Print Inspection: RL011682

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored with weekly progress noted until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who were reviewed for changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 10/2025 with diagnoses including dementia. The resident’s 02/02/26 through 05/03/26 clinical record was reviewed. The following was identified: In a 04/08/26 observation note, staff documented the resident experienced a witnessed fall and sustained a skin tear above his/her left eyebrow. There was no documented evidence the resident’s skin condition was monitored, with progress noted at least weekly through resolution. In an interview on 05/07/26 at 10:45 am, Staff 4 (RCC) confirmed the lack of documented monitoring through resolution for Resident 4’s skin tear. The need to ensure changes of condition were monitored with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator) and Staff 4 on 05/07/26 at 2:00 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2026 with diagnoses including congestive heart failure and atrial fibrillation. The resident’s 01/01/26 through 05/04/26 clinical record was reviewed and the following was identified: The resident’s service plan indicated the community nurse would monitor weeping edema in bilateral legs and a wound on the resident’s right shin weekly. There was no documented evidence the resident’s skin condition was monitored, with weekly progress noted through resolution. On 05/07/26 at 12:10 pm, Staff 4 (RCC) confirmed the documentation of skin monitoring did not occur at least weekly through resolution. On 05/07/26 at 2:35 pm, the need to ensure short-term changes of condition were monitored with weekly progress noted until the condition resolved was reviewed with Staff 1 (Administrator) and Staff 4. They acknowledged the findings. 3. Resident 2 moved into the facility in 02/2026 with diagnoses including Alzheimer’s dementia. The resident’s 02/02/26 to 05/04/26 clinical record was reviewed and the following was identified: An observation note dated 03/29/26 documented an unwitnessed fall, which resulted in surgical repair of the resident’s left hip. The resident returned to the facility on 03/31/26. An observation note on 04/03/26 documented, “This morning caregiver reported that the bandage on injured hip is turning dark,” and the resident was sent to the ER to have the incision treated. There was no documented evidence of monitoring of the surgical incision again until 04/15/26, twelve days after the resident’s ER visit. The facility failed to document weekly progress of the surgical incision through resolution. Staff 6 (LPN) documented the incision was healed and discontinued monitoring on 04/25/26. On 05/07/26 at 12:10 pm, Staff 4 (RCC) confirmed monitoring of the incision had not been completed with weekly progress noted through resolution. The need to ensure short-term changes of condition were monitored with weekly progress noted until the condition resolved was reviewed with Staff 1 (Administrator) and Staff 4 on 05/07/26 at 2:35 pm. They acknowledged the findings. 4. Resident 3 moved into the facility in 02/2025 with diagnoses including Alzheimer’s disease. The resident’s 02/02/26 through 05/03/26 clinical record was reviewed. The following was identified: In a 03/15/26 incident report, staff documented the resident “became combative” with the staff during a shower and “sustained a triangle shaped skin tear on [his/her] right arm.” There was no documented evidence the resident’s injury was monitored, with weekly progress noted through resolution. In an interview on 05/07/26 at 10:19 am, Staff 4 (RCC) confirmed the lack of documented monitoring through resolution for Resident 3’s skin tear. The need to ensure changes of condition were monitored with weekly progress documented until resolution was discussed with Staff 1 (Administrator) and Staff 4 on 05/07/26 at 1:35 pm. They acknowledged the findings.

1. Residents identified have had the short term monitoring found resolved. Current review completed of all Temporary Service plans with confirmation that short term monitoring is being documented and nursing staff completing resolution and weekly skin monitoring as indicated. Community will ensure short term changes of condition are monitored with weekly progress notes until the condition is resolved. 2. The community will follow the following processes to assure temporary service plans are completed timely and any short term change of condition is documented at least weekly through resolution. The community utilizes the following processes available in EHR (electronic health record.) a.Temporary Service Plans (TSP) in the EHR. Med Techs are to use only the approved TSP's and are to implement and notify RCC and RN using the Nurse reporting guidline form. RCC or RN to review and DC TSP's. b.EHR Alert Charting following the Alert Charting Guidelines c. White board updated for all skin concerns for licensed nursing to review, assess, and document weekly in the EHR. Clinical Meeting held Monday - Friday- responsibilities: a.Review Observation Notes Monday- Friday b.Review Incident Reports Monday -Friday- Coordinate with Administration for investigations c.Nurse to work with Med Techs and RCC to assure alert charting and TSP’s are utilized appropriately and that the information is accurate.. d.Review Alert Charting in EHR Monday-Friday Med Tech responsibilities: a. Use only approved EHR TSP. b.Prompt notifications following Nurse notification guidelines document. c.Follow charting guidelines to assure prompt and accurate reporting of resident status Administrator Responsibility a.Morning Stand up done daily with clinical meeting b. Administrator reviews all IR's and observation notes Monday through Friday. Staff trained to provide weekend notifications to ED per Call Guideline document. 3. Daily review of TSP's, Weekly clinical meeting with Regional RN.This system requires daily monitoring and weekend Med Techs trained regarding notifications to Nurse and Administrator using the company notification form. 4. RCC, RN and Administrator with oversight of VP of Health Services and COO.

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 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were administered only after documented, non-pharmacological interventions were tried with ineffective results for 1 of 2 sampled residents (# 2) who had an order for PRN psychotropic medications. Findings include, but are not limited to: Resident 2 moved into the facility in 02/2026 with diagnoses including Alzheimer’s dementia. The resident’s 04/01/26 to 05/04/26 MAR and clinical record were reviewed and revealed the following: The resident had an order for Lorazepam 1 mg tablet, administer 0.5 tablet to 1 tablet two times daily as needed for anxiety. The MAR indicated staff administered the 1 mg dose of the medication on six occasions between 04/01/26 and 04/30/26. The resident’s record lacked documented evidence non-pharmacological interventions were attempted and ineffective for four of the six administrations. On 05/07/26 at 12:10 pm, Staff 4 (RCC) confirmed staff had not consistently been documenting attempted non-pharmacological interventions were ineffective prior to administering the psychotropic medication. The need to ensure PRN psychotropic medications were administered only after documented, non-pharmacological interventions were tried with ineffective results was reviewed on 05/08/26 at 2:35 pm with Staff 1 (Administrator) and Staff 4. They acknowledged the findings.

1.The residents identified has had MAR updated for resident specific non-pharmacological interventions prior to administration of medications. A new question was added to the EMAR to prompt for documentation that 4 non-pharmacological interventions were attempted prior to administration of psychtropic medication.All residents on a PRN psychotropic medication were audited to assure that non-pharmacological interventions were in place with question to document prior to use. Community will ensure PRN psychotropic medications are administered only after documented, nonpharmacological interventions are tried with ineffective results. 2.Nursing adds non-pharmacolocal resident specific interventions any time a new medication is ordered. Med Techs trained to notify nursing any time they see a PRN psychotropic. In addition with the 3rd check of all orders the RN will review. In additon, this will be reviewed quarterly with the service conference and referral to nursing if resident has a PRN psychotropic medication. 3. With all new orders and quarterly 4. RCC and RN with oversight of Administrator.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) accurately capture care time and care elements staff were providing to residents for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 02/2025 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the 04/13/26 service plan and Resident 3’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Monitoring physical conditions or symptoms; and * Supervising, cueing or supporting while eating. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Administrator) and Staff 4 (RCC) at 1:35 pm on 05/07/26. They acknowledged the findings. 2. Resident 4 moved into the facility in 10/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the 04/22/26 service plan and Resident 4’s ABST data was completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks and fall prevention; * Monitoring physical conditions or symptoms; * Assisting with leisure activities; * Providing non-drug interventions for behavior; * Providing non-drug interventions for pain; * Providing supervision, cueing or support while eating; * Providing ambulation assistance, escorting to and from meals and activities; * Providing transfer assistance in or out of bed or chair; and * Helping with bowel and bladder management. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator) and Staff 4 (RCC) on 05/07/26 at 2:00 pm. They acknowledged the findings. 3. Resident 1 moved into the facility in 09/2026 with diagnoses including congestive heart failure and atrial fibrillation. Observations of the resident, interviews with staff, and review of the 04/22/26 service plan and Resident 4’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks and fall prevention; * Providing treatments; * Supervising, cuing, or supporting while eating; and * Transferring in or out of bed or chair. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator) and Staff 4 (RCC) on 05/07/26 at 2:35 pm. They acknowledged the findings. 4. Resident 2 moved into the facility in 02/2026 with diagnoses including Alzheimer’s dementia. Observations of the resident, interviews with staff, and review of the 04/15/26 service plan and Resident 4’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Monitoring behavioral conditions or symptoms; and * Safety checks and fall prevention. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator) and Staff 4 (RCC) on 05/07/26 at 2:35 pm. They acknowledged the findings.

1.Residents 1, 2, 3, 4were updated on the ABST specifc to the items mentioned in the SOD. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts and while reviewing service plans in conjunction. Schedule and staffing has been reviewed to meet the needs in relation to ABST. The current RCC now has the duty of maintaining the ABST with oversight of RN and Administrator. RCC received additional training from an RCC at another community with extensive experience and no deficiences on ABST. 2. The ABST is updated promptly as changes occur ensuring reflecting current needs. Any new staff completing the ABST will received company sponsored training with staff with ABST competency. 3. The ABST is reviewed at least weekly and with changes of condition, new admissions, and quarterly with service conferences by the RCC to ensure accuracy. The schedule is updated daily as needed when changes occur to reflect current ABST needs meeting state requirement. New admissions are done prior to move in. 4. RCC and Administrator with oversight of COO and VP of Health Services as company quality assurance activities.Community will ensure the Acuity Based Staffing Tool (ABST) accurately captures care time and care elements staff are providing to residents.

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview it was determined the facility failed to ensure the interior was free from unpleasant odors. Findings include, but are not limited to: The interior of the memory care was toured on 05/04/26 at 3:25 pm. The following was identified: Pervasive odors were present throughout the Monarch and Garden sides and did not dissipate during the survey. On 05/05/26 at 10:20 am, Staff 18 (Regional Facilities Services Director) stated the facility was replacing flooring from residents’ rooms when they were vacated in an effort to mitigate odors by recurrent incontinent episodes. The odors proliferated into the common areas, however, and he did not know of any plans to replace the flooring in those areas. The need to ensure the facility was free of unpleasant odors was reviewed with Staff 1 (Administrator) and Staff 3 (Facilities Services Director) on 05/06/26 at 10:30 am. They acknowledged the findings.

1. Community will ensure the interior is free from unpleasant odors. Additional air fresheners (15) have been purchased and placed strategically throughout Community to ensure odors are eliminated. Flooring has been removed and replaced with waterproof LVP in identified areas to eliminate odors. Walkthrough of the Community was completed and verified that no additional odors were noted. 2.The following systems are implemented to assure this violation is corrected. a. Daily walkthrough by administrator or designee to assure community is free from unpleasant odors. b. Maintenace department and/or Housekeeping will be promptly notified of any unpleasant odors. c. In-service completed will all staff regarding notification of unpleasant odors promptly to housekeeping or maintenance. If odor continues, prompt notification to administrator. 3. Daily walkthrough by administrator or designee. Report during morning stand-up of any concerns that have arisen with prompt plan of correction. Monthly during company mini-mock survey. 4. Housekeeping and Maintenace with oversight of administrator.

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

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers and failed to provide a manually operated emergency call system in each toilet and bathing facility used by residents and visitors. Residents were unable to contact staff to request help when needed, constituting a threat to their health, safety, and welfare. Findings include, but are not limited to: The facility was a memory care unit that was had two “sides,” Monarch and Garden. Staff on either side communicated through walkie talkies. During the tour of the facility’s interior on 05/04/26 at 3:25 pm, direct care staff in Monarch and Garden units were interviewed regarding the facility’s call system. Staff 9 (CG) reported seeing pull cords in resident bathrooms, but had never responded to a call from one, and did not know if they were operable. Care staff were instructed to provide hourly safety checks to all residents to offer ADL assistance. Staff 9 reported some residents had whistles to use to summon care staff. In an interview on 05/04/26 at 4:14 pm, Staff 11 (CG) stated two residents in Garden unit had tab alarms and “one or two” residents in Monarch unit had whistles to summon care staff when they required assistance. He stated care staff provided hourly safety checks to residents to offer assistance with care needs. On 05/04/26 at 4:35 pm, Staff 1 (Administrator) confirmed the facility had no call system connecting resident units to the care staff. Staff 1 and Staff 4 (RCC) confirmed the pull cord call system in each resident’s bathroom had not been operable for “a couple of years.” The facility failed to ensure residents had a working call system, which left residents unable to call for assistance when needed and placed the residents’ health, safety, and welfare at risk. On 05/04/26 at 5:34 pm, a written plan of correction was requested of Staff 1, to be submitted by 9:30 am on 05/05/26. The plan of correction was accepted at 11:05 am on 05/05/26. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to have an operational call system that connected residents to the care staff or staff pagers was discussed with Staff 1 and Staff 4 (RCC) on 05/05/26. They acknowledged the findings.

1. A new call system was installed and verified working on 5/8/2026/ 2. Community Maintenance Team staff will ensure system correction by performing weekly spot checking and monthly full system checking. Staff Inserviced on need for immediate reporting of call system is noticed to not be functioning properly. 3. Weekly and Monthly testing of system. Monthly reporting to corporate team during Mini-Mock Survey report required. 4. Community Maintenance Team with oversight of Administrator.

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

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit. Findings include, but are not limited to: On 05/04/26 at 5:03 pm, observations of the shared bathroom between roommates in Rooms 221 and 223 on the Monarch side revealed no locking mechanism for the residents to lock the doors from inside the bathroom. On 05/05/26 at 8:30 am, Staff 4 (RCC) demonstrated the locks on shared bathroom doors in Garden side were inoperable because strike plates had not been installed for the door latches to secure into. Staff 4 confirmed residents throughout the facility were not able to lock their shared bathroom doors from inside their bathrooms for privacy. On 05/08/26 at 2:35 pm, the need to ensure each individual had privacy in his or her own unit, including privacy when using shared bathrooms between roommate units, was discussed with Staff 1 (Administrator) and Staff 4. They acknowledged the findings.

Community will ensure each individual has privacy in his or her own unit. Community Maintenance Team staff will ensure system correction by ensuring each resident bathroom has locking doors. Community Maintenance Team staff will ensure sytem correction by performing quarterly audits of resident bathrooms throughout the community. Community Maintenance Team staff who will ensure the systems corrections are completed and monitored consists of the Communities Regional MD, MD and AMD. All failures to ensure systems corrections shall be reported to the Community Administrator immediately.

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

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

Referral tag- refer to C513

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 11, 13, and 17) completed all required pre-service dementia training topics and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/05/26 at 2:35 pm with Staff 2 (Business Office Manager). The following was identified: a. There was no documented evidence Staff 11 (CG), Staff 13 (CG), and Staff 17 (MT), hired 02/10/26, 03/16/26, and 04/06/26, respectively, had completed one or more of the following pre-service dementia training topics for direct care staff: * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. b. There was no documented evidence Staff 11, Staff 13, and Staff 17 demonstrated competency in one or more of the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documenting and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * Other duties, including medication pass and treatments. The need to ensure the required pre-service training was completed and staff demonstrated competency in assigned job duties within 30 days of hire was discussed on 05/05/26 at 2:35 pm with Staff 2 and on 05/07/26 at 2:00 pm with Staff 1 (Administrator) and Staff 4 (RCC). They acknowledged the findings.

1. Complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. 2.Designated staff trainers (experienced Med Tech, Caregiver and/or RCC, Dining supervisor) perform evaluated competency checks on their department staff to observe demonstrated performance skills. The Business Office Manager (BOM) monitors competency checks using tools such as the training tracker spreadsheet to ensure training is properly completed, and then record the documents in appropriate files. All on-line modules (Relias and Oregon Care Partners) are completed prior to beginning work on the floor or within the 30 day compliance date depending on if it is pre-service or 30 days. Company approved Orientation and competencies are done for each employee. Process: Hire, Onboarding with Orientation form and required pre-service trainings including CPR, First Aid,and Food Handerlers, shadowing on the floor, demonstrated competencies, finish 30 day trainings. BOM monitors staffing to assure compliance and trainings are completed. 3.The Business Office Manager or designee maintains the tracking spreadsheet to assure accuracy of training and within all required timeframes per policy and OAR. The BOM notifies managers if there are staff who are not in compliance. 4. BOM with Administrator oversight.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270, C330, and C362.

Referral Tag- refer to C270

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: