Print Inspection: RL012618

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of the facility operations, and supervision and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to: During the relicensure survey, conducted 06/22/26 through 06/26/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the severity and number of citations. Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas: 411-054-0045 (1-2) C280: Resident Health Services 411-054-0045 (2) C290: Resident Health Services: On and Off Site 411-054-0055 (1)(a) C300: Systems: Medication & Treatment The facility put immediate plans of correction in place during the survey. Refer to deficiencies in the report.

- Regional Team Member or Designee reviewed SOD with ED and assisted in developing POC ensuring understanding of areas of opportunity. - Senior ED has been assigned to assist ED with day-to-day questions and processes - Regional Team Member or Senior ED will be onsite at least 1 day per week for 60 days for additional training support and ensuring Community systems are stabilizing - Regional Team Member or Senior ED will audit via observation, staff/resident interview, and/or documentation review validate improvement weekly x 3 weeks then monthly x 2 months. -ED is responsible

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to implement written policies and procedures that promoted high quality services and health and safety for residents, including effective methods for responding to and resolving resident complaints. Findings include, but are not limited to: During the relicensure survey, conducted 06/22/26 through 06/26/26, observations were made, interviews with residents and family were conducted, resident council notes from 04/2026 to 06/2026 were reviewed, and a group interview was conducted. Observations from 06/22/26 through 06/26/26 identified the following: * Lunch meal service began late on one occasion and took up to one and a half hours to serve on four occasions; and * Meals served to residents in their rooms were at unpalatable food temperatures. During sampled resident interviews the following concerns were heard: * Witness 4 (Family Member) noted the facility staff did not treat the call button like an emergency. He reported waiting for up to two hours, and said he often went and found people to help. * Resident 2 noted that s/he had pressed the call button, and staff didn’t respond for one and a half hours. * Resident 3 noted it took minutes to hours before someone came to help. The call pendant wasn’t working right, and the batteries needed changed every couple of days. On 06/24/26 at approximately 9:00 am, a call light report was requested. Review of the call light report from 06/06/26 through 06/22/26 confirmed wait times that exceeded 20 minutes over 13 percent of the time, with 23 calls exceeding an hour. Resident Council meeting minutes from 04/01/26 through 06/03/26 were reviewed with Staff 7 (Life Enrichment Director) on 06/24/26 at 9:40 am. The following resident concerns were identified: * Call pendants were old and not maintained; * There were significant delays in answering call lights on all shifts; * Staff were seen using their personal phones while on duty; and * Newly hired staff did not receive adequate training. Staff 7 confirmed during the interview that call lights were “a problem,” and staff couldn’t respond fast enough. There was no documented evidence the above concerns identified from the Resident Council meetings had been addressed, responded to, or resolved. During a resident group interview conducted on 06/24/26 at 11:00 am, the following concerns were reported: * Delays answering call lights on all shifts; * Call pendants were old and needed replacement; * Delays in medication administration, especially on weekends; * Food quality, menu offerings, and limited alternate selections; * Running out of personal care supplies and meal condiments; * Significant delays with meal service, especially room tray delivery, resulting in unpalatable food; * Staff turnover in the kitchen which resulted in direct and non-direct care staff cooking meals; and * The facility brought in “takeout” often, and the group believed it was because of staffing shortages. The group residents said they usually went to Staff 1 (ED) to voice their concerns, but he hadn't gotten back to some of them at the time of the group interview. On 06/24/26 at 1:05 pm, Staff 1 stated he used sticky notes to track resident concerns until they were resolved. He acknowledged that he did not have a system to maintain documentation of the resident grievances and their resolution, was not monitoring or providing quality assurance around call lights and was not using the company’s grievance system. The need to ensure the implementation of written policies and procedures that promoted high-quality services and health and safety for residents, including effective methods for responding to and resolving resident complaints, was reviewed with Staff 1 on 06/26/26 at 11:25 am. He acknowledged the findings.

-ED reviewed resident council meeting notes 4/26 – 6/26, as well as resident council meeting notes & interview notes from survey, addressing concerns identified. Each area of concern had a plan built that will be reviewed with the residents during the next resident council meeting 8/5/2026 taking into account their feedback. The resolution/plan will then measured for effectiveness through monitoring and resident feedback via informal & formal. Grievance Process will be reviewed with Residents during Residents 8/05/26 resident council meeting. - Regional Team Member or Designee re-educated ED and LED on the grievance process. - The grievance process was reviewed during all staff meeting. - ED or Designee will conduct random audits via documentation review or resident interview on grievance process effectiveness weekly x 3 weeks then monthly x 2 months. - ED is responsible.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the accuracy and preservation of resident records for 1 of 4 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 12/2023 with diagnoses including hemiplegia, type 2 diabetes mellitus, and acute pain. The resident’s 03/22/26 to 06/22/26 clinical record was reviewed, and the following was identified: Resident 1 was admitted to HH services on 05/28/26 for a non-pressure chronic ulcer on the right foot. S/he was subsequently admitted to hospice services on 06/18/26, with an admitting diagnosis of transient cerebral ischemic attack (stroke). During an interview on 06/24/26 at 9:34 am, Witness 1 (HH RN) stated HH orders for wound care were provided to the facility at the time of Resident 1’s admission to HH on 05/28/26. However, no such orders were found in the resident’s medical record. On 06/15/26, the HH agency re-sent the admission orders to the facility. The orders indicated they were printed by the HH agency on 06/15/26, and the fax confirmation was dated 06/15/26. However, the faxed copy of the orders was stamped and dated 06/08/26 by Staff 3 (RN). During an interview on 06/24/26 at 2:21 pm, Staff 3 was unable to account for this discrepancy. From 06/25/26 through the time survey exited the facility, Staff 3 was not present and available to interview. The need for the facility to ensure the accuracy and preservation of resident records was discussed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 4 (Regional Director of Operations) on 06/26/26 at 9:13 am. They acknowledged the findings.

- Regional RN or Designee conducted a comprehensive review of Resident 1’s record addressing concerns identified. - HSD or Designee identified current residents receiving home health and hospice services, coordinated with providers to receive and review all current orders, addressing concerns identified. - Regional staff re-educated ED, RCC, HSD, MTs on ensuring accuracy and preservation of resident records including training on three folder process, SMART process and coordination process with home health and hospice providers. - HSD or Designee will conduct random audits via record review, interview with home health /hospice provider for compliance weekly x 3 weeks monthly x 2 months. - ED is responsible

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the immediate health, safety, or welfare of residents for 1 of 1 sampled resident (# 6) who smoked and used oxygen. Resident 6 smoked while wearing an oxygen canula. This placed residents at risk and constituted an immediate threat to residents’ health and safety. Findings include, but are not limited to: Resident 6 was admitted to the facility in 12/2025 with diagnoses including chronic obstructive pulmonary disease. Resident 6's current service plan and evaluation, updated 06/15/26, was reviewed and noted the resident smoked, used oxygen as needed, and was alert and oriented with mild cognitive impairment. The service plan noted s/he had been “educated on ensuring prior to smoking to remove and turn [his/her] oxygen off, and the safety concerns if [he/she] does not comply.” The service plan also stated Resident 6 “may keep smoking materials AND sm12oke independently.” On 10/13/26 at 8:30 am, Resident 6 was observed seated on a bench adjacent to the front door actively smoking while wearing a nasal canula with an oxygen concentrator. Staff 2 (Resident Services Director Traveler) and Staff 23 (Regional Operations Manager) were immediately notified. During an interview on 10/13/26 at 10:52 am, Staff 14 (CG) confirmed she was aware Resident 6 smoked with his/her oxygen in place. When asked what staff did when this was observed, she stated they advised Resident 6 to turn off and remove nasal canula while smoking and reminded Resident 6 of the dangers of smoking with oxygen on. When asked if Resident 6 complied with the request, Staff 14 stated “[he/she] does not comply” and left the oxygen in place and continued to smoke. When asked if management was aware, Staff 14 stated, “Oh yes.” The tank of concentrated oxygen and tube next to an open flame created a fire hazard. This placed residents at risk and constituted an immediate threat to residents’ health and safety. During an interview on 10/13/26 at 11:00 am with Staff 1 (ED), Staff 2, Staff 23, and Witness 5 (Consultant RN), Staff 2 acknowledged the facility was aware Resident 6 had smoked while wearing the nasal canula on previous occasions. An immediate plan of correction to address the reasonable precautions was requested from Staff 1 on 10/13/26 at 11:07 am. The plan of correction was received and accepted by the survey team on 10/13/26 at 11:40 am. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. In an interview on 10/14/26 at 12:45 pm, the need to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 1. He acknowledged the findings.

•Immediate POC was given to State on 9/21/2026 •Resident #6 had a new smoking evaluation completed by the RN on 10/13/2026. The RN reviewed the risks and benefits of smoking, offered smoking cessation resources, and provided education on oxygen safety, including safe smoking practices specific to the Inogen Rove 6 Portable Oxygen Concentrator. Resident #6 agreed to have the community manage smoking materials. Going forward, the resident will obtain smoking materials from the Med Tech and leave the oxygen concentrator and cannula outside the designated smoking area. The resident’s physician was notified, and the service plan was updated to reflect the interventions. •ED or Designee reviewed other current residents who smoke for oxygen use, no other residents who smoke use portable oxygen •ED or Designee re-educated staff on safe smoking practices for Resident #6. Training included community management of smoking materials and verification that the oxygen concentrator is completely turned off, the nasal cannula is removed, and both the concentrator and cannula remain outside the designated smoking area prior to providing smoking materials. •ED or Designee re-educated staff on the safety risks associated with smoking and oxygen use, including steps to take if established safe smoking practices are not followed. •ED or Designee will audit safe smoking practices via observation, and/or resident staff feedback daily x 4 days, then 3 x week for 2 weeks then weekly x 3 weeks then monthly x 2 months. •ED is responsible.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physical injuries of unknown cause were reported to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse for 1 of 1 sampled resident (#4) with reportable incidents. Findings include but are not limited to: Resident 4 was admitted to the facility in 04/2024 with diagnoses including occlusion and stenosis of the carotid artery with a history of falls. Resident 4’s clinical record from 03/22/26 to 06/21/26 was reviewed and the following was identified: Resident 4’s 06/13/26 evaluation indicated s/he had both short- and long-term memory deficits, was alert and oriented to person only, and had impaired communication. * On 04/27/26, a facility MT documented in an incident report that the resident had skin abrasions on both knees, on the left ankle, and there was redness to the resident’s left lower back following a fall. * On 05/28/26 a facility nurse documented in progress notes that an unwitnessed fall resulted in abrasions to the resident’s knee and a skin tear to his/her left hand. The corresponding investigations for physical injuries of unknown cause did not rule out abuse, and the injuries were not reported to the local Department office. This was confirmed by Staff 2 (Resident Services Director Traveler) on 06/26/26 at 11:26 am. The surveyor requested Staff 2 report the two injuries to the local Department office on 06/26/26, and verification was received on 06/26/26 at 2:20 pm. The need to promptly investigate all reports of suspected abuse and injuries of unknown cause and report the incidents to the local Department office if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 06/26/26 at 1:03 pm. They acknowledged the findings.

- Resident #4 no longer resides in Community. - HSD or Designee reviewed incidents over the past 30 days for proper investigation and reporting, addressing concerns identified. -Regional staff re-educated ED, RCC, HSD on the need to promptly investigate all reports of suspected abuse and injuries of unknown cause and report the incidents to the local Dept office if abuse could not be ruled out. - HSD or Designee will conduct random audits on incidents via document review or staff/resident interview for proper reporting & investigation weekly x 3 weeks then monthly x 2 months -ED is responsible.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0030 (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 meals were palatable at an acceptable temperature for residents receiving room trays. Findings include but are not limited to: During the relicensure survey, conducted 06/22/26 through 06/26/26, the lunch meal was observed each day. The posted lunch time was 12:00 pm. The lunch service began late on one occasion, and on four occasions the meal service took up to one and one half hours to serve out. Two CGs served the main dining room first and then delivered lunch to the rooms from a tray cart and a beverage cart. Observations showed the last tray was served between 1:20 pm to 1:30 pm each day. During a group interview conducted on 06/24/26 at 11:00 am, there were numerous food complaints. A test tray was requested the same day at 12:32 pm as the kitchen staff were loading the meal cart. The cart left the kitchen at 12:58 pm. Immediately after passing the last room tray, the CG delivered the test tray to the conference room at 1:30 pm. Food temperatures were taken and found to be below an acceptable temperature for palatability. Staff 1 (ED) was invited to taste the meal, and he acknowledged that the food was “lukewarm and not where it should be.” He stated it tasted good but was not hot enough. The need to ensure meals were served at a palatable temperature for residents receiving room trays was discussed with Staff 1 on 06/26/26 at approximately 11:35 am. He acknowledged the findings.

ED or Designee observed meal pass to identify improvement opportunities developing an improvement plan that includes; staffing, serve order / timing, room tray process, drink pass, and equipment needs. -Dining Committee meeting held with residents to review plan to improve food temperature, allowing for additional feedback from residents to incorporate into plan. -ED or Designee re-educated Dining Services Manager, Dining Staff and Care Staff on the requirements to serve palatable food at an acceptable temperature, training also included plan review. -ED is responsible

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 411-054-0040 (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, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition and ensure weekly progress was noted until the condition was resolved for 3 of 4 sampled residents (#s 1, 2, and 4) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 12/2023 with diagnoses including hemiplegia, type 2 diabetes mellitus, and acute pain. Resident 1’s clinical records from 03/22/26 through 06/22/26 and current service plan, dated 06/17/26, were reviewed. There was no documented evidence the facility determined what resident-specific action or intervention was needed for the resident and/or monitored the resident through resolution of the condition for effectiveness and adverse effects for the following short-term changes of condition: * Resident 1 was hospitalized from 05/17/26 through 05/22/26 related to bleeding of the stomach and intestines. There was no documented evidence staff had been provided monitoring instructions, or the resident had been monitored through resolution for any complications following hospitalization; * On 05/27/26, Resident 1 returned to the facility after a visit to the emergency department related to syncope and fainting. There was no documented evidence staff had been provided monitoring instructions for the resident upon return from the hospital or that the resident had been monitored through resolution; * On 05/28/26, Resident 1 was admitted to HH services with a diagnosis of a non-pressure chronic ulcer of the right foot and orders to provide wound care to the great right toe twice daily. There was no documented evidence staff had been provided monitoring instructions for the resident upon return from the hospital related to the wound care and signs and symptoms of complications to report; * On 06/12/26, Resident 1 returned to the facility after undergoing an angiogram procedure [to determine blood flow through blood vessels] and was diagnosed with “decreased circulation with gangrene due to blocked arteries.” The discharge instructions were to restart taking clopidogrel (a blood thinner) and “pause taking” metformin (to control blood sugar). There was no documented evidence staff had been provided monitoring instructions for the resident upon return from the hospital or that the resident had been monitored through resolution; and * On 06/17/26, Resident 1 was admitted to hospice and started on multiple new medications, including OxyContin 15 mg (for pain) orally twice daily, oxycodone 5mg every hour PRN for pain, lorazepam 0.5 mg every three hours as needed for anxiety, and haloperidol 1 mg every hour as needed for agitation or nausea. There was no documented evidence staff had been provided monitoring instructions for the resident upon return from the hospital or that the resident had been monitored through resolution. The need to ensure the facility determined what resident-specific action or intervention was needed for the resident and/or monitored the resident through resolution of the condition for effectiveness and adverse effects was discussed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 4 (Regional Director of Operations) on 06/26/26 at 9:13 am. They acknowledged the findings. Example #2: Tiffany 2. Resident 4 moved into the facility in 04/2024 with diagnoses including major depressive disorder. The resident’s 03/22/26 through 06/21/26 clinical record was reviewed. The following was identified: a. In a 03/30/26 order administration note, staff noted the resident’s groin was red, raw, bleeding, and had a sour smell. There was no documented evidence the facility determined and documented what interventions were needed for the resident, communicated the interventions to staff, and monitored the skin concern, with progress noted at least weekly, through resolution. In an interview on 06/25/26 at 12:11 pm, Staff 5 (RN) confirmed the lack of documented interventions, communication of interventions to staff, and monitoring through resolution for Resident 4’s skin concern. b. In a 04/17/26 service plan amendment, staff noted the resident had a decrease in his/her dosage of lorazepam (for anxiety) to once daily. There was no documented evidence the resident’s change in medication was monitored, with progress noted at least weekly through resolution. In an interview on 06/25/26 at 12:11 pm, Staff 5 confirmed the lack of documented monitoring through resolution for Resident 4’s medication change. c. In a 05/26/26 service plan amendment, staff noted the resident experienced an injury fall. There was no documented evidence that the fall was monitored, with progress noted at least weekly through resolution. In an interview on 06/25/26 at 12:11 pm, Staff 5 confirmed the lack of documented monitoring through resolution for Resident 4’s fall. The need to determine, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition and ensure weekly progress was noted until the condition was resolved was discussed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 6 (RCC) on 06/26/26 at 1:03 pm. They acknowledged the findings. Example #3: Tiffany 3. Resident 2 moved into the facility in 06/2026 with diagnoses including acute and chronic respiratory failure. During the acuity interview on 06/22/26 at 2:00 pm, Resident 2 was identified as someone who moved into the facility recently. The resident’s 06/01/26 to 06/21/26 clinical record was reviewed and the following was identified: There was no documented evidence of monitoring the resident’s move into the facility. On 06/25/26 at 12:11 pm, Staff 5 (RN) confirmed the resident’s move-in had not been monitored 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 (ED), Staff 2, and Staff 6 (RCC) on 06/26/26 at 12:57 pm. They acknowledged the findings.

-Regional RN of Designee conducted a comprehensive review of Resident #1 and Resident #2 record addressing concerns identified. Resident #4 no longer resides in Community. -HSD or Designee reviewed current residents for change of condition monitoring, addressing concerns identified. -Regional Staff re-educated ED, RCC, HSD on the requirement to monitor residents for change of condition and the SMART meeting process. -HSD or Designee will conduct random audits on resident records for change of condition monitoring compliance weekly x 3 weeks then monthly x 2 months. -ED is responsible

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 2 sampled residents (#1) who experienced a significant change of condition. Resident 1 experienced a significant worsening of his/her wound and uncontrolled pain. Findings include, but are not limited to: Resident 1 moved into the facility in 12/2023 with diagnoses including hemiplegia, type 2 diabetes mellitus, and acute pain. The resident was admitted to HH services on 05/28/26 for a non-pressure chronic ulcer on the right foot. S/he was subsequently admitted to hospice services on 06/18/26 with an admitting diagnosis of transient cerebral ischemic attack. A review of the resident's clinical record dated between 03/22/26 and 06/22/26 identified the following: A progress note entered on 05/24/26 by Staff 8 (Lead MT) stated, “Resident has complained and yelled of pain in [his/her] legs/foot.” A progress note entered on 05/26/26 by Staff 6 (RCC) stated, “There appears to be a small/medium red in color open area to bottom of toe and the tip is black in color and painful. When removing/applying sock [Resident] is yelling out in pain and kicking [his/her] leg…. [Resident] states… pain is unmanaged [sic] and worse hour by hour.” A HH visit note completed on 06/04/26 by a HH nurse stated, “Patient reports 7/10 pain in rt [right] toe. Toe with brown eschar [necrotic tissue] on rt [right] great toe.” A progress note entered on 06/05/26 by Staff 3 (RN) stated, “…resident is now a two person transfer with gait belt due to continued pain to the RLE [right lower extremity].” A progress note entered on 06/12/26 by Staff 3 stated, “Significant change monitoring is indicated due to recent hospitalization due to… dry-gangrene wound to right great toe….” On 06/24/26 at 9:34 am, Resident 1 was observed telling Witness 1 (HH RN), “my pain is 9/10, the procedure [the 06/12/26 angiogram, a procedure to determine blood flow through blood vessels] didn’t help.” The wound with eschar on the resident’s right great toe and uncontrollable pain constituted a significant change in condition requiring an RN assessment. During an interview on 06/24/26 at 2:21 pm with Staff 3, Staff 2 (Resident Services Director Traveler), and Staff 6, the facility provided the wound assessment for the right great toe completed by Staff 3 on 06/18/26. However, upon review of the full assessment by the surveyor, it was noted the assessment was completed for the resident’s right middle toe secondary to a skin tear, not for the right great toe with eschar. From 06/25/26 through the time survey exited the facility, Staff 3 was not present and available to interview. There was no documented evidence the facility ensured an RN assessment, which included documentation of findings, resident status, and interventions made as a result of the assessment, was completed for a resident who experienced a worsening of the wound and uncontrolled pain. The facility’s failure to take these actions placed Resident 1 and other residents at risk. An immediate plan of correction was requested from Staff 1 (ED) on 06/24/26 at 6:22 pm. The plan of correction was received and accepted by the survey team on 06/24/26 at 8:29 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure(s) associated with the licensing violation(s). The need to ensure the RN at minimum assessed all residents with a significant change of condition was reviewed with Staff 1 (ED), Staff 2, and Staff 4 (Regional Director of Operations) on 06/26/26 at 9:13 am. They acknowledged the findings.

-Immediate POC was given to state on 6/26/26 - Regional RN of Designee conducted comprehensive review of Resident #1 record, addressing concerns identified. - Regional RN or Designee reviewed current residents for significant change of condition to ensure appropriate RN assessments were completed, addressing concerns identified. - Regional Staff or Designee re-educated ED, RCC, HSD on significant change of condition, the requirement for an RN assessment and the SMART meeting process. - HSD or Designee will conduct random audits via SMART meeting, record review for Sig change of condition compliance weekly x 3 weeks then monthly x 2 months - ED is responsible.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0045(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 observation, interview, and record review, it was determined the facility failed to ensure staff were informed of new interventions, the service plan was adjusted, and service providers left written information in the facility that addressed the on-site services being provided, with any clinical information necessary for facility staff to provide supplemental care when services were provided by an outside provider, for 2 of 3 sampled residents (#s 1 and 4) whose records were reviewed. The facility failed to update the service plan and follow wound care treatment orders for Resident 1, whose wound continued to worsen. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 12/2023 with diagnoses including hemiplegia, type 2 diabetes mellitus, and acute pain. Review of clinical records, including the HH agency plan of care, the 06/17/26 service plan, progress notes from 03/22/26 through 06/22/26, and HH agency visit notes revealed the following: The resident was admitted to HH services on 05/28/26 for a non-pressure chronic ulcer on the right foot. S/he was subsequently admitted to hospice services on 06/18/26 with an admitting diagnosis of transient cerebral ischemic attack (stroke). The HH agency plan of care for the period from 05/28/26 through 07/26/26 was filed in the resident’s medical chart. The plan established weekly HH nursing visits. A progress note entered on 05/26/26 by Staff 6 (RCC) stated, “There appears to be a small/medium red in color open area to bottom of toe and the tip is black in color and painful…. [Resident] states… pain is unmanaged [sic] and worse hour by hour.” A skin wound evaluation entered on 05/26/26 by Staff 21 (LPN) stated, “dark like bruising on great toe.” The site of injury was identified as right toe. A HH visit note completed on 05/28/26 by a HH nurse stated, “Patient admitted to home health services. Wound cleansed, patted dry, painted w/ betadine, allowed to air dry. Please complete wound care twice daily.” A skin wound evaluation entered on 06/02/26 by Staff 21 stated, “response to treatment: deteriorated… communication/coordination: [HH] now seeing resident for wound care.” A HH visit note completed on 06/04/26 by a HH nurse stated, “Patient reports 7/10 [sic] pain in [right] toe. Toe with brown eschar [necrotic tissue] on rt [right] great toe.” A HH visit note completed on 06/09/26 by a HH nurse stated, “…Continue wound care twice daily.” An after-visit summary on 06/12/26 following an angiogram [to determine blood flow through blood vessels] stated Resident 1 was diagnosed with “decreased circulation with gangrene due to blocked arteries.” The summary indicated the next HH visit was scheduled for 06/15/26. A progress note entered on 06/13/26 stated Staff 3 (RN) left a voice mail for the HH agency requesting signed orders for wound care. No HH visit note for a visit on 06/15/26 was included in the resident’s medical chart or entered in the progress notes. During an interview on 06/24/26 at 9:34 am, Witness 1 (HH RN) confirmed her visit on 06/15/26 and stated, “I told their nurse [Staff 3] about [wound] care twice daily, but she said they need orders. They had orders. I asked our office to re-fax them.” The re-faxed orders were included in the resident’s medical chart. The orders were printed on 06/15/26, and the fax confirmation was dated 06/15/26. However, the faxed orders were stamped and dated 06/08/26 by Staff 3. During an interview on 06/24/26 at 2:21 pm, Staff 3 was unable to account for this discrepancy. From 06/25/26 through the time survey exited the facility, Staff 3 was not present and available to interview. The order received on 06/15/26 to provide wound care to the resident’s “right great toe” was entered into the MAR on 06/18/26 for one day; however, the order as entered in the MAR did not specify the body part to receive wound care. A review of the service plan and temporary service plans indicated no interventions were provided or communicated to staff for wound care to the resident’s right great toe. In an interview on 06/24/26 at 10:21 am, Staff 12 (MT) stated the only wound care she was aware of and provided to Resident 1 was to apply moisture barrier ointment to the groin area. A HH visit note completed during the discharge visit from HH on 06/24/26 by a HH nurse stated, “…Measurements: 4.0 x 1.8 x UTA [unable to assess]. Covered w/ eschar, dry. Continue twice daily wound care.” Witness 1 deferred further questions related to the right great toe wound to the facility. There was no documented evidence the facility took actions to communicate wound care treatment orders to staff, provide wound care treatment per physician orders, act on the worsening wound condition, and update the service plan accordingly. The facility’s failure to take these actions placed Resident 1 and other residents at risk, and the resident’s wound and related pain continued to worsen. An immediate plan of correction was requested from Staff 1 (ED) on 06/24/26 at 6:22 pm. The plan of correction was received and accepted by the survey team on 06/24/26 at 8:29 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure(s) associated with the licensing violation(s). The need to ensure the facility staff were informed of new interventions, the service plan was adjusted, and service providers left written information in the facility that addressed the on-site services being provided, with any clinical information necessary for facility staff to provide supplemental care when services were provided by an outside provider, was discussed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 4 (Regional Director of Operations) on 06/26/26 at 9:13 am. They acknowledged the findings. 2. Resident 4 moved into the facility in 04/2024 with diagnoses including occlusion and stenosis of the carotid artery. The resident was identified during the acuity interview on 06/22/26 as receiving hospice services. Review of progress notes and outside provider documentation from 03/22/26 through 06/21/26 included the following skin issues noted by the provider: * 04/29/26 – Bruise on the right and left knee and on the left side; * 05/27/26 – Pain and redness under left breast and bruise on midline of back at left side; and * 06/12/26 – Redness on fold under neck. There was no documented evidence the facility management or licensed nurse were notified of the skin issues identified by the outside providers to ensure that the service plan was adjusted, and reporting protocols were in place. This was confirmed with Staff 2 (Resident Services Director Traveler) on 06/26/26 at 11:20 am. The need to ensure staff were informed of on-site outside provider information and the service plan was adjusted, if necessary, was reviewed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 06/26/26 at 1:03 pm. They acknowledged the findings.

-Immediate POC was given to state on 6/26/26 -Regional RN or Designee conducted comprehensive review of Resident #1 record, addressing concerns identified. Resident #4 no longer resides in Community. -HSD or Designee reviewed Home Health and Hospice documentation for current residents ensuring any information, new interventions, and/or service plan updates are current, addressing concerns identified. -Region team member or Designee re-educated the MT, RCC, HSD, and ED on the requirements for coordinating care with outside service providers. Education included ensuring facility staff are informed of all outside provider services and new interventions, updating the resident's service plan to reflect those services and interventions, and verifying that outside providers leave written documentation in the community describing the services provided, along with any clinical information necessary for facility staff to safely provide supplemental care and ensure continuity of care. -HSD or Designee will conduct random audits via documentation review and/or communication with outside providers for compliance weekly x 3 weeks then monthly x 2 months -ED is responsible

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 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents whose medications were administered by the facility were put at risk related to the failure of the facility to ensure all staff who passed medication had been observed and evaluated by the facility to perform safe medication and treatment administration unsupervised. Findings include, but are not limited to: 1. During the relicensure survey, conducted 06/22/26 through 06/26/26, review of the planned and posted staffing schedule from 06/07/26 to 06/22/26 revealed the following: * Staff 7 (Life Enrichment Director), a non-direct care staff member, was scheduled to work as an MT, administering medication to residents on seven occasions between 06/11/26 through 06/22/26. In an interview on 06/25/26 at 12:00 pm, Staff 1 (ED) confirmed the facility had no documented evidence Staff 7 had been observed and evaluated by appropriate facility staff to perform safe medication and treatment administration unsupervised. On 06/25/26 at 2:30 pm, Staff 7 confirmed she had administered medication and treatments to residents without being observed and evaluated to perform safe medication and treatment administration unsupervised. * Staff 1, a non-direct care staff member, administered medication and treatments to residents on 06/13/26. There was no documented evidence Staff 1 had been observed and evaluated by appropriate facility staff to perform safe medication and treatment administration unsupervised. In an interview on 06/25/26 at 12:47 pm, he confirmed he completed competency training for medication administration on 06/24/26, during the relicensure survey. The facility failed to ensure all staff members who administered medications were observed and evaluated to perform safe medication and treatment administration unsupervised with written documentation maintained. This placed all residents who received medications administered by the facility at risk for potential harm. An immediate plan of correction to address a safe medication and treatment system related to training staff who administered medications was requested from Staff 1 on 06/25/26 at 3:31 pm. The plan of correction was received and accepted by the survey team on 06/25/26 at 6:38 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violations. 2. Administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas: * C303: Systems: Medication and Treatment Orders; * C310: Systems: Accurate Medication Administration Record; * C303: Systems: Psychotropic Medications; and * C372: Training within 30 days: Direct Care Staff. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1, Staff 2 (Resident Services Director Traveler), and Staff 6 (RCC) on 06/26/26 at 1:04 pm. They acknowledged the findings.

-Immediate POC was given to state on 6/26/26 - Staff 1 has been observed & evaluated by appropriate facility staff for medication administration. Staff 7 will no longer be administering medications. - HSD or Designee has reviewed current medication administration staff records for documentation, addressing concerns identified. - Regional staff have re-educated HSD, ED, RCC on the requirement that all staff who pass medication must have documented evidence that they have been observed and evaluated by appropriate facility staff to perform safe medication and treatment administration unsupervised. - HSD or Designee will conduct random audits on medication administration staff records for compliance weekly x 3 weeks then monthly x 2 months. - ED is responsible

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. 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 interview and record review, it was?determined?the facility?failed to?ensure medication and treatment orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 2, and 3) whose prescriber orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 06/2026 with diagnoses including acute and chronic respiratory failure. Review of Resident 2's clinical record from 06/01/26 to 06/22/26 revealed the following: a. The resident had physician orders to receive the following PRN medications with a start date of 06/02/26: * Guaifenesin – give ten mL by mouth every four hours as needed for cough for ten days. The end date was documented as 06/12/26; * Hydroxyzine – give one 25 mg tablet by mouth every eight hours as needed for anxiety for 14 days. The end date was documented as 06/16/26; and * Meclizine – one 25 mg tablet by mouth every eight hours as needed for dizziness for 14 days. The end date was documented 06/16/26. After the respective prescribed end dates, the resident received one dose of guaifenesin, six doses of hydroxyzine, and one dose of meclizine. On 06/23/26 at 10:57 am, Staff 2 (Resident Services Director Traveler) acknowledged the facility did not have prescriber orders to continue the medications past their original end dates. b. The resident had a physician’s order to receive one 120 mg capsule of diltiazem one time a day for hypertension, with parameters to hold for systolic blood pressure below 100 or heart rate below 50. The resident received the medication daily from 06/12/26 through 06/20/26 with no corresponding documentation of the resident’s blood pressure or heart rate to determine whether the medication should be administered or held per physician’s order. The lack of documented vitals was confirmed by Staff 3 (RN) on 06/23/26 at 12:15 pm. c. The resident had a physician’s order to receive one liter per minute of oxygen delivered via cannula to keep saturation levels greater than 90%. Staff were ordered to monitor oxygen saturation levels and liters per minute each shift. There was no documented monitoring of the resident’s oxygen saturation levels or liters per minute in 17 of 18 shifts between 06/11/26 and 06/17/26. The lack of documented vitals was confirmed by Staff 3 on 06/23/26 at 12:15 pm. The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 06/26/26 at 12:57 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 02/2026 with diagnoses including pain and chronic kidney disease. Review of Resident 3’s clinical record from 05/01/26 to 06/22/26 revealed the following orders were not carried out as prescribed: * The resident had a physician order dated 04/27/26 to receive Buprenorphine 10MCG/HR patch topically, apply one patch onto the skin once weekly for pain. The medication was documented as “med not received” and not administered on five occasions between 05/11/26 and 06/15/26. * Trospium Chloride 20 mg tab one tablet by mouth twice daily in the morning and the evening on an empty stomach 30 minutes before or after a meal, for chronic kidney disease. The medication was documented as “med not received” and not administered on 40 occasions between 06/01/26 and 06/22/26. * Fluticasone OTC 50MCG nasal spray for seasonal allergies. The medication was documented as “med not received” and not administered on 18 occasions between 06/01/26 and 06/22/26. On 06/26/26 at 10:00 am, Resident 3 confirmed she had not been receiving these medications. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 6 (RCC) on 06/26/26 at 1:04 pm. They acknowledged the findings. 3. Resident 1 moved into the facility in 12/2023 with diagnoses including hemiplegia, type 2 diabetes mellitus, and acute pain. Resident 1's HH physician orders, hospice legally authorized prescriber orders, and MARs from 06/01/26 through 06/22/26 were reviewed. Interviews with facility staff and the outside providers were conducted. The following was identified: a. The HH physician orders last updated and signed on 06/05/26 contained the following orders: “Right great toe: twice daily: cleanse with wound cleanser and woven gauze/soap and water, pat dry, paint with betadine, allow to air dry… SN [skilled nurse] to manage wound care 1 x weekly. Patient/caregiver to manage wound care between nurse visits.” There was no documented evidence wound care was provided as ordered. In an interview on 06/24/26 at 10:21 am, Staff 12 (MT) stated the only wound care she was aware of and provided to Resident 1 was to apply moisture barrier ointment to the groin area. b. The hospice legally authorized prescriber orders, dated 06/17/26, contained the following orders: * “Doxylamine succinate 25mg (for sleep) one tablet orally at bedtime”; * “Insulin glargine 100 unit/ml subcutaneous pen (to control blood glucose) 30 units daily”; * “Check CBG prior to meals and administer insulin with meals”; and * “Cleanse wound to right big and middle toe each visit. Clean and irrigate with soap and water using clean technique, cover with dressing. Facility staff will perform wound care according to coordinated plan of care.” There was no documented evidence the order for doxylamine succinate and instructions to administer insulin with meals were transcribed to the resident’s MAR and therefore were not followed. A new order to increase the insulin dose from 20 units to 30 units was given on 06/17/26. There was no documented evidence the 30-unit insulin dose was administered starting 06/17/26, or that the wound care was performed as ordered. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 4 (Regional Director of Operations) on 06/26/26 at 9:13 am. They acknowledged the findings. ?

- Regional RN or Designee reviewed orders for Resident 1, 2, and 3, addressing concerns identified. - HSD or Designee reviewed current resident orders for accuracy, parameters & set up of parameters as well as the meds not available report for the last 7 days, addressing concerns identified. - Regional Staff or designee re-educated MTs, RCC, HSD, ED on the requirement to ensure medication and treatment orders are carried out as prescribed by physician order or other legally recognized practitioner. - Training included must have prescriber orders for all medications, order with parameters must be documented on, steps to take if medication is not available, and 3 folder system. - Regional Staff re-educated ED, RCC, HSD on SMART meeting and medication not available report. HDS or Designee will conduct random audits on medication administration for compliance weekly x 3 weeks then monthly x 2 months. - ED is responsible.

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 (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 residents' MARs included reasons for use, resident-specific parameters, and instructions for PRN medications for 3 of 4 sampled residents (#s 1, 3, and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 12/2023 with diagnoses including hemiplegia, type 2 diabetes mellitus, and acute pain. Resident 1's 06/01/26 through 06/22/26 MAR and physician orders were reviewed and revealed the following: a. The following PRN medications lacked instructions for sequential order of use: * Tylenol 325mg (for mild pain); * Diclofenac sodium 1% gel (for pain); and * Oxycodone 5mg (for pain or shortness of breath). b. The following PRN medications lacked resident-specific parameters for use: * Amlodipine 5mg (for blood pressure); * Losartan 100mg (for blood pressure); * Lantus (to control blood glucose); * Haloperidol 1mg (for agitation); and * Lorazepam 0.5mg (for anxiety). c. The following medications lacked documented reasons for use: * Amlodipine 5mg (for blood pressure); * Oxycontin 15mg (for pain); and * Baclofen 5mg (for muscle spasms). The need to ensure MARs were accurate and provided reasons for use, resident-specific parameters, and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 4 (Regional Director of Operations) on 06/26/26 at 9:13 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 02/2026 with diagnoses including pain and chronic kidney disease. Review of Resident 3’s clinical record from 06/01/26 to 06/22/26 revealed the following: The following medications lacked an indication for use on the MAR: * Buprenorphine 10MCG/HR Patch (for pain); * Cefpodoxime 200mg (for UTI); * Cephalexin 250mg (for UTI); * Hydroxyzine Pamoate 25mg (anxiety); * Senna 8.6mg (constipation); and * Thermotabs Oral (minerals/electrolytes). The need to ensure MARs were accurate and included reasons for use was discussed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 6 (Resident Care Coordinator) on 06/26/26 at 1:04 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 04/2024 with diagnoses including occlusion and stenosis of the carotid artery. Resident 4’s 06/01/26 through 06/21/26 MAR and prescriber orders were reviewed. The following was identified: The resident had the following two prescriber orders for calmoseptine ointment: * Topically apply a thin layer to affected area continuously every day for erythema (redness of the skin or mucus membranes); and * Topically apply to coccyx every day for pressure injury care/skin breakdown prevention. On 06/25/26 at 1:26 pm, Staff 12 (MT) reported she administered both treatments to the resident’s coccyx but noted there were no additional instructions in the eMAR. When asked about what is meant by “continuously” she stated, “Continue to do it. I guess I don’t know what it means.” The MAR failed to include the dosage for the calmoseptine ointment and specific instructions related to location of application. The need to ensure MARs were accurate and included the dosage and specific instructions for all medications was reviewed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 6 (RCC) on 06/26/26 at 1:03 pm. They acknowledged the findings.

- Regional RN did comprehensive review of Resident #1 and Resident #3 Medications. Resident #4 no longer resides in Community. - HSD or Designee reviewed current resident PRN orders for reasons for use and resident specific parameters for use, addressing concerns identified. - Regional Staff or Designee re-educated MTs, RCC, HSD on requirement to ensure MARS are accurate & provide reasons for use, include dosage, resident specific parameters and instructions for PRN medications. Training also reviewed steps to take if these components are missing or an order is not clear. - HSD or Designee will conduct random audits on PRN medications for compliance weekly x 3 weeks then monthly x 2 months. - ED is responsible.

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

OAR 411-054-0055 (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 documentation that non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medication for 1 of 1 sampled resident (#2) whose record was reviewed for PRN psychotropic medications. Findings include, but are not limited to: Resident 2 moved into the facility in 06/2026 with diagnoses including acute and chronic respiratory failure. The resident’s signed prescriber orders and 06/01/26 to 06/21/26 MAR and progress notes were reviewed, and the following was identified: The resident had orders to receive 25 mg of hydroxyzine by mouth every eight hours as needed for anxiety for 14 days. Resident 2 received the PRN hydroxyzine from an unlicensed staff member eleven times between 06/12/26 and 06/22/26. On 06/23/26 at 12:15 pm, Staff 3 (RN) confirmed there was no documentation of non-pharmacological interventions being tried with ineffective results prior to the administration of the PRN psychotropic medication in seven of the eleven administrations. The need to ensure PRN psychotropic medications were administered after documented non-pharmacological interventions were tried with ineffective results was discussed with Staff 1 (ED), Staff 2 (Resident Services Director Traveler), and Staff 6 (RCC) on 06/26/26 at 12:57 pm. They acknowledged the findings.

- Regional RN or Designee reviewed Resident #2 PRN psychotropic medications for non-pharmacological interventions, addressing concerns identified. - HSD or Designee reviewed current residents receiving PRN Psychotropic medications for non-pharmacological interventions, addressing concerns identified. - Regional Staff or Designee Re-educated HSD, RCC, MTs on the requirement that non-pharmacological interventions are tried with ineffective results prior to administering PRN psychotropic medications. - HSD or Designee will conduct random audits on PRN psychotropic medications for compliance weekly x 3 weeks then monthly x 2 months - ED is responsible.

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 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents were informed of the risks and benefits associated with any device with potential restraining qualities, less restrictive alternatives were evaluated prior to the use of the device, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident’s service plan for 1 of 1 sampled resident (# 4) who used bilateral side rails. Findings include, but are not limited to: Resident 4 moved into the facility in 04/2024 with diagnoses including occlusion and stenosis of the carotid artery. During the acuity interview on 06/22/26, Resident 4 was identified as using side rails. Observations of the resident’s room throughout the survey identified bilateral half side rails in the up position. In an interview on 06/24/26 at 11:04 am, Staff 13 (CG) reported the resident used the rails to assist with turning during ADLs. Resident 4’s 06/16/26 service plan did not include the resident’s bilateral side rails. On 06/25/26 at 1:26 pm, Staff 12 (MT) stated she did not know how the facility instructed her on the use and precautions of side rails. The resident’s 03/31/26 “Supportive Device Safety Evaluation and Consent” document was reviewed. There was no documented evidence the resident was informed of the risks and benefits associated with the device, and no evidence less restrictive alternatives were evaluated prior to the use of the device. In an interview with Staff 2 (Resident Services Director Traveler) on 06/26/26 at 12:07 pm, she acknowledged the facility’s evaluation form did not include the required components, and the expectation was for the evaluator to document the components as a narrative. The need to ensure residents were informed of the risks and benefits associated with any device with potential restraining qualities, lesser restrictive alternatives were evaluated prior to the use of the device, the facility had instructed caregivers on the correct use and precautions related to use of the device, and documentation of the use of the device was included in the residents’ service plan was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 06/26/26 at 1:03 pm. They acknowledged the findings.

- Resident #4 no longer resides in Community. - HSD or Designee identified residents with any device with potential restraining qualities and reviewed for appropriate documentation, addressing concerns identified. - Regional Staff of Designee re-educated ED, HSD, RCC on requirement to ensure residents are informed of risks and benefits associated with any device with potential restraining qualities, lesser restrictive alternatives were evaluated prior to the use of the device, the facility had instructed caregivers on the correct use and precautions related to the use of the device, and documentation of the use of the device was included in the residents service plan. - HSD or Designee will conduct random audits via documentation review, interviews or observation of devices with potential restraining qualities for compliance weekly x 3 weeks then monthly x 2 months. - ED is responsible.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 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 observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and ensure ancillary staff including licensed nurses and administrators were not used to meet the minimum caregiver staffing requirements. Findings include, but are not limited to: During the acuity interview on 06/22/26, the following was identified: * The facility was home to 40 residents; * Four residents required two-person transfer assist with a mechanical lift, with two requiring two-person assist with all cares; * One resident required cueing, set-up, and feeding assistance requiring 30-40 minutes per meal(?); * Three residents were identified as a fall risk; and * Two residents were identified as having behaviors. The staffing plan provided by the facility as of 06/25/26 was as follows: * Day shift: 5:45 am to 2:00 pm - two MTs, two CGs; * Swing shift: 1:45 pm to 10:00 pm - two MTs, two CGs; and * Night shift: 9:45 pm to 6:00 am - one MT, one CG. a. Observations during the survey from 06/22/26 through 06/26/26 showed: * There were no planned structured activities on 06/22/26, and the Life Enrichment Director was working as an MT; and * Meals were served up to 1.5 hours after the posted lunch service time. b. During resident, family, and staff interviews conducted 06/22/26 through 06/26/26, the following was revealed: * Witness 4 (Family Member) noted the facility staff did not treat the call button like an emergency. He reported waiting for up to two hours, and he often went and found people to help; * Resident 2 noted s/he had pressed the call button, and staff didn’t respond for one and one half hours; * Resident 3 noted it took minutes to hours before someone came to help. The call pendant wasn’t working right, and the batteries needed changed every couple of days; and * In an interview on 06/24/26 at 9:40 am, Staff 7 (Life Enrichment Director) confirmed there were significant delays in answering call lights on all shifts. She reported call lights were “a problem,” and that staff couldn’t respond fast enough. c. During a resident group interview conducted on 06/24/26 at 11:00 am, the following concerns were reported: * Delays answering call lights on all shifts; * Delays in medication administration, especially on weekends; * Delays with meal service, especially room tray delivery resulting in cold food. * Staff turnover in the kitchen which resulted in direct and non-direct care staff cooking meals; and * The facility brought in “takeout” often and the group believed it was because of staffing shortages. d. On 06/24/26 at approximately 9:00 am, a call light report was requested. Review of the call light report from 06/06/26 through 06/22/26 confirmed wait times that exceeded 20 minutes over 13 percent of the time with 23 calls exceeding an hour. e. Review of the planned and posted staff schedule dated from 06/07/26 to 06/23/26 revealed the following: * Staff 1 (ED) and Staff 3 (RN) worked as day shift MTs on 06/13/26; * Staff 7 had been scheduled to work as a MT on six occasions during the swing shift, one occasion during the day shift and one occasion as a CG during the day shift; and * From 06/17/26 through 06/23/26 over 28.5% of 21 of direct care shifts were covered by ancillary staff. The need to ensure the facility had qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and ensure ancillary staff, including licensed nurses and administrators, were not used to meet the minimum caregiver staffing requirements, was discussed with Staff 1 on 06/26/26 at 11:25 am. He acknowledged the findings.

- Regional staff or Designee reviewed staffing with ED and developed plan for coverage not including ancillary staff; review looked at trends by day and by shift, call light report last 7 days, meals, attendance, prn staff, recruitment, wages in market and all coverage options outside ancillary staff when a need arises. - ED or Designee will review staffing in daily stand up meeting M-F so identified needs can be addressed. - Regional Director of Operations or Designee re-educated ED and RCC on the requirement to ensure the facility had qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and ensure ancillary staff, including licensed nurses and administrators, were not used to meet the minimum caregiver staffing requirements. -ED or Designee will audit staffing through documentation review and/or resident interview weekly x 3 weeks then monthly x 2 months. - ED is responsible

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 411-054-0070 (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 5 of 5 newly hired direct care staff (#s 11, 12, 17, 18, and 20) had completed pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (ED) on 06/24/26 at 11:38 am. There was no documented evidence Staff 11 (MT), hired 01/06/26; Staff 12 (MT), hired 04/06/26; Staff 17 (CG), hired 03/13/26; Staff 18 (CG), hired 02/02/26; and Staff 20 (Cook), hired 04/13/26, had completed pre-service orientation training prior to beginning their job responsibilities in one or more of the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Food handler’s certificate; * Infectious disease prevention; * Home and community-based services training; * Department approved LGBTQIA2S+ training; * Dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating, and responding to behaviors, and reducing the use of antipsychotic medications; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Specific aspects of dementia care and ensuring the safety of residents with dementia, addressing pain, providing food and fluids, preventing wandering and elopement, and use of a person-centered approach. The need to ensure newly hired staff had completed pre-service orientation training prior to beginning their job responsibilities was discussed with Staff 1, Staff 2 (Resident Services Director Traveler), and Staff 6 (RCC) on 06/26/26 at 12:49 pm. They acknowledged the findings, and no additional documentation was provided.

- Direct Care Staff #11, #12, #17, #18, & #20 completed pre-service orientation training. - ED or Designee audited pre-service training for compliance for direct care staff, addressing concerns identified. -Employee training tracker has been established that will be reviewed for required training documetation prior to staff starting on the floor - Regional Staff or Designee re-educated ED and RCC on the requirement to ensure newly hired staff complete pre-service orientation training prior to beginning their job, training included review of employee training tracker now in place. - ED or Designee will audit newly hired staff for pre-service compliance weekly x3 weeks then monthly x2 weeks. - ED is responsible.

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 direct care staff (#s 11, 12, 17, and 18) had demonstrated competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (ED) on 06/24/26 at 11:38 am. There was no documented evidence Staff 11 (MT), hired 01/06/26; Staff 12 (MT), hired 04/06/26; Staff 17 (CG), hired 03/13/26; and Staff 18 (CG), hired 02/02/26, had demonstrated competency within 30 days of hire in one or more of the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving, and sanitation; * Other duties as applicable (med pass, treatments); and * First Aid and abdominal thrust. On 06/24/26 at 11:38 am, Staff 1 acknowledged abdominal thrust training was provided to facility staff on 06/23/26, during the relicensure survey. The need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1, Staff 2 (Resident Services Director Traveler), and Staff 6 (RCC) on 06/26/26 at 12:49 pm. They acknowledged the findings, and no additional documentation was provided.

-Direct Care Staff #11, #12, #17 & #18 completed training required w/in 30 days of hire, including demonstrated competency. -ED or Designee audited w/in 30 days of hire training for compliance for direct care staff, addressing concerns identified. -Regional Staff or Designee re-educated ED and RCC on the requirement to ensure direct care staff have demonstrated competency in all assigned duties w/in 30 days of hire. -ED or Designee will audit newly hired staff for training w/in 30 days of hire compliance weekly x3 weeks then monthly x2 weeks. -ED is responsible.

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 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: During a tour of the facility 06/22/26 at 2:05 pm, the following was identified: a. Common areas in ALF portion of the facility: * Carpet in all common areas throughout the building was dirty, damaged, covered with stains and hard water deposits, and in need of cleaning and/or repair; * Doors and door frames to resident rooms throughout the facility were worn, damaged with exposed wood, and had black streaks and scratches; and * Fish tank in the lobby area had murky water and a thick coating of algae. b. Building exterior: * Paint was peeling and chipped on the beams under the roof apexes throughout the exterior of the building; and * Soffit under the roof was warped and damaged in various places. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 22 (Maintenance Director) on 06/23/26 at 3:14 pm. They acknowledged the findings.

- Carpet in common areas have been cleaned, doors and door framed to resident rooms have been repaired and/or touched up with paint, fish tank in lobby area was cleaned, paint on beams under roof apexes has been touched up, and soffit under roof was re-attached and/or repaired. - Maintenance Director or Designee walked property for cleanliness and good repair, addressing items identified. - ED or Designee re-educated the Maintenance Director on the requirement to keep the building clean and in good repair. - Maintenance Director of Designee will conduct random audits on environment weekly x 3 weeks then monthly x 2 months. - ED is Responsible

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. 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:

Refer to C370

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: