cleanliness, food labeling, and food storage practices for the next 60 days, then weekly thereafter. 5. Responsible Parties: Culinary Director – Overseeing kitchen compliance, sanitation, and food safety Maintenance Supervisor – Ensuring timely repair of kitchen equipment and structures 6. Completion Date: 9/15/25

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: On 12/02/25 at 10:40 am, the facility’s main kitchen was observed to need cleaning in the following areas: Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following: * Oven interior; * Flooring, including perimeter, underneath appliances and spice shelf; * Dish machine area: walls, pipes, floor, and floor drain; and * Several cabinet interiors. The areas in the main kitchen which required cleaning were observed and discussed with Staff 1 (Executive Director) and Staff 7 (Assistant Administrator) on 12/02/25 at 11:20 am. The findings were acknowledged.

The facility immediately addressed the identified deficiencies on 12/02/25 by completing a thorough cleaning of all areas noted during the survey, including the oven interior, flooring (including under appliances and shelving), dish machine area (walls, pipes, floor, and drain), and cabinet interiors. The findings were reviewed with the Executive Director and Assistant Administrator at the time of observation. To prevent reoccurrence, the Culinary Director or designee will ensure a consistent kitchen cleaning schedule is followed. Kitchen staff will complete required cleaning tasks by the end of every shift, with emphasis on food contact surfaces, equipment, floors, and hard-to-reach areas. Cleaning expectations will be reviewed with dietary staff. The Culinary Director or designee will monitor and evaluate compliance through visual inspection of the kitchen by the end of every shift. Any concerns identified will be addressed promptly and documented to support ongoing compliance with Food Sanitation Rules OAR 333-150-000.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). 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 move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 3 moved into the facility in 04/2025 with diagnosis including type 2 diabetes mellitus and hypertension. The new move-in evaluation failed to address the following elements: * Preferred pronouns; * Gender identity; * Customary routines including sleeping; * Mental health issues including history of treatment and effective non-drug interventions; * Pain including non-pharmaceutical interventions; and * Review of risk indicators including smoking, alcohol and drug use status. The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (ED) and Staff 2 (Assistant Administrator) on 07/16/25. Staff acknowledged the findings.

Tag: C0252 Regulation: OAR 411-054-0034(1-6) – Resident Move-In and Evaluation Requirements (page 30) Deficiency: The facility failed to ensure the move-in evaluation for Resident #3 addressed all required elements outlined in the regulation. Missing information included preferred pronouns, gender identity, customary routines, mental health history, pain management, and risk indicators (smoking, alcohol, and drug use). Plan of Correction 1. Immediate Correction (Completed by 7/22/25): The move-in evaluation for Resident #3 was immediately reviewed and updated to include: A.Preferred pronouns and gender identity. B.Customary routines (including sleeping habits). C.Full mental health history and non-pharmaceutical interventions. D.Pain profile, including non-drug pain management strategies. E.Comprehensive risk indicator review (smoking status, alcohol use, non-prescribed drug use). F.Resident and legal representative were involved in the completion of the missing components, ensuring accuracy and person-centered care. G.Updated documentation was signed, dated, and filed in Resident #3’s chart in the on-site records system. 2. Systemic Changes (Completed by 9/15/25 ): The Move-In Evaluation Tool was revised to: Include clearly labeled sections for pronouns, gender identity, pain management strategies, mental health history, and all risk indicators required under OAR 411-054-0034. Utilize checkbox prompts and mandatory completion fields to avoid omissions. Clearly differentiate between initial evaluation and quarterly evaluations, with a dedicated section to indicate when “no changes” are present. 3. Move in evaluations and service plans to include regulatory requirements under OAR 411-054-0034(1-6). Best practices in conducting trauma-informed, inclusive, and person-centered resident interviews. Accurate documentation and timely updates for all required evaluation elements. Emphasis on the inclusion of gender identity, pronouns, mental health history, and non-drug pain management in the service planning process. 4. Monitoring and Oversight (Initiated 8/6/25 – Ongoing): All new move-in evaluations will be reviewed by the Assistant Administrator or Administrator within 24 hours of admission to confirm completeness

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 reflected residents’ needs, provided clear direction regarding the delivery of services, included a written description of who should provide the services and what, when, how, and how often the services should be provided, and were being implemented for 3 of 5 sampled residents (#s 2, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2023 with diagnoses including schizoaffective disorder. The resident’s progress notes, dated 04/01/25 through 07/14/25, service plan, dated 06/06/25, behavioral support plan, dated 06/26/25, temporary service plan, dated 06/20/25, and outside provider notes, dated 04/01/25 through 05/08/25 were reviewed. Resident 2 was observed, and staff were interviewed. The resident’s service plan was not reflective of the resident’s needs and/or did not provide clear caregiving instruction in the following areas: * What staff should monitor for relating to the resident's siderails and who to report to if the siderails were loose; * Resident 2’s communication style when there was high emotion involved (e.g. happiness, anger, sadness, etc.); * Interventions for staff to use when the resident exhibited high emotions to better understand him/her; * What triggered Resident 2 to yell out while in common spaces and how staff could assist to calm him/her down (e.g. internal stimuli telling the resident to do things s/he doesn't want to do and staff letting the resident know that s/he can tell the internal stimuli to leave him/her alone); * How the resident presented when internal stimuli became negative; * Favorite music, including Elvis and 1970's and 1980's rock and roll; * Fluid preferences including diet soda, which could also be used as a behavior intervention; * Resident specific details relating to showers and ability to complete the task; * Resident specific details relating to the ability to dress self from the waist up; * PRN two-person assist for transfers; * Ability to ambulate self to the dining room; * The resident exhibiting behaviors relating to urination versus incontinence; * The efficacy of taking Resident 2 to the restroom versus using a urinal; * Home health involvement; * Actual use of the call light; * Enjoying YouTube videos and acoustic guitar music in the common area; * Current skin issues; and * Resident 2’s specific triggers relating to verbal aggression (e.g. other residents calling him/her names, internal stimuli, etc.). The need to ensure service plans were reflective of residents’ needs, provided clear caregiving instruction, and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 2:26 pm. They acknowledged the findings. 2. Resident 4 moved into the facility in 06/2024 with diagnoses including a traumatic brain injury. The resident's service plan, dated 07/09/25, and behavioral support plan, dated 06/24/25, were reviewed and staff were interviewed. The service plan was not reflective of the resident's needs and/or did not provide clear caregiving instruction in the following areas: * Conflicting information related to bathing; * Location of where the resident "prepares [his/her] own meals"; * How Resident 4 got to and from medical appointments; * Who escorted the resident to and from his/her medication appointments; * Location of where Resident 4's cigarettes were stored; * Interventions relating to refusals; and * Interventions to help staff negate resident-to-resident altercations, both physical and verbal. The need to ensure service plans were reflective of residents’ needs, provided clear caregiving instruction, and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 2:26 pm. They acknowledged the findings. 3. Resident 6 moved into the facility in 10/2023 with diagnoses including schizophrenia, auditory hallucinations, and type 2 diabetes mellitus. The resident’s record was reviewed, including the resident's current service plan, dated 04/30/25, behavioral support plan, dated 04/29/25, temporary service plans, dated 05/02/25 through 07/10/25, progress notes, dated 04/15/25 through 07/14/25, smoking assessment, dated 05/08/25, and outside provider documentation. Interviews with staff were conducted, and the following was identified: The service plan was not reflective of the resident’s current care needs, did not provide clear direction regarding the delivery of services, and/or was not implemented in the following areas: * Accurate diet texture; * Smoking supervision instruction that included full supervision when resident had his/her vaping device; * Behaviors including vaping inside the facility and sharing his/her vape when not supervised; * Number of staff needed for grooming and bathing; * Dressing assistance that included needing two staff as needed; * Instruction related to when the resident was involved in verbal altercations; * Accurate outside provider information; * Preferred pronouns and sexual identity; * Ability to leave the community unsupervised; and * Ability to use call light. The need to ensure resident service plans were reflective of the resident’s current care needs, provided clear direction regarding the delivery of services, and/or was implemented was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings.

Tag: C0260 Regulation: OAR 411-054-0036(1–4) – Service Plans: General (Page 43) Deficiency Summary: The facility failed to ensure service plans were: Reflective of resident needs; Inclusive of clear caregiving instructions; Accurate in defining who provides services, as well as the what, when, how, and how often; Readily available and implemented for 3 of 5 sampled residents (#2, #4, and #6). Supervision status for leaving the community and use of the call light. Behavior tracking and verbal aggression intervention protocols. Each plan was signed, dated, and distributed to care staff. A copy was offered to the resident or legal representative. 1. Immediate Corrections (Completed by 7/24/25): Resident #2: Service plan was comprehensively updated to include: Communication style, emotional triggers, and appropriate staff interventions. Behavioral health symptoms and staff response strategies (e.g., responses to internal stimuli). Bathing and dressing abilities, PRN transfer assistance, ambulation capacity. Preferences for music, beverages, and entertainment used as interventions. Incontinence patterns, urination behaviors, and restroom preferences. Accurate assistive device use (call light, siderails). Home health involvement and current skin status. Detailed caregiver instructions and task-specific protocols with assigned staff roles. Resident #4: Service plan revised to address: Clarified bathing support level. Location and role in meal preparation. Transportation and escort details for medical and medication appointments. Storage location and supervision regarding cigarettes. Interventions for care refusals and behavior support related to resident-to-resident altercations. Resident #6: Service plan updated to include: Accurate diet and texture instructions. Vaping behavior protocols and supervision guidelines. Dressing, bathing, and grooming support levels (including need for two-person assistance). Correct provider involvement and emergency contact information. Preferred pronouns and gender identity. Supervision status for leaving the community and use of the call light. Behavior tracking and verbal aggression intervention protocols. Each plan was signed, dated, and distributed to care staff. A copy was offered to the resident or legal representative. 2. Systemic Changes (Completed by 9/15/25): The Service Plan Template was revised to include: Mandatory fields for: pronouns, gender identity, assist levels for ADLs/IADLs, behavioral supports, supervision needs, triggers, interventions, and assigned staff. Clarified structure separating: Initial plans (pre-move-in and within 30 days) Quarterly updates Required descriptions of who provides the service, what is done, when, how, and how often. 3.Completed service plans will be review by the Executive Director or Designated staff to ensure that all areas are addressed.

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 updated quarterly and with significant changes of condition, were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and were implemented for 1 of 2 sampled residents (#8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 8 moved into the facility in 01/2023 with diagnoses including Type 1 diabetes and right below-the-knee amputation. Upon entering the facility on 12/01/25, the current service plan available to staff was dated 07/16/25. At 3:24 pm on 12/01/25, Staff 1 (Executive Director) confirmed that this was the most recent service plan. The service plan had not been updated quarterly or with the resident’s significant change of condition which occurred on 11/19/25. On 12/02/25, Staff 1 provided an updated copy of the resident’s service plan, now available to staff, to review. The resident's current service plan available to staff, and progress notes and temporary service plans dated 09/15/25 through 12/01/25 were reviewed. Interviews with staff and the resident were conducted, and the resident was observed. The resident's service plan was not reflective of current needs, was not implemented, and/or did not provide clear direction to staff in the following areas: * Difficulty with hearing; * Name (service plan referred to the resident using an incorrect name multiple times); * Shower preference time of day; * Frequency of assistance needed for grooming tasks, including shaving and teeth brushing; * Location of meals; * Meals cut up into bite sized pieces; * As-needed nutritional supplement availability; * Incontinence care assistance and location; * Number of staff assisting with transfers; * Side of amputated limb; * Assistance to provide when donning or doffing prosthesis, including presence of sock underneath; * Use of straw with drinks; * Use of blanket to prop left side when seated; and * Care of wheelchair, including cleaning and lack of arm and leg rests on wheelchair. The need to ensure service plans were updated, reflective, implemented, and provided clear direction to staff was reviewed with Staff 1 and Staff 7 (Assistant Administrator) at 8:30 am on 12/03/25. They acknowledged the findings.

The facility immediately reviewed Resident #8’s service plan upon identification of the deficiencies. Errors and omissions were corrected, and the service plan was updated to reflect the resident’s current needs, preferences, diagnoses, and required assistance. The updated service plan was made available to staff. To prevent reoccurrence, the Facility RN will collaborate with the licensed nurse to ensure service plans are reviewed and updated at least quarterly and with any significant change in condition. Staff will be trained of the importance of following the most current service plan and documenting changes in resident needs. The Facility RN or licensed nurse will monitor compliance by completing three random service plan audits per week until compliance is met to ensure service plans are accurate, current, implemented, and provide clear direction to staff. Any identified issues will be corrected promptly. Monitoring will continue as needed to support ongoing compliance.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine resident-specific interventions for residents following a change of condition, communicate those actions or interventions to staff on each shift, monitor each resident consistent with their evaluated needs, and/or monitor and document weekly progress until the condition resolved for 5 of 5 sampled residents (#s 2, 3, 4, 5, and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 moved into the community in 02/2022 with diagnoses including bipolar disorder and traumatic brain injury. The resident’s progress notes dated 04/01/25 through 07/11/25, corresponding temporary service plans, and documented weights from 01/14/25 through 07/03/25 were reviewed, and interviews with staff were conducted. a. Progress notes documented the following resident-to-resident altercations: * 04/10/25 – “Resident bullying another resident by calling them [two expletives and a pejorative].” * 04/23/25 – An unsampled resident hit Resident 5 on the hand, who then hit the unsampled resident on the head. There was no documented evidence the facility determined and documented actions or interventions and monitored the resident consistent with his or her evaluated needs after the altercations. b. During the acuity interview on 07/14/25 the resident was identified as having a recent significant weight loss. A significant change of condition assessment for severe weight loss, dated 07/15/25, documented “[Resident] has been on meal monitoring…” Staff 2 (Director of Nursing) reported on 07/15/25 that the resident had been on meal monitoring since 07/02/25 and had been eating “100% of lunch and dinners.” Meal documentation logs from 07/02/25 through 07/15/25 documented multiple refusals of breakfasts, lunches, and dinners. Staff 2 reported that she had not been monitoring the meal logs, and that there should have been a notification on the computer for staff to alert her when the resident wasn’t eating. There was no documented evidence the facility had monitored the resident consistent with his/her evaluated needs. The need to ensure the facility determined and documented what resident-specific action or interventions were needed for changes of condition, including resident-to-resident altercations, and monitored the resident at least weekly according to their evaluated needs through resolution, was Staff 1 (ED), Staff 2, Staff 3 (RN), and Staff 4 (Lead RCC) on 07/16/25 at 10:15 am. They acknowledged the findings. 2. Resident 6 moved into the facility in 10/2023 with diagnoses including schizophrenia, auditory hallucinations, and type 2 diabetes mellitus. The resident’s record was reviewed, including the resident’s current service plan, dated 04/30/25, behavioral support plan, dated 04/29/25, temporary service plans, dated 05/02/25 through 07/10/25, progress notes, dated 04/15/25 through 07/14/25, side rail assessment, dated 05/13/25, and outside provider documentation. Interviews with staff were conducted, and the following was identified: * 04/22/25: New hospital bed; * 04/23/25: Resident to resident verbal altercation; * 04/30/25: Change in toileting behaviors and increased assistance required; * 05/13/25: New bilateral side rails; * 05/20/25: Open sore on left shin; and * 06/11/25: Graduated from hospice services and no longer had additional outside support. There was no documented evidence the facility determined resident-specific interventions, communicated the determined actions or interventions to staff on each shift, and/or monitored each change of condition with weekly progress noted through resolution, for the above noted changes of condition. The need to ensure each change of condition was identified, had documentation of resident specific interventions, the determined interventions were communicated to staff on each shift and were monitored weekly through resolution, was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings. 3. Resident 3 moved into the facility in 04/2025 with diagnosis including type 2 diabetes mellitus and hypertension. The resident’s record was reviewed, including the resident’s current service plan, dated 05/11/25, behavioral support plan, dated 05/05/25, temporary service plans, dated 04/01/25 through 07/11/25, progress notes, dated from 04/01/25 through 07/14/24, and weight records, dated 04/01/25 through 06/24/25. Interviews with staff were conducted, and the following was identified: Weight record review showed the following: * 04/01/25 – 193 pounds (admission); * 05/09/25 – 184.6 pounds; and * 06/24/25 – 179 pounds. There was no documented evidence an evaluation of the resident’s status was conducted, any interventions determined, interventions communicated to staff on each shift, or that the resident was monitored following the weight loss trend. On 07/16/25 at 2:21 pm, the resident’s weight record was reviewed with Staff 3 (RN). When asked who was responsible for monitoring the resident’s weight, she reported no one was assigned to review or monitor them. The need to ensure each change of condition was identified, had documentation of resident-specific interventions, the determined interventions were communicated to staff on each shift and were monitored weekly through resolution was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/16/25 at 1:45 pm. They acknowledged the findings. 4. Resident 2 moved into the facility in 08/2023 with diagnoses including schizoaffective disorder. The resident’s progress notes, dated 04/01/25 through 07/14/25, a temporary service plan, dated 06/20/25, MARs, dated 06/01/25 through 07/14/25, and outside provider notes, dated 04/01/25 through 05/08/25, were reviewed, and staff were interviewed. Resident 2 experienced the following changes of condition: * 05/01/25: Resident-to-resident altercation which resulted in Resident 2 falling out of his/her wheelchair; * Potential skin injuries related to fall on 05/01/25; * Two pressure wounds located on buttocks; and * 06/07/25: Red rash identified in the fold of the resident's skin. There was no documented evidence the facility determined actions or interventions for the changes of condition, communicated those actions or interventions to staff on each shift, or monitored with weekly progress noted through resolution. The need to determine actions or interventions for the resident’s changes of condition, communicate the determined actions or interventions to staff on each shift, and monitor with weekly progress noted through resolution was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 4 (Lead RCC) on 07/15/25 at 2:44 pm. They acknowledged the findings. 5. Resident 4 moved into the facility in 06/2024 with diagnoses including a traumatic brain injury. The resident's progress notes, dated 04/14/25 through 07/13/25, were reviewed and staff were interviewed. The following changes of condition were noted: * 05/01/25: Resident-to-resident altercation; * 05/20/25: Documentation of the resident "bullying" another resident; and * Multiple entries of the resident refusing medications that treated high cholesterol, Korsakoff Syndrome (neurological disorder that affects memory), and aggression. There was no documented evidence the facility determined actions or interventions for the changes of condition, communicated those actions or interventions to staff on each shift, or monitored with weekly progress noted through resolution. The need to determine actions or interventions for the resident’s changes of condition, communicate the determined actions or interventions to staff on each shift, and monitor with weekly progress noted through resolution was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 2:26 pm. They acknowledged the findings.

Tag: C0270 – OAR 411-054-0040 (1-2): Change of Condition and Monitoring (page 54) Plan of Correction 1. Immediate Corrective Action Taken (Completed by 07/24/2025): A comprehensive audit was completed on all residents who experienced a change of condition in the last 90 days. Documentation was reviewed to ensure all identified changes had appropriate individualized interventions, communication to staff on all shifts, and documented weekly monitoring. Where deficiencies were found, corrective action was taken immediately, including updates to service plans and staff direction. 2. Policy Review (Completed by 07/24/2025): Facility policies related to Change of Condition were reviewed and in compliance to meet OAR 411-054-0040(1-2) requirements. Timely recognition and documentation of short-term and significant changes Development and communication of individualized interventions Weekly monitoring and documentation until resolution Consistent communication across shifts via documentation and staff handoff protocols 3. A new Change of Condition QA Tracking Tool will implemented on (8/11/25). All identified changes in condition are tracked to ensure: Interventions are individualized and properly documented Communication is completed across shifts Weekly monitoring is performed and documented until the issue is resolved. 4. Responsibility and Oversight: Administrator is responsible for ensuring overall implementation and sustained compliance. Director of Nursing is responsible for overseeing the RN team to ensure appropriate clinical assessment, documentation, and timely interventions are completed for all changes of condition

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 a timely RN assessment was completed for 1 of 1 sampled resident (#5) who experienced a significant change of condition. Findings include, but are not limited to: Resident 5 moved into the community in 02/2022 with diagnoses including bipolar disorder and traumatic brain injury. During the acuity interview on 07/14/25 the resident was identified as having a recent severe weight loss. The resident's monthly weights dated 01/14/25 through 07/03/25 were reviewed, observations were made, and interviews with staff were conducted during the survey. The resident's weights were recorded as follows: * 01/14/25 – 114.2 pounds; * 06/13/25 – 111.6 pounds; and * 07/03/25 – 104.0 pounds. On 07/15/25 the surveyor requested a current weight for Resident 5. The resident weighed 105.8 on 07/15/25. From 06/13/25 to 07/03/25 the resident lost 7.6 pounds, or 6.8% of his/her body weight in 20 days, which constituted a severe weight loss that required an RN assessment. The RN assessment for a significant change of condition was completed on 07/15/25, during the survey. There was no documented evidence a timely RN assessment had been completed for the significant change of condition. The need to ensure a timely RN assessment was completed when a resident experienced a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Director of Nursing), Staff 3 (RN), and Staff 4 (Lead RCC) on 07/16/25 at 10:15 am. They acknowledged the findings.

Tag C0280 – OAR 411-054-0045 (1)(a, f)(A), (C–F): Resident Health Services (Page 69) Deficiency Summary: The facility failed to ensure a timely RN assessment was completed for one resident (Resident #5) who experienced a significant change of condition, namely, a severe, unplanned weight loss of 6.8% over 20 days. The required RN assessment was not documented until 07/15/2025, after the surveyor’s inquiry, which does not meet regulatory timeliness standards. Plan of Correction: 1. Immediate Corrective Actions (Completed by 07/24/2025): A comprehensive clinical review was completed on all residents who experienced significant weight changes or other changes of condition in the past 60 days. An RN completed assessments and documentation for any missed or delayed evaluations, including Resident #5. Nutritional interventions and service plans were updated where applicable, and relevant care team members were notified. 2. Policy and Procedure Review (Completed by 7/22/25): Policies and procedures regarding RN responsibilities for timely assessment, monitoring, and participation in service planning were reviewed to reflect current regulatory standards (OAR 411-054-0045). Included: Clear guidelines for what constitute a significant change of condition (including unplanned weight loss thresholds). Timeframes for RN assessments following a significant change (within 24–48 hours). Defined RN responsibilities for documenting assessments, identifying interventions, and participating in care planning. 3. A new Weight Tracking Tool was implemented on (8/11/25). All identified changes in weights are tracked to ensure: Interventions are individualized and properly documented Communication is completed across shifts When a change of Condition has occurred Weekly monitoring is performed and documented until the issue is resolved. Responsible party DON or assigned designated RN

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 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided for 2 of 3 sampled residents (#s 2 and 3) who received on-site health services. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2023 with diagnoses including schizoaffective disorder. The resident’s progress notes, dated 04/01/25 through 07/14/25, service plan, dated 06/06/25, temporary service plan, dated 06/20/25, MARs, dated 06/01/25 through 07/14/25, and outside provider notes, dated 04/01/25 through 05/08/25 were reviewed, and staff were interviewed. Resident 2 received services from an HHRN relating to two Stage II pressure ulcers. Recommendations from the HHRN for staff "to apply calazime cream twice daily [and] as needed" was documented on 04/01/25, 04/08/25, 04/22/25, and 05/08/25. There was no documented evidence of the intervention being communicated to staff. On 07/15/25 at 2:44 pm, Staff 3 (RN) confirmed the recommendation was not communicated to staff and the intervention had not been done. The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with Staff 1 (ED), Staff 3, and Staff 4 (Lead RCC) on 07/15/25 at 2:44 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 04/2025 with diagnoses including type 2 diabetes mellitus and hypertension and was identified in the acuity interview as receiving HH PT and speech therapy services. On 07/15/25 at 10:33 am, Staff 13 (MT/CG) reported the resident required two-staff assistance for transfers due to fall risk. The resident had a walker in his/her room, and it was only used during PT sessions. The resident used a wheelchair for mobility. Resident 3’s clinical records, including PT and speech therapy recommendations, showed the following: * 05/01/25: Documented recommendations including continue on a mechanical soft det with cut up food, “thin-straws okay, pills whole, aspiration precautions, eating in room okay”; * 05/19/25: To help the resident sit up in a chair for two to four hours per day with the breaks, to assist with wheelchair mobility for two to four laps per day, and to assist the resident in, and lying straight leg raise exercise 20 times on each leg; * 05/28/25: The resident was up for minimum of “1 meal per day out of the room” and “2-3 hours total (minimum) in wheelchair or recliner”; * 06/08/25: “3 hours total in W/C [wheelchair] per day,” single-leg knee to chest stretches three times a day for one to two minutes each, butterfly stretches three times a day for one to two minutes, heel slides three times a day with 10 to 20 repetitions; and * 06/25/25: Float the left heel on a pillow. There was no documented evidence that these recommendations were communicated to the staff for coordination of care related to outside healthcare services. 07/16/25 at 1:45 pm, the above findings were shared the above findings with Staff 1 (ED) and Staff 7 (Assistant Administrator). They acknowledged the findings.

Plan of Correction for C0290 – OAR 411-054-0045(2): On- and Off-Site Health Services (Page 75) Deficiency Summary: The facility failed to ensure that staff were informed of new interventions and that the service plans were updated following the provision of on-site health services for 2 of 3 sampled residents. Recommendations from outside providers, including wound care and therapy services, were not integrated into the service plans or communicated to direct care staff. 1. Immediate Correction (Completed by): A full chart review was conducted for all residents currently receiving home health or hospice services. Identified missing or outdated outside provider recommendations were reviewed by the Director of Nursing (DON) and Resident Care Coordinators (RCCs) and promptly integrated into service plans. All affected residents were reassessed to confirm that care was being provided according to current clinical recommendations. Providers were contacted to re-send documentation where gaps existed. Staff were updated on current interventions during a scheduled huddle and documentation was verified. 2. Implementation of Third-Check Protocol (Effective 7/22/25): A Third-Check Protocol has been implemented to ensure proper integration of outside provider recommendations into resident care. Process: Upon receipt of outside provider documentation (e.g., wound care, PT/OT/ST, hospice, etc.), the RCC or assigned Licensed Nurse must perform a three-point verification (third check): Review the provider’s written documentation. Confirm service plan is updated to reflect the recommendation. Verify the intervention is documented on the appropriate task sheet or MAR (if applicable). 4.Responsible party. Director of Nursing (DON): Oversees the third-check process and reviews audit results weekly. Ensures the nursing team implements outside provider recommendations appropriately and promptly. Provides coaching or disciplinary follow-up for staff failing to comply with the protocol. Works with RCCs to revise workflows and documentation systems for sustainability.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. 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 establish and maintain effective infection prevention and control protocols to provide a safe and sanitary environment in the kitchen when preparing resident meals, during meal service, and while performing ADL care for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: 1. On 07/15/25, interviews with staff and observations of the facility kitchen, food preparation, and food service were conducted, and the following was identified: Multiple direct care staff were observed to serve residents meals without the use of a protective barrier over potentially contaminated clothing. The need to ensure the kitchen had established and maintained effective infection prevention and control protocols to provide a safe and sanitary environment when preparing resident meals and during meal service was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings. 2. Observations were made during the survey to determine adherence to universal precautions for infection control. On 07/15/25, at approximately 10:49 am, the surveyor obtained permission and observed Staff 13 (MT/CG), and Staff 15 (CG) provide incontinence care to Resident 3. During the observation, Staff 15 failed to change gloves after removing a soiled incontinent product and wiping fecal matter from Resident 3’s bottom area. Staff 15 touched the resident’s blanket and a new brief while wearing the same soiled gloves. Additionally, Staff 15 noted he was wearing double gloves and removed the outer pair before applying barrier cream to the resident’s buttocks. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/16/25 at 1:45 pm. They acknowledged the findings.

Tag C0295 – OAR 411-054-0050(1–5): Infection Prevention & Control (page 83) During the survey conducted on 07/15/25, the facility was found to be out of compliance with infection prevention and control standards required under OAR 411-054-0050. The following issues were identified: Meal Service Hygiene Issues: Staff were observed serving resident meals without wearing protective barriers (such as aprons) over potentially contaminated clothing. This posed a risk for cross-contamination during food service and preparation in the kitchen. Inadequate Use of Universal Precautions During Care: A caregiver failed to change gloves after handling a soiled brief and wiping fecal matter during incontinence care. The same gloves were then used to touch clean supplies and the resident’s blanket. Additionally, improper use of double-gloving was observed, where only the outer glove was removed before applying barrier cream. These findings indicate that the facility failed to consistently follow universal precautions and maintain effective infection control practices in both dining and resident care areas. Leadership acknowledged these concerns during the exit interviews. Completion Date: 1. Immediate Corrective Action Taken As of (7/22/25 ), all direct care staff were immediately re-educated on proper PPE use, including wearing clean protective covering (gown or apron) over clothing during food service. PPE supplies were inventoried and restocked. Responsible Parties: Administrator, Infection Control Specialist (ICS), Director of Nursing (DON), RCCs, Med Techs, and Caregivers 2.Weekly Random Spot Checks: The Infection Control Specialist and Resident Care Coordinator will conduct weekly random spot checks in both resident care and dining areas to monitor staff compliance with infection control protocols. These checks will include observations during: Meal preparation and service. Incontinence and personal care tasks. General staff adherence to hygiene practices. Responsible Parties: Infection Control Specialist – Conducts audits and staff re-education. Resident Care Coordinators – Monitor care practices and follow up on identified concerns. Administrator – Oversees compliance

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)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 5 sampled residents (#s 3, 4, and 6) whose MARs and physician orders were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 06/2024 with diagnoses including a traumatic brain injury. The resident’s MARs, dated 06/01/25 through 07/14/25, and signed physician orders were reviewed. Resident 4 lacked written, signed physician or other legally recognized practitioner orders documented in his/her facility record for the following medications and treatments that the facility was responsible to administer: * Atorvastatin (for high cholesterol); * Multivitamin (for supplement); * Treatment orders for "abrasions, scrapes, and skin tears"; * Acetaminophen (for pain); and * Treatment orders for "reddened or excoriated areas of [perineum] area". The need to ensure the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 2:26 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 04/2025 with diagnoses including type 2 diabetes mellitus. Observations were made of the resident's care on 07/15/25, and interviews with the resident and facility staff were conducted. The resident’s 06/01/25 through 07/14/25 MARs, physician orders and home health nurse visit notes, dated 04/29/25 through 07/02/25, were reviewed during the survey and showed the following: A physician order, dated 04/14/25, stated to apply Nystatin powder “to groin twice daily for fungal rash then discontinue when resolved.” Additionally, to apply Nystatin powder to groin as needed. The MAR showed the powder was on hold without a supporting physician order or documentation. On 07/15/25, approximately 10:49 am, the surveyor obtained permission and observed Staff 13 (MT/CG), and Staff 15 (CG) provide incontinence care to Resident 3. During the observation, it was noted the resident had rashes in the groin area and on the buttocks. On 07/16/25 at 1:45 pm, the findings were reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator). Staff 1 reported she was unsure why the Nystatin powder was on hold. They acknowledged the findings. 3. Resident 6 moved into the facility in 10/2023 with diagnoses including schizophrenia and auditory hallucinations. The resident’s physician orders, dated 07/08/25, and MARs dated 06/14/25 through 07/14/25, were reviewed and interviews with staff were conducted. The following was identified: The residents record lacked signed physician orders for the following medications: * Omeprazole 20mg (for acid reflux); * Polyethylene glycol (for constipation); * Acetaminophen 325 mg (for pain) as needed; and * Artificial tears (for dry eyes) as needed. On 07/17/25 at 12:09 pm, Staff 3 (RN) confirmed the lack of physician orders for the above medications. The need to ensure written, signed physician orders were documented in the resident’s record for all medications and treatments the facility was responsible to administer was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings.

Plan of Correction – C0303 Rule: OAR 411-054-0055(1)(f–h) (Page 88) Date of Compliance By: 8/15/25 Summary of Deficient Practice The facility failed to ensure that all medications and treatment orders were carried out as prescribed and that written, signed orders from a physician or other legally recognized practitioner were documented in the resident’s facility record. This affected 3 of 5 sampled residents, resulting in a lack of clarity and oversight related to prescribed treatments, including pain medications, topical treatments, and PRN use protocols. 1. Corrective Actions for Cited Residents for Residents #3, #4, and #6, all missing or undocumented physician orders for medications and treatments were obtained, signed, and filed in the clinical records by 07/18/2025. The MARs were immediately updated to match all current practitioner orders. Care teams, including med techs and assigned nurses, were re-educated on each resident’s specific treatment plan. The Nystatin treatment for Resident #3 was clarified and restarted per the physician’s direction. Responsible Parties: DON, RN Staff, RCCs 2. Systemic Changes to Prevent Recurrence A. Order Verification Process Implementation: All new medication or treatment orders will undergo a three-step verification: 1.Entry by Licensed Nurse 2. Review by RCC or assigned nurse 3. Final third check by RN or designated Licensed Nurse designated, with confirmation that each order is signed, current, and documented in the resident’s chart and MAR. Any PRN or held medications must have written authorization and a rationale documented in the chart. DON to ensure oversite that the process is being followed. Discrepancies will be immediately corrected, with retraining if needed. Admission Protocols: All new resident admissions or readmissions will trigger a 48-hour follow-up review by the DON or designee to verify complete and signed medication/treatment orders.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 2 sampled residents (#8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 8 moved into the facility in 01/2023 with diagnoses including Type 1 diabetes and right below-the-knee amputation. Resident 8's current physician's orders and MAR, dated 11/01/25 through 12/01/25, were reviewed. a. The resident had the following signed orders for PRN pain medication: * Acetaminophen 500 mg, take one tablet by mouth every six hours for pain. If ineffective, see tramadol order; and * Tramadol 50 mg, take one tablet by mouth every six hours as needed for moderate pain, use second for pain unrelieved by as needed acetaminophen. Tramadol was administered to the resident on four occasions during the reviewed time period. On all four occasions, there was no documentation that acetaminophen had been tried and pain was unrelieved prior to administering tramadol. b. The resident had the following signed orders for PRN medication to treat loose stools: * Loperamide 2 mg, take two capsules by mouth as needed after first loose stool, then take one capsule by mouth every eight hours for subsequent loose stools. Use first for complaint of loose stools, if ineffective see Metamucil order. * Metamucil 0.4 gm, take two capsules by mouth every day as needed for loose stools, use second if loperamide not effective. Metamucil was administered to the resident on three occasions during the reviewed time period. On two of the three occasions, Metamucil was administered prior to following orders for loperamide. The need to ensure all medications were administered as prescribed was reviewed with Staff 1 (Executive Director) and Staff 7 (Assistant Administrator) at 8:30 am on 12/03/25. They acknowledged the findings.

The facility immediately reviewed Resident #8’s medication orders and MAR upon identification of the deficiencies. Medication administration expectations for PRN medications were reviewed with medication technicians to ensure medications are administered in the correct order and as prescribed. Immediate education was provided to all medication technicians regarding following physician orders, appropriate sequencing of PRN medications, and required documentation. To prevent reoccurrence, Resident Care Managers or designated medication technicians will complete an end-of-shift review of PRN medication administration to ensure orders were followed and documentation is complete. The Executive Director, Assistant Administrator, or designee will monitor compliance through review of MARs and end-of-shift reports at least weekly. Any identified issues will be addressed promptly with additional education as needed. Monitoring will continue to support ongoing compliance with medication administration requirements.

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

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 1 of 1 sampled resident (# 4) who had documented medication refusals. Findings include, but are not limited to: Resident 4 moved into the facility in 06/2024 with diagnoses including a traumatic brain injury. The resident's MARs, dated 06/01/25 through 07/14/25, physician's orders, and progress notes, dated 04/14/25 through 07/13/25, were reviewed. Staff documented in the progress notes that the resident refused multiple medications from 04/18/25 through 07/13/25; however, they did not specify which medications the resident refused. There was no documented evidence the resident's refusal to consent to orders were communicated to the physician. The need to ensure the facility notified the physician or other legally recognized practitioner of medication refusals was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 2:26 pm. They acknowledged the findings.

Plan of Correction: C0305 – OAR 411-054-0055(1)(j-k) (page 94) Resident Right to Refuse & Practitioner Notification Summary of Deficiency: During the survey, it was determined that the facility did not meet the requirements related to a resident’s right to refuse medications and the responsibility to notify the prescribing practitioner. Key Findings: •Resident #4, who has a history of traumatic brain injury, had multiple documented refusals of medications between April and July 2025. •Staff progress notes recorded the resident’s refusals, but failed to specify which medications were declined. •There was no evidence that the resident’s physician or prescriber was notified of the refusals, as required by regulation. The facility did not ensure timely communication with the physician regarding the resident’s ongoing refusal to consent to treatment, which is a violation of the resident’s rights and compromises clinical oversight. Corrective Actions Taken (Completed by 07/24/2025): Resident Record Review: Resident #4’s medical chart was immediately reviewed. Documentation was updated to specify which medications were refused. A summary of refusals were sent to the residents’ primary prescriber on 07/21/2025. Resident’s right to refuse care was reaffirmed and documented. No adverse outcomes were noted from missed medications. Ongoing Compliance: Medication refusals will be fax according to how and when the physician wants to be notified by the RCC. RCC Or assigned Licensed nurse will ensure Medication refusal documentation. Follow-up with prescriber as appropriate. Any discrepancies will be immediately corrected and addressed with involved staff By the DON or designated licensed nurse. A daily audit by the RCC or med tech will be done on their assigned residents to ensure that all medication refused were documented and faxed according to how and when the physician wants to be notified prior to leaving end of shift.

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

OAR 411-054-0055 (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 which included the reason for use and staff initials for 2 of 5 sampled residents (#s 4 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 06/2024 with diagnoses including a traumatic brain injury. The resident's MARs, dated 06/01/25 through 07/14/25, physician orders, and progress notes, dated 04/14/25 through 07/13/25, were reviewed. The following inaccuracies were noted: a. Staff signed the MAR as a medication was administered but documented in a progress note the resident had refused to take the medication. b. Per interview with Staff 1 (ED) on 07/17/25 at 2:26 pm, the facility directed staff to obtain the initials of two staff members when administering certain medications. This was implemented relating to the verification of the resident's refusals of medications. There were 137 times out of 181 total entries lacking the initials of the second staff member. c. The facility directed staff to preform safety checks on Resident 4 at 10:00 am, 1:00 pm, 4:00 pm, 7:00 pm, and 10:00 pm. During those safety checks, staff were to answer "yes" or "no" if the resident was out of the facility or if s/he was sleeping. Staff left the answers blank eight times. d. Staff were directed to document the resident's vitals once a month. There were blanks on 06/04/25 and 07/01/25 with no explanation from staff of why the vitals were not obtained. e. The MAR directed staff to obtain Resident 4's weight twice weekly. There was a space for staff to initial that the weight was obtained and a space for staff to document the resident's weight. Although staff did initial four times confirming the weight had been obtained, there was no weight documented. Additionally, there were seven times when staff documented that the weight was held, or not obtained, but there was no documentation as to the reason why Resident 4 was not weighed. The need to ensure residents’ MARs were accurate was discussed with Staff 1 and Staff 7 (Assistant Administrator) on 07/17/25. They acknowledged the findings. 2. Resident 6 moved into the facility in 10/2023 with diagnoses including schizophrenia and auditory hallucinations. The resident’s physician orders, dated 07/08/25, and MARs, dated 06/14/25 through 07/14/25, were reviewed, and interviews with staff were conducted. The following was identified: The MAR lacked a reason for use for the following medications: * Candesartan 16mg tab; and * Metoprolol succinate XL 25 mg. On 07/17/25 at 12:09 pm, Staff 3 (RN) confirmed the lack of reason for use for the above medications. The need to ensure each medication had a reason for use documented was reviewed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 1:11 pm. They acknowledged the findings.

Plan of Correction – C0310: Medication Administration (page 96) Summary of Findings: During the survey, it was found that the facility failed to maintain accurate Medication Administration Records (MARs) for two residents (#4 and #6). For Resident 4, there were multiple discrepancies including: medication refusals incorrectly signed as administered, missing second staff initials for medications requiring dual verification, incomplete safety check documentation, missing vital sign records, and inconsistent weight documentation. For Resident 6, MARs lacked required “reason for use” for prescribed medications. These lapses indicate a breakdown in MAR accuracy and medication administration protocols. Corrective Actions Taken: 1.Immediate Staff Re-Education: All med techs and licensed nursing staff were immediately re-educated on MAR documentation requirements, including: Documenting medication refusals accurately. Ensuring that two staff initials are present when dual signature verification is required. Recording vital signs and weights as ordered, with explanations if skipped. Including the reason for use for all prescribed medications on the MAR. Re-education completed by 07/24/25. 2. Resident Record Updates: For Resident 4: All MAR entries for June–July were audited. Missing documentation, reasons for refusal, and required follow-ups were corrected. Vitals and weight documentation protocols reinforced. For Resident 6: MARs were updated to include the reasons for use for Candesartan and Metoprolol as per the physician’s intent. Systemic Measures Implemented: 1. MAR Documentation Standardization: Standard operating procedure updated to require all MARs to be reviewed for: Complete medication details (including reason for use). Proper initialing and documentation after administration. Correct documentation of refusals and explanations for missed entries (e.g., weights or vitals). 2. Daily MAR Audit Process: RCCs or designee will conduct daily report audits of MARs to ensure: No missing initials or documentation errors. Proper entries of all clinical and safety protocols (vitals, weights, refusals, etc.). Findings will be reviewed by the DON or designated nurse to address trends or retraining needs.

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a sufficient number of care staff to meet the minimum required staffing standards based on the acuity and needs of each resident. Findings include, but are not limited to: During the acuity interview on 07/14/25, it was identified the facility had three different buildings and was home to 67 residents. The facility’s posted staffing plan indicated the facility staffing levels were: * Bachelor Building: Day shift – six care staff; * Bachelor Building: Night shift – four care staff; * Broken Top Building: Day shift – six care staff; * Broken Top Building: Night shift – three care staff; * Washington Building: Day shift – six care staff; and * Washington Building: Night shift – four care staff. The facility’s staffing schedule was reviewed on 07/16/25 for the week of 07/07/25 through 07/13/25. The facility had two shifts during 24 hours; 6:00 am to 6:30 pm and 6:30 pm to 6:00 am, thus 42 shifts were reviewed. Thirteen out of those 42 shifts, or 30.95%, were not staffed according to the facility’s posted staffing plan. On 07/17/25 at 2:26 pm, the need to ensure the facility had a sufficient number of care staff to meet the minimum required staffing standards based on the acuity and needs of each resident was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator). They acknowledged the findings.

Plan of Correction – C0360: Staffing Requirements (page 103) Summary of Findings: During the survey, it was determined that the facility did not consistently staff each building according to the posted staffing plan. The facility operates three buildings (Bachelor, Broken Top, and Washington), serving 67 residents. A review of staffing schedules from 07/07/25 through 07/13/25 showed that 13 of the 42 reviewed shifts (30.95%) were under-staffed compared to the posted staffing plan. This failure does not meet OAR 411-054-0070 requirements for ensuring sufficient, qualified, and awake direct care staff based on resident acuity and structural layout. Corrective Actions Taken: 1. Immediate Staffing Adjustment: Staffing was immediately adjusted to ensure all three buildings are staffed according to the posted plan at all times. Float staff and on-call team members were assigned to fill schedule gaps starting (7/22/25). Systemic Measures Implemented: DON and Administrator now perform a monthly acuity-based staffing review to match staffing levels with residents' changing physical, behavioral, and clinical needs. Adjustments to staffing plans are made based on the acuity assessment outcomes. Ongoing Monitoring: Daily Monitoring: The Administrator and RCCs will conduct daily reviews of schedules to ensure full shift coverage and verify staffing compliance by building.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 5 sampled residents (#s 2, 3, and 4) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 04/2025 with diagnoses including type II diabetes mellitus. The current service plan dated 05/11/25, temporary service plans, and the residents’ corresponding ABST individual minutes were reviewed, and interviews with staff were conducted. The following was identified: The resident's care time and care elements were not reflective in the following areas: * Monitoring physical conditions or symptoms; * Monitoring behavioral conditions or symptoms; * Providing treatments; * Providing and ensuring non-drug interventions for behaviors; * Providing repositioning; and * Providing additional care services. 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 7 (Assistant Administrator) on 07/16/25 at 2:54 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2023 with diagnoses including schizoaffective disorder. The resident’s service plan, dated 06/06/25, behavior plan, dated 06/26/25, temporary service plan, dated 06/20/25, MARs, dated 06/01/25 through 07/14/25, and Resident 2’s corresponding ABST individual minutes were reviewed. Interviews with staff were conducted. The resident's care time for the corresponding care elements was not reflective in the following areas: * Responding to call lights; * Bathing; and * Providing additional care services. The need to ensure the facility’s ABST accurately captured care time in all care elements that staff were providing was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 2:26 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 06/2024 with diagnoses including a traumatic brain injury. The resident’s service plan, dated 07/09/25, behavior plan, dated 06/24/25, MARs, dated 06/01/25 through 07/14/25, and Resident 4’s corresponding ABST individual minutes were reviewed. Interviews with staff were conducted. The resident's care time for the corresponding care elements was not reflective in the following areas: * Monitoring behaviors; * Ensuring non-drug interventions for behaviors; and * Cueing/Redirection relating cognitive impairment. The need to ensure the facility’s ABST accurately captured care time in all care elements that staff were providing was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/17/25 at 2:26 pm. They acknowledged the findings.

Plan of Correction – C0362: Acuity-Based Staffing Tool (ABST) (Page 109) Summary of Findings: During the survey, it was identified that the facility failed to maintain an accurate and individualized Acuity-Based Staffing Tool (ABST) that captured all required care elements being provided to residents as outlined in their service plans. In a sample of five residents, three (Residents #2, #3, and #4) had ABST documentation that did not accurately reflect the actual care services provided, such as behavioral monitoring, non-drug interventions, treatments, cueing, bathing assistance, and response to call lights. This inconsistency violates OAR 411-054-0037 (1)(b–g), which requires individualized, up-to-date staffing tools based on actual resident care needs. Corrective Actions Taken: Immediate ABST Audit and Revision: The ABSTs for all residents, beginning with Residents #2, #3, and #4, were reviewed and revised by the Administrator to accurately reflect current care elements being provided. Service plans and behavior support plans were cross-referenced to ensure complete alignment with the ABST. Systemic Changes Implemented: The Administrator will coordinate all updates related to service plans, including changes in condition, new skin concerns, behavioral changes, and other relevant clinical information. This coordination will occur in collaboration with: •Resident Care Coordinators (RCCs) •Licensed Nurses •Director of Nursing (DON) •Behavioral Support Specialist As changes occur, the Administrator will ensure that the ABST (Assessment-Based Service Tool) is updated promptly to reflect the current needs of the resident. This collaborative approach ensures accuracy, consistency, and timely updates to support individualized resident care.

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed quarterly, at the same time as the service plan update, and/or with a significant change of condition for 1 of 2 sampled residents (#8), failed to use the results of the ABST to develop and routinely update the facility’s staffing plan, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to: a. Resident 8 moved into the facility in 01/2023 with diagnoses including Type 1 diabetes and right below-the-knee amputation. The resident experienced a significant change of condition on 11/19/25 when s/he returned to the facility after being at a hospital and a skilled nursing facility for approximately six weeks. The resident’s ABST was last updated on 08/07/25. b. During the acuity interview on 12/01/25, it was identified the facility had three different buildings and was home to 63 residents. Staff 1 (Executive Director) stated and documented on the ABST entrance questionnaire that the facility staffed a day shift and a night shift, with care staff working 12-hour shifts from either 6:00 am to 6:30 pm or 6:00 pm to 6:30 am. The facility’s ABST was divided into three shifts, day, swing, and night. During an interview with Staff 1 on 12/01/25, at 4:09 pm, she stated that she was not currently using the ABST to develop or update the facility’s posted staffing plans, as the three shifts shown on the ABST did not align with the two shifts scheduled by the facility. She stated she staffed based on the minimum specific needs contract staffing requirements. She acknowledged that this did not account for situations where resident acuity may require increased staffing levels above the specific needs contract minimums. She acknowledged that the Oregon Administrative Rules stated facilities must use the ABST, in addition to the specific needs contract requirements, to determine minimum staffing requirements. c. Staff 1 stated the facility currently had residents in three buildings: Bachelor, Broken Top, and Washington. The facility’s posted staffing plan indicated the facility staffing levels for 11/20/25 through 11/30/25 were: * Bachelor Building: Day shift – six care staff; * Bachelor Building: Night shift – four care staff; * Broken Top Building: Day shift – six care staff; * Broken Top Building: Night shift – four care staff; * Washington Building: Day shift – six care staff; and * Washington Building: Night shift – four care staff. The facility’s staffing schedule dated 11/20/25 through 11/30/25 was reviewed, and Staff 7 (Assistant Administrator) confirmed on 12/02/25 that the schedule included all staff, including agency staff, who had worked during that time period. Of the 66 shifts reviewed, 14 shifts, or 21%, were not scheduled to meet or exceed the facility’s posted staffing plan. The need to ensure residents’ ABST evaluations were updated at least quarterly and with significant changes of condition, the ABST was used to develop and update the posted staffing plan, and that the facility ensured consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1 and Staff 7 on 12/03/25 at 8:30 am. They acknowledged the findings.

The facility immediately updated the Acuity-Based Staffing Tool (ABST) to reflect the facility’s current 12-hour staffing shifts. The ABST for Resident #8 was reviewed and updated to reflect the resident’s current condition following the significant change on 11/19/25. To prevent reoccurrence, the Administrator will coordinate with licensed nursing staff to ensure the ABST is reviewed and updated at least quarterly, at the same time as service plan updates, and with any significant change in resident condition. The facility will use the ABST, in addition to specific needs contract requirements, to develop and update the posted staffing plan. Staffing assignments will be adjusted as needed to meet identified acuity needs. The Administrator or designee will monitor compliance by reviewing ABST updates, posted staffing plans, and staffing schedules to ensure staffing meets or exceeds the posted plan. Reviews will occur at least monthly and when significant changes in resident acuity are identified. Any discrepancies will be addressed promptly to support ongoing compliance.

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents for 4 of 4 newly hired staff (#s 18, 19, 20 and 21) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 07/16/25 with Staff 7 (Assistant Administrator). There was no documented evidence the Staff 18 (MT), hired 05/19/25, Staff 19 (CG), hired 05/19/25, Staff 20 (CG) hired 06/04/25, and Staff 21 (Activity Coordinator), hired 06/09/25, had completed orientation and the pre-service training on one or more of the following required topics prior to providing services: * Resident rights and values and CBC care; * Abuse reporting requirements; * Infectious Disease Preventions; and * Approved LGBTQIA2S+ course. The need to ensure staff had completed pre-service orientation prior to providing services was reviewed with Staff 1 (ED) and Staff 7 on 07/16/25 at 1:45 pm. They acknowledged the findings.

Regulation: OAR 411-054-0070 (3-4) Tag: C0370 – Pre-Service Orientation and Training Requirements (Page 115) Summary of Noncompliance: On July 16, 2025, the Department determined that the facility failed to ensure pre-service orientation and training was completed before staff began providing services to residents. Four staff members (#18, 19, 20, and 21) lacked documented evidence of required training in key areas, including: Resident rights and values of community-based care (CBC) Abuse reporting requirements Infectious disease prevention Department-approved LGBTQIA2S+ training This oversight created a potential risk for resident safety and dignity, particularly for vulnerable populations, including LGBTQIA2S+ residents, and compromised compliance with foundational training requirements. Corrective Actions Taken: 1. Immediate Remediation (Completed by 07/22/2025): Staff 18, 19, 20, and 21 staff member completed the required trainings, including: Resident Rights and CBC Values Abuse Reporting and Prevention Infectious Disease Prevention (Department-approved curriculum) LGBTQIA2S+ Awareness and Nondiscrimination Training Training certificates were obtained and filed in personnel records. 2. The Administrator and Assistant Administrator will conduct a comprehensive audit of all employee files to ensure that required trainings have been completed. This includes: •Verification that all initial and ongoing training requirements have been met. •Confirmation that each employee has completed their annual state-approved trainings within the required timeframes. Moving forward, the Administrator and Assistant Administrator will maintain a training compliance tracker and conduct quarterly reviews of employee files to ensure continued compliance with all training requirements.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 18, 19, 20 and 22) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire and were trained in First Aid and abdominal thrust. Findings include, but are not limited to: Staff training records were reviewed on 07/16/25 with Staff 7 (Assistant Administrator). There was no documented evidence Staff 18 (MT), hired 05/19/25, Staff 19 (CG), hired 05/19/25, Staff 20 (CG) hired 06/04/25, and Staff 22 (CG), hired 03/20/25, had demonstrated competency on one or more of the following required topics within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and abdominal thrust training. The need to ensure staff had demonstrated competence in any duty assigned and completed First Aid and abdominal thrust training within 30 days of hire was reviewed with Staff 1 (ED) and Staff 7 on 07/16/25 at 1:45 pm. They acknowledged the findings.

Tag: C0372 Rule: OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire Direct Care Staff (Page 124) Summary of Findings: During a regulatory survey, it was found that the facility failed to ensure that four newly hired staff members (#18, #19, #20, and #22) completed required training within 30 days of hire. Specifically, there was no documented evidence of staff demonstrating competency in the following required areas: Role of service plans in providing individualized care Providing assistance with activities of daily living (ADLs) Understanding changes associated with normal aging Identifying, documenting, and reporting changes in residents’ conditions Recognizing conditions that require assessment, treatment, and observation General food safety, serving, and sanitation First Aid and abdominal thrust training 1. Immediate Action Taken: All staff identified in the finding completed the required training and demonstration of competency. First Aid and abdominal thrust training was scheduled and completed for staff #18, #19, #20, and #22. Competency checklists for ADLs, change of condition, and individualized care via service plans were completed under direct observation by the RCC or designated Licensed nurse 2. Staff Onboarding Checklist (8/5/25 ): A revised New Hire Compliance Checklist has been implemented. This checklist must be completed and signed by the Assistant Adminitrator and Administrator prior to the employee’s first scheduled shift. It includes: Verification of completion of all required pre-service topics. A Standardized 30-Day Competency Packet will be created and must be completed with verification signatures from supervisory staff (DON, licensed nurses or RCC) before staff may work independently by 8/15/25

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 direct care staff (#s 30, 31, and 32) demonstrated satisfactory performance in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Training records were reviewed on 12/02/25. There was no documented evidence Staff 30 (MT), Staff 31 (MT), and Staff 32 (MT), hired 09/15/25, 09/16/25, and 10/13/25, respectively, had demonstrated competency in all required areas and within 30 days of hire in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 7 (Assistant Administrator) on 12/02/25 at 4:15 pm, and with Staff 1 (ED) and Staff 7 on 12/03/25 at 8:10 am. They acknowledged the findings.

The facility immediately reviewed the training records for Staff #30, #31, and #32. The identified staff completed additional training and competency review in the required areas, including service plans, assistance with ADLs, normal aging, identification and reporting of changes of condition, and conditions requiring assessment, treatment, observation, and reporting. Documentation was updated to reflect completion. To prevent reoccurrence, the facility will review current staff training records within three days to identify and address any missing or incomplete competency documentation. Any deficiencies identified will be corrected. Going forward, the Assistant Administrator or designee will review and audit training and competency documentation for all new hires to ensure required competencies are completed and documented within 30 days of hire.

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

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 direct care staff (#s 13, 23 and 24) completed a minimum of 12 hours of in-service training annually based on their anniversary date of hire on topics related to the provision of care. Findings include, but are not limited to: Annual in-service training records were reviewed on 07/16/25 with Staff 7 (Assistant Administrator) and showed the following: Staff 13 (MT) hired 07/11/23, Staff 23 (CG) hired 11/02/21, and Staff 24 (CG) hired 07/29/22, lacked documentation of a minimum of 12 hours in annual in-service training based on their anniversary date of hire on topics related to provision of care and chronic disease in the Community Based Care (CBC) population. On 07/16/25 at 1:45 pm, the above findings were reviewed with Staff 1 (ED) and Staff 7 who acknowledged the findings.

Plan of Correction – C0374: Annual and Biennial Inservice for All Staff (page 129) Summary of Findings: During the survey conducted on 07/16/25, it was determined that the facility failed to ensure 3 of 4 direct care staff (Staff #13, #23, and #24) completed a minimum of 12 hours of in-service training annually, based on their anniversary date of hire, as required by OAR 411-054-0070 (6–8). Additionally, documentation did not reflect completion of in-service hours covering essential topics such as care provision, chronic disease, LGBTQIA2S+ inclusivity, and dementia care. Corrective Actions: 1. Immediate Training Review and Completion (Completed by 07/23/2025): All cited staff (Staff #13, #23, and #24) have completed a training audit and were immediately scheduled to complete any missing required hours. Trainings covered: person-centered care, dementia care (minimum 6 hours), LGBTQIA2S+ protections, infectious disease control, chronic diseases, and HCBS compliance. Staff training files were updated to include certificates and sign-in logs. These are maintained in the HR compliance binder and digital personnel files. 2. Annual and Biennial Training Calendar Implementation (Completed by 07/24/2025): An electronic and printed in-service training calendar was created to track all annual, biennial, and specialty trainings by hire date anniversary. Staff receive quarterly printouts of their training status. 3. Designated LGBTQIA2S+ Training Representatives The facility designated two LGBTQIA2S+ training representatives: These representatives finalized our biennial LGBTQIA2S+ training plan, including Dep5. Ongoing Monitoring and Review (Effective 07/25/2025): The Administrator or designated staff will review training compliance quarterly.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Six months of fire and life safety records were requested on 07/14/25 and reviewed on 07/15/25 with Staff 6 (Facility Director). The following was identified: Fire drills were not conducted every other month in accordance with OFC. Therefore, there was no documented evidence of the following required components: * Date and time of fire drill; * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * Staff members on duty and participating; * Numbers of occupants evacuated; and * Evidence alternate routes were used during fire drills. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 1 (ED), Staff 6 and Staff 7 (Assistant Administrator) on 07/16/25 at 1:45 pm. They acknowledged the findings.

Plan of Correction – C0420 OAR 411-054-0090 (1-2) Regulation Title: Fire and Life Safety: Fire Drills and Documentation (page 139) Summary of Deficiency: The facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code. Required documentation was incomplete or missing and failed to demonstrate: Fire drill frequency and rotation across shifts Simulated fire origin and escape route used Staff participation and number of residents evacuated Evacuation time Problems encountered or residents who resisted participation Use of alternate escape routes Corrective Actions Taken: 1. Immediate Correction: A fire drill will be conducted on 8/13/25 to establish compliance. All required elements (date, time, origin, route, staff involved, evacuation time, and resident participation) were documented in full. Fire alarm system was activated during the drill as required. 2. Documentation Review and Reconstruction: Fire drill documentation from the past 6 months was reviewed. Any missing data or records were noted, and retraining was initiated for responsible staff. Systemic Changes Implemented: 1. Fire Drill Tracking Calendar: A Fire Drill Log Calendar has been implemented and posted in the Facility Director’s office. This calendar outlines bi-monthly unannounced fire drills rotated among all shifts. Responsible Party: Facility Director or designated staff 2. Fire Drill Documentation Form Update: A standardized Fire Drill Checklist was updated to ensure all required Oregon Fire Code elements are included. Forms now include prompts for alternate escape routes and staff-resident evacuation notes.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training at least annually. Findings include, but are not limited to: The facility’s fire and life safety procedures and training for residents were reviewed on 07/15/25 with Staff 4 (Lead RCC) and showed the following: There was no documented evidence the facility provided annual fire and life safety training to the residents. The need to ensure residents received fire and life safety training at least annually, was discussed with Staff 1 (ED) and Staff 7 (Assistant Administrator) on 07/6/25 at 1:45 pm. They acknowledged the findings.

Plan of Correction – C0422 OAR 411-054-0090 (5)Regulation Title: Fire and Life Safety – Training for Residents (page 144) Summary of Deficiency: It was determined the facility failed to ensure that residents received required fire and life safety training at least annually, as required by Oregon Administrative Rule. Upon review of training records with Staff 4 (Lead RCC) on 07/15/25, there was no documentation confirming that annual fire and safety training was provided to residents. Corrective Actions Taken: 1. Immediate Resident Training Completed: As of 8/13/25, all current residents will be capable of understanding safety instructions were re-instructed on fire and life safety procedures. Instruction included evacuation procedures, responsibilities during drills, and designated meeting locations. Documentation was completed, including date, resident attendance, and training content. Responsible Party: Administrator or Designated Staff 2. Admission Process Updated: Resident admission checklist was updated to include a documented fire and safety training within 24 hours of move-in. 3.All residents will be included in annual fire and life safety training. A master training calendar has been implemented to ensure this training is scheduled and conducted consistently each year for all current residents. 4. Training Documentation Template: A standardized Resident Fire and Life Safety Training Log has been developed, which includes: Date of training Training topics Staff leading training Resident names and signatures or notation of inability to participate due to cognitive status Responsible Party: Administrator or designated staff

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240, C260, C303, and C372.

See Plan of Correction

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to ensure each individual had privacy in his/her own unit for 1 of 1 sampled resident (# 3) who required staff assistance for all ADLs. Findings include, but are not limited to: Resident 3 moved into the facility in 04/2025 with diagnoses including type 2 diabetes mellitus. Observations of the resident and interviews with staff from 07/14/25 through 07/16/25 revealed the resident relied on staff for most of ADLs and care. On 07/01/25 at 10:27 am, Staff 19 (CG) and Staff 29 (CG) were observed to provide incontinent care for Resident 3 in the resident's bed. The bed was located facing the windows in Resident 3's unit. The blinds were open, and the resident was visible to people passing by outside of the facility. Staff provided incontinent care and changed Resident 3's clothes with the blinds open. The need to ensure privacy in resident's units was discussed with Staff 1 (ED), and Staff 7 (Assistant Administrator) on 07/16/25 at 1:45 pm. They acknowledged the findings.

Plan of Correction – H1517 OAR 411-004-0020(2)(d) Regulation Title: Individual Privacy – Own Unit (page 146) Summary of Deficiency: Based on observation and staff interviews, the facility failed to ensure privacy for Resident #3 during care provision. On 07/01/2025 at 10:27 AM, caregivers were observed providing incontinence and clothing care to the resident in full view of the facility's exterior due to open window blinds. The resident, who requires assistance with all activities of daily living, was left exposed to public view, which constitutes a breach of privacy as defined under OAR 411-004-0020(2)(d). Corrective Actions Taken: Immediate Remediation (Completed 07/16/2025): 1.Staff 19 and Staff 29 were immediately coached and re-educated regarding the requirement to ensure resident privacy by closing blinds and securing the environment before providing any personal care. Responsible Party: Licensed nurse or RCC 2.An immediate in-service training was conducted with all direct care staff following the identified privacy breach involving Resident #3. The training focused on the importance of maintaining resident dignity and privacy during care, including: Ensuring window blinds or coverings are closed during personal care. Being mindful of surroundings that could expose residents to public view. Reinforcing resident rights as outlined in OAR 411-004-0020(2)(d). 3.To prevent future occurrences: This policy will now be a required component of the staff orientation checklist. All new hires will receive training on protecting resident privacy during care as part of their onboarding process. The Resident Care Coordinators (RCCs) and/or Shift Leads will monitor for compliance and provide immediate correction and coaching as needed. The Administrator or designee is responsible for ensuring training is completed and documented

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:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: During the survey, conducted on 07/14/25 through 07/16/25, record review, and interviews with staff confirmed that most residents did not have keys to their units. On 07/16/25 at 1:12 pm, Staff 1 (ED) reported residents were offered a key upon admission based on their key assessment status. If a resident declined the key, it was not provided, and the decision was documented. On 07/16/25 at 1:45 pm, when asked for documentation of the key evaluation for Resident 1, 2, 3, 4, 5 and 6, Staff 1 (Administrator) showed for some of the residents’ evaluations, but not all. Review of records for Resident 3 showed no documented evidence the residents had been provided a key to their rooms or had been evaluated for the ability to manage keys to their rooms. On 07/16/25 at 3:30 pm, Staff 25 (Program Director) reported he followed up with Resident 3 and he expressed that he wanted a key. Staff 25 reported the key would issue to the resident shortly. The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Administrator) and Staff 7 (Assistant Administrator) on 07/16/25. They acknowledged the findings.

Plan of Correction – H1518 OAR 411-004-0020(2)(e) Regulation Title: Individual Door Locks – Key Access Page (148) Summary of Deficiency: During the survey conducted from 07/14/25 to 07/16/25, it was identified that the facility failed to ensure all residents were provided keys to their units or had properly documented evaluations related to key access. Several residents, including Resident #3, had no documentation of key evaluations or evidence of key issuance. The facility acknowledged the oversight. To address the identified deficiency regarding resident key access and documentation, the following corrective actions have been taken: 1.Installation of Key Hooks: Key hooks have been installed inside the closet of every resident’s unit to ensure keys are stored securely and privately. 2.Key Issuance: The Facilities Director created and issued new keys for all residents. Each key will placed on the appropriate key hook within the resident's closet by 8/11/25. 3.Monthly Key Audits: The Resident Care Coordinators (RCCs) will conduct monthly audits to verify that all residents have keys. 4.Any missing or lost keys will be reported and immediately replaced by the Facilities Director within 24 hours or if on weekends the next business day. Responsible Parties: •Facilities Director – Key creation and replacement •RCCs – Monthly audits and documentation •Administrator – Oversight and compliance tracking

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

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors, which included the LGBTQIA2S+ protections and non-discrimination notice. Findings include, but are not limited to: Refer to C 152.

L0152 OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (page 150) Please refer to C 152

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by:

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure the move-in evaluation addressed all required elements, including pronouns and gender identity, for 1 of 1 resident (# 3) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

L0252 OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (Page 152) Please refer to C 252

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 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department approved LGBTQIA2S+ course, for 4 of 4 newly hired staff (#s 18, 19, 20, and 21) whose training records were reviewed. Findings include, but are not limited to: Refer to: C 370.

L0370 OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (page154) Please refer to C 370

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: