Print Inspection: RL009055

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 4 and 5) who were in an intimate relationship. Findings include, but are not limited to: Residents 4 and 5 were admitted to the facility in 01/2022 and 10/2025, respectively, with diagnoses including dementia. Interviews with staff, observations conducted on 01/27/26 and 01/28/26, and review of current service plans dated 12/30/25 and 12/09/25 indicated the service plans for Residents 4 and 5 were not reflective of the residents' current behaviors and did not provide clear direction to staff regarding the following: * Physical intimate relationship between Residents 4 and 5. During interviews conducted on 01/27/26 and 01/28/26, multiple staff reported Residents 4 and 5 were frequently observed together holding hands, hugging, and kissing. Staff further reported the residents had been observed together in each other’s beds. On 01/27/26 and 01/28/26, Residents 4 and 5 were observed eating meals together, hugging, and placing their arms around one another. Review of the service plans for Residents 4 and 5 identified the plans did not address the observed physical intimate relationship and failed to provide clear direction to staff regarding monitoring, supervision, interventions, or staff response related to the residents’ interactions. The need to ensure resident service plans were reflective of current behaviors and provided clear directions to staff was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Memory Care Coordinator) and Staff 4 (Memory Care Coordinator) on 01/29/26 at 11:45 pm. The staff acknowledged the findings.

C0260-Service Plan: General- 1. All residents affected by this deficiency have been reviewed and corrected as follows: Resident #4 has a new service plan with updates including specific direction for care staff that includes specific directions and interventions for staff to follow regarding this intimate relationship and what the staff should immediately report to the RN and Executive Director.. Resident #5 has a new reflective service plan for staff to follow including specific directions and interventions for staff to follow regarding their intimate relationship and what the staff should immediately report to the RN and Executive Director. 2. RN, RCC's and Executive Director are completing a full review of all resident service plans to ensure they are resident specific and include all needed details related to care and needed interventions and directions for staff for each resident's individual needs. 3. ED and RN to review resident service plans for accuracy quarterly and as needed for changes of condition to ensure the service plans are reflective and provide clear instructions for staff. 4. ED and RN will ensure all service plans are accurate and reflective for each individual resident.

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 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior of the building and all equipment were maintained. Findings include, but are not limited to: The interior of the building was toured at 10:00 am on 01/27/26, and the following was identified: Residents were housed in four neighborhoods, each with a laundry area separated from the dining rooms by folding doors. • 100 Hall (Walnut) -- two sections of the laundry area flooring approximately 1’ x 1’ were missing, exposing an uncleanable surface; • 200 Hall (Ivy) -- a section of the laundry area flooring approximately 1’ x 1’ was missing, exposing an uncleanable surface; • 300 Hall (Lily) -- two sections of the laundry area flooring approximately 1’ x 1’ were missing, exposing an uncleanable surface; and • 400 Hall (Daisy) -- a section of the laundry area flooring approximately 1’ x 1’ was missing, exposing an uncleanable surface, and the folding doors to separate the dining room from the laundry room were missing. The facility was toured with Staff 1 (Executive Director), and Staff 5 (Physical Plant Director) at 1 pm on 01/27/26. They acknowledged the areas needing repair. The need to ensure the interior of the facility was maintained and in good repair was discussed with Staff 1 and Staff 2 (Health and Wellness Director) at 11:00 am on 01/29/26. They acknowledged the findings.

C0513-Doors, Walls, Elevators, odors- 1-Quote for flooring received, approved and flooring repairs completed for all 4 listed neighborhoods affected by this deficiency on 02/11/2026 by our outside flooring vendor. 2. ED and Maintenance Director to complete monthly physical plant walk thru's to identify repairs needed within the facility and will create a plan at time the deficiency is identified. 3. ED and Maintenance Director will utilize our TELS system and create work orders with identified completion dates to track work orders for completion and compliance. 4. Executive Director and Maintenance Director will oversee this process for complaince.

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

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C260.

Please refer to Plan listed above for Tag C0513-

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C513.

Please refer to plan listed above for tag C0260-

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