OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 11/2018 with diagnoses including acute chronic diastolic (congestive) heart failure, unspecified atrial fibrillation, and unspecified delusional disorders. The resident’s clinical record, including the 02/10/26 service plan, was reviewed, interviews with staff and the resident were conducted, and observations were made. The service plan was not reflective of the resident’s current care needs and lacked clear direction regarding the delivery of services in the following areas: * Oral/dental status; * Instructions to staff related to behaviors and delusions; and * Resident 3 was independent with managing laundry. An interview and observation with Resident 3 on 04/06/26 at 1:00 pm confirmed he/she had no teeth present. In an interview with Staff 17 on 04/07/26 at 11:40 am, he stated Resident 3 was “particular” about doing his/her own laundry and would stay within visual sight of the laundry room when items were being laundered. An interview with Resident 3 on 04/08/26 at 1:43 pm confirmed s/he did prefer to manage their own laundry. An interview with Staff 6 (MT/Resident Assistant) on 04/07/26 at 9:47 am confirmed Resident 3 had been heard screaming at people in his/her apartment who were not there. In an interview with Staff 7 (Resident Assistant) on 04/08/26 at 11:21 am, she stated Resident 3 was often heard yelling, “Get out!” in the apartment when no one else was present. Staff 7 confirmed she had reviewed the service plan and no information and/or instructions to staff related to the behaviors exhibited by Resident 3 were available in the service plan. The need to ensure service plans were reflective of residents’ needs and preferences and provided clear direction regarding the delivery of services was reviewed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), Staff 3 (Community RN), and Staff 4 (Interim Administrator) at 10:28 am on 04/09/26. They acknowledged the findings. 2. Resident 1 moved into the facility in 02/2026 with diagnoses including atrial fibrillation, right below knee amputation, pacemaker, and stroke. Observations were made of the resident's care on 04/07/26 and 04/08/26, interviews with the resident and facility staff were conducted, and the service plan, dated 04/03/26, and the resident’s MARs from March 1st through April 6th/2026 were reviewed. Resident 1's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions for bleeding precautions and interventions while on anticoagulation therapy; * Incorrect reference to resident not requiring assistance with dressing/undressing and using mechanical lift for toileting; * Incorrect reference to resident being continent with bowel and bladder; * Incorrect reference to resident requiring assistance with meals; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; and * Pacemaker precautions, instructions for proper maintenance, and how to monitor malfunctions. During an interview on 04/07/26 at 2:51 pm, Staff 8 (Resident Assistant) stated the resident always required a two-person assist with toileting and “the last few days two persons assist with everything [ADLs] due to behaviors.” Observations of personal care on 04/07/26 and 04/08/26 confirmed Resident 1 required two people with bed mobility, repositioning, dressing/undressing, and assistance with incontinence care. Staff 7 (Resident Assistant) was interviewed on 04/08/26 at 10:12 am and stated Resident 1 “always wants help even when can do it [him/herself]. On 04/07/26 at 10:59 am Resident 1 was observed transferring independently from bed to wheelchair by using a sliding board. Review of the MARs confirmed the resident was taking duloxetine (for depression) daily and Eliquis (for heart health). The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), and Staff 3 (Community RN) on 04/09/26 at 11:03 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 06/2022 with diagnoses including heart failure. The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The 04/03/26 service plan was not reflective of the resident’s current care needs and/or lacked clear instructions in the following areas: * Assistance with transfers, including how many staff needed depending on location; * Ability to ambulate; * Assistance with wheelchair mobility, dressing, and toileting; * Skin integrity, including history of pressure sores and how to promote healing; * Fall history and interventions, including what staff should do if the resident was intoxicated; and * Outside providers, including home health nursing. Observations and interviews with the resident and staff on 04/06/26 through 04/08/26 indicated the resident was no longer ambulatory, needed one to two staff for transfer assistance in and out of the recliner or bed, and was currently seen by HH nursing for pressure sores on both buttocks since 01/2026. The need to ensure service plans were reflective of resident needs and provided clear instruction to staff was discussed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), and Staff 3 (Community RN) on 04/09/26 at 11:35 am. They acknowledged the findings.

Regional Director Health Services(RDHS) will provide inservice for Resident Care Coordinator (RCC) and Assistant Health Services Director (AHSD) on performing resident evaluations, service plans in a timely manner (prior to move-in, within first 30 days, at least every 90 days and with change of condition)by 5/8/26 RDHS will provide RCCs and AHSD inservice on evaluations and service plans including service plan requirements and the expectation that service plans reflect current, individualized resident needs and provide clear instructions for staff on care needs and services for residents by 5/8/26. AHSD will perform evaluations and update the service plans to reflect resident's needs and provide clear instructions for staff on resident care needs and services for Residents 1, 2, and 3 by 06/08/26 The RDHS will conduct an audit of all current residents' service plans to identify missing information.The AHSD and RCCs will update current resident service plans identified by the RDHS to reflect residents current care and service needs by 06/08/26 Service plans will be reviewed and updated quarterly for all residents, and immediately following any significant change of condition. The community nurse will conduct a monthly audit of a minimum of 25% of resident service plans to verify accuracy between quarterly review cycles. Findings will be reported to the Executive Director/Administrator monthly. The RCCs are responsible for the completion and accuracy of service plans. The community nurse is responsible for clinical accuracy and oversight. The Executive Director/Administrator is responsible for monitoring the monthly audit results and ensuring sustained compliance

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure that actions or interventions were determined and documented for short-term changes of condition, failed to communicate the determined actions or interventions to staff on all shifts, failed to monitor each resident consistent with his/her evaluated needs and service plan, and failed to document progress, at least weekly, through resolution for 1 of 3 sampled residents (#2) who experienced pressure sores and multiple falls. Resident 2 had buttock wounds that worsened, caused unnecessary discomfort, and resulted in an emergency department (ED) visit. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 06/2022 with diagnoses including heart failure. During the acuity interview on 04/06/26 at 9:30 am, Resident 2 was identified as having a pressure ulcer, needing more ADL assistance, and receiving home health nursing and PT services. A review of Resident 2’s clinical record, from 01/06/26 through 04/06/26, revealed the following: a. The resident’s 04/03/26 service plan indicated the resident was a “moderate skin risk,” and staff were to report changes in skin integrity and notify “RCC/Nurse if … there is skin breakdown.” * Observations and interviews with Resident 2 and staff, from 04/06/26 through 04/08/26, revealed the resident preferred to sit in his/her recliner during the day with a pressure relief cushion in place, ate all meals in his/her room, used a wheelchair for all mobility, required one- to two-person assistance with transfers to and from the recliner and bed, required intermittent assistance with toileting, experienced intermittent bowel and bladder incontinence, and needed wheelchair escorts to and from the bathroom. * An observation note dated 01/12/26 identified redness to Resident 2’s groin and coccyx area and notified the Health and Wellness Director. There was no documented evidence interventions were determined and communicated to staff on all shifts to prevent further skin breakdown for the redness on the coccyx. * An observation note written by Staff 3 (Community RN), dated 01/16/26, four days after the coccyx redness was identified, documented direct care staff reported the resident had “bleeding on [his/her] coccyx.” Staff 3 recommended a shower to clean the area and requested “HH Wound Care … to assist with skin care needs and skin breakdown.” During an interview on 04/08/26 at 1:10 pm, Staff 3 acknowledged she did not complete additional documentation on the status of the wound that included measurements, appearance, odor, or drainage, and the service plan was not updated with actions or interventions and communicated to staff to prevent the wound from worsening. The HH nursing evaluation occurred on 01/24/26, eight days after the bleeding was identified. * An observation note on 01/26/26 from a MT documented the resident was “still experiencing open wounds in the buttocks area,” noted the resident would “benefit from a doughnut pillow to sit on,” and the wound area was “painful and sore” as the resident only “sits at this time.” There was no documented evidence a cushion was addressed by HH PT until 02/19/26, 24 days later. * Thirteen days after the wounds were noted as bleeding, on 01/29/26, a home health RN note indicated Resident 2 had “stage 2 pressure ulcers” on both buttocks and provided a brief description of the wound beds. * Subsequent HH RN notes from 02/10/26 and 02/13/26 noted the “wounds are not healing” and were “tender during cleaning.” * On 02/21/26 the HH RN documented there was “slight improvement noted” to the wounds but no measurements were provided. * Fourteen days after the last updated status of the resident’s wounds, an observation note dated 03/07/26 revealed, “Resident was sent out” and was seen in the ED for “buttock Sacral pressure ulcer.” Discharge physician orders from 03/07/26 included “ambulate and out of bed during daytime hours, no sleeping in recliner, rotate every 2 [hours] in bed, use specialized pillows to reduce pressure.” A temporary service plan (TSP) was created on 03/08/26 with the physician’s instructions. * Observation notes on 03/10/26 noted “extreme pain” and resident “crying out during toileting,” and on 03/12/26 the resident had complained the wounds were “very painful.” * On 03/15/26 a wound care note from a HH nurse indicated the left buttock wound was improving and “right buttock wounds are not healing.” * Eleven days after the last documented evidence of the status of the wounds on 03/20/26, a 03/31/26 HH nurse noted “scant” bleeding, “photos taken, not measurements,” and no additional information on the status of the wounds was documented. Resident 2 was noted to have redness on his/her coccyx which worsened and became stage 2 pressure ulcers on both buttocks, experienced unnecessary discomfort, and required an ED visit. Prior to the wounds worsening and the ED visit, the facility failed to determine and document what actions or interventions were needed to prevent further skin breakdown and communicate actions or interventions to staff on each shift. The facility also failed to consistently monitor the progress of each wound at least weekly. During an interview on 04/08/26 at 11:40 am, Staff 3 indicated the process for skin monitoring was to document progress weekly on skin check forms. She acknowledged the only skin check form she could find for Resident 2’s wounds was dated 03/10/26, and she had completed another one on 04/07/26. They were provided to the surveyor. * Review of the 03/10/26 skin check form revealed measurements were from the home health visit on 02/17/26, 21 days prior. The measurements were for the left coccyx wound and did not include any information regarding the right buttock wounds. During an interview on 04/09/26 at 10:05 am, Witness 1 (RN Home Health) indicated HH had been treating the resident’s wounds since 01/24/26 and were identified as stage 2 upon evaluation. The resident has been treated for one wound on the left buttock and three small wounds on the right buttock. Following the wound care on 04/09/26, Witness 1 stated, “The wounds on the right buttock look the best they have ever been” and were healing. With the resident’s permission, a surveyor observed the wounds on 04/09/26 and confirmed the wound on the left buttock had closed, and one wound remained open on the right buttock. The need to ensure that actions or interventions were determined and documented for changes of condition, actions or interventions were communicated to staff on all shifts, and changes were monitored consistent with the resident’s evaluated needs through resolution, with progress documented at least weekly, was reviewed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), and Staff 3 at 3:03 pm on 04/07/26. They acknowledged the findings. b. Fall interventions identified on Resident 2’s 04/03/26 service plan indicated s/he was a moderate fall risk. The service plan instructed staff to provide shift safety checks, to use the resident’s walker when ambulating, to use his/her wheelchair safely, to complete safety rounding, to encourage the resident to wear supportive footwear, and to keep personal possessions and the call light within the resident’s reach. Observations of Resident 2 during the survey revealed s/he received wheelchair escorts to and from the bathroom and, when in the community, staff provided assistance with transfers and incontinence management, ensured s/he wore supportive footwear, and completed safety checks every 30 to 60 minutes. A walker and power wheelchair were in the resident’s apartment but s/he was no longer ambulatory and did not use the power wheelchair. Review of Resident 2’s 01/06/26 through 04/06/26 clinical record revealed the following: * On 01/04/26 Resident 2 had two non-injury falls in his/her living room. There was no documented evidence that fall interventions were identified and communicated to staff on all shifts or that interventions were implemented and monitored for effectiveness. * On 01/09/26 Resident 2 had a non-injury fall after self-transferring to his/her recliner. Interventions identified from the incident report included, “Staff to provide verbal cueing as needed, ensure resident has proper fitting footwear reminder, maintain clear pathways/remove clutter, keep assistive device in site [sic], and increase observation of resident during waking hours.” There was no documented evidence the facility communicated the new interventions to staff on all shifts, the interventions were implemented, or that staff monitored the interventions for effectiveness. * On 01/11/26 Resident 2 attempted to self-transfer and had a non-injury fall. There was no documented evidence new interventions were determined and communicated to staff on all shifts or that prior interventions were reviewed for effectiveness. * On 01/13/26 Resident 2 attempted to self-transfer and had a non-injury fall. There was no documented evidence new interventions were determined and communicated to staff on all shifts or that prior interventions were reviewed for effectiveness. There was no documented evidence the facility consistently determined and communicated fall interventions to staff on all shifts and monitored the interventions for implementation and effectiveness, consistent with the resident’s evaluated needs and service plan. On 04/08/26 at 1:10 pm, Staff 3 (Community RN) confirmed the interventions determined for the 01/09/26 fall were not communicated to staff on all shifts and monitored for implementation and effectiveness. She also acknowledged there was no documented evidence that new interventions were determined, communicated to staff on all shifts, or prior interventions were reviewed for effectiveness for the falls on 01/11/26 and 01/13/26. The need to ensure the facility identified and communicated interventions to staff on all shifts and to ensure residents were monitored consistent with their evaluated needs and service plan was discussed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), and Staff 3 at 11:35 am on 04/08/26. They acknowledged the findings.

RDHS performed inservice training for Community Nurse and RN on 4/10/26 :Change of Conditions-Assessment Requirements, Timelines, Definitions and Monitoring requirements. RDHS provided inservice on 4/10/26 for Community Nurse and RN on Skin & Wound Oversight Requirements: including skin checks, wound care reporting; coordination of care, reporting to medical providers, family/POA notifications, documentation and monitoring requirements. Medication Techs (MT), Caregivers and RCCs received inservice on:identification, reporting, and documentation of all resident changes to meet Oregon regulatory and Sinceri safety standards, this training included the implementation of use of Skin/Bath Sheets and change of condition report forms - completed by 4/17/26 MT received inservice on use of 24 Hour report, completing incident reports, and alert charting requirements- completed by 4/17/26 MT received inservice on wound/skin care which included understanding that all skin/wound treatments must be documented on the Treatment Administration Record (TAR) as ordered by the provider and delegated by the RN- completed by 4/17/26 Resident#2 - RN Consultant performed Significant Change of condition (COC)assessment on 4/16/26, implemented Temporary Service Plan(TSP) for staff with instructions for resident care ; coordination of care with outside provider who is providing wound care. RN has resident on weekly monitoring and continues to coordinate care with outside provider. RN Consultant and RDHS/RN completed an audit of all current residents needs and for all residents identified with a change of condition the RN Consultant and/or RDHS/RN completed COC assessment and implemented TSP for staff with instructions for resident care and coordinated care with outside care providers for all current residents by 4/24/26 The RN Consultant will review all active change of condition communications weekly to verify interventions are documented, communicated to all shifts, and that weekly progress is being documented. Skin check forms will be completed weekly for any resident with active wounds. The Executive Director/Administrator will review COC documentation in monthly quality audits. The RN Consultant is responsible for timely documentation of COC assessments, interventions, and weekly progress notes. The AHSD/HSD and RCC are responsible for day-to-day communication of interventions across shifts. The Executive Director/Administrator is responsible for monthly oversight of COC documentation compliance

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 observation, interview, and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 2 sampled residents (# 2) who experienced significant changes of condition. Resident 2’s wounds worsened, s/he experienced pain, and required an emergency department (ED) visit. Findings include, but are not limited to: Resident 2 moved into the facility in 06/2022 with diagnoses including heart failure. During the acuity interview on 04/06/26 at 9:30 am, Resident 2 was identified as having a pressure ulcer, had been needing more ADL assistance, and was receiving home health nursing and PT services. The resident's 01/06/26 through 04/06/26 clinical record was reviewed. The resident was observed, and interviews with staff and the resident were conducted. * Observations and interviews with Resident 2 and staff on 04/06/26 through 04/08/26 revealed Resident 2 preferred to sit in the recliner during the day, with a pressure relief cushion in place, and was being seen by HH nursing for wounds on his/her buttocks. * An observation note dated 01/12/26 identified redness to Resident 2’s groin and coccyx area and notified the Health and Wellness Director. * An observation note written by Staff 3 (Community RN), dated 01/16/26, four days after the coccyx redness was identified, documented direct care staff reported the resident had “bleeding on [his/her] coccyx.” Staff 3 recommended a shower to clean the area and requested “HH Wound Care … to assist with skin care needs and skin breakdown.” * Thirteen days after the wounds were noted as bleeding, on 01/29/26, a home health RN note indicated Resident 2 had “stage 2 pressure ulcers” on both buttocks and provided a brief description of the wound beds. Resident 2 experienced a significant change of condition related to pressure sores on both right and left buttocks. The facility failed to ensure an RN assessment was completed that documented findings, resident status, and interventions made as a result of the assessment. The wounds worsened, the resident experienced unnecessary and required an ED visit. During an interview on 04/08/26 at 1:10 pm, Staff 3 (Community RN) acknowledged there was no RN assessment for the resident’s stage 2 pressure sores. She indicated they were short-staffed when making the transition to the change of ownership in 10/2025 and the need for an assessment was overlooked. The need to ensure all significant changes of condition were assessed by an RN, with documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), and Staff 3 at 11:35 am on 04/08/26. They acknowledged the findings. Refer to C270, example 1a.

The RN Consultant completed a comprehensive RN assessment for Resident 2 on 04/16/26 documenting current wound status, findings, resident status, and interventions. The assessment was placed in the resident's clinical record. RN Consultant and RDHS/RN completed an audit of all current residents needs and for all residents identified with a change of condition the RN Consultant and/or RDHS/RN completed COC assessment and implemented TSP for staff with instructions for resident care and coordinated care with outside care providers for all current residents by 4/24/26 The RN Consultant will review all active change of condition communications weekly to verify interventions are documented, communicated to all shifts, and that weekly progress is being documented. Skin check forms will be completed weekly for any resident with active wounds. The Executive Director/Administrator will review COC documentation in monthly quality audits. The RN Consultant is responsible for timely documentation of COC assessments, interventions, and weekly progress notes. The AHSD/HSD and RCC are responsible for day-to-day communication of interventions across shifts. The Executive Director/Administrator is responsible for monthly oversight of COC documentation compliance

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements staff were providing to residents for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2026 with diagnoses including atrial fibrillation, right below knee amputation, pacemaker, and stroke. The resident’s Acuity Based Staffing Tool (ABST) data, the 04/03/26 service plan, and change in plan of care communication notes were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST calculation did not incorporate expected care time in the following areas: * Responding to call lights; * Monitoring physical conditions or symptoms; * Ensuring non-drug interventions for behaviors; * Providing treatments; * Providing non-drug interventions for pain management; * Medication administration, passing out medications; * Ambulation, escorting to and from meals or activities; * Helping with bowel and bladder management; and * Dressing and undressing. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), and Staff 3 (Community RN) on 04/09/26 at 11:03 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 11/2018 with diagnoses including acute chronic diastolic (congestive) heart failure, unspecified atrial fibrillation, and unspecified delusional disorders. Observations of the resident, interviews with the resident and staff, and review of the 02/10/26 service plan and Resident 3’s ABST data was completed. Interviews with staff and the resident during the period of the survey confirmed Resident 3 was independent with his/her ADL’s. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Hygiene and mouth care; * Dressing and undressing; and * Grooming (nail care and brushing hair). The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), Staff 3 (Community RN), and Staff 4 (Interim Administrator) at 10:28 am on 04/09/26. They acknowledged the findings. 3. Resident 2 moved into the facility in 06/2022 with diagnoses including heart failure. The resident’s Acuity Based Staffing Tool (ABST) data, and the 04/03/26 service plan, were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST calculation did not incorporate expected care time in the following areas: * Safety checks, fall prevention; * Responding to call lights; * Repositioning in bed or chair; * Transferring in or out of bed or a chair; * Bathing; * Helping with bowel and bladder management; and * Dressing and undressing. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Regional Director of Operations), Staff 2 (ED, The Lodge), and Staff 3 (Community RN) on 04/09/26 at 11:35 am. They acknowledged the findings.

Elderwise Adminstrator Consultant provided inservice to AHSD and RCC on ABST Provider Training- on 4/22/26 Residents #1, 2, 3 ABST has been updated to reflect resident care needs. AHSD and RCCs will audit current residents' ABST data and correct inaccuracies for any residents with incomplete or inaccurate care time capture by 06/08/26 The facility implemented a process for the RCC to validate ABST data accuracy prior to move in, at least every 90 days and with each change of condition service plan, review using direct care staff interviews, observations, and cross-reference with the service plan. ABST data will be reviewed and updated quarterly for all residents at the time of the quarterly service plan review. Monthly spot audits of a sample (minimum 25%) of resident ABSTs will be conducted by RDHS. Findings will be reported to the Executive Director/Administrator monthly.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated and reviewed for each resident before the resident moved in, whenever there was a significant change of condition, and updated no less than quarterly for 2 of 3 (#s 1and 2) sampled residents and multiple unsampled residents. Findings include, but are not limited to: During the acuity interview at 9:33 am on 04/06/26, Staff 2 (ED, The Lodge), Staff 3 (Community RN), Staff 15 (RCC, The Lodge), and Staff 16 (RCC, ALF) confirmed the facility census was at 30 residents. The facility’s ABST data was reviewed on 04/06/26 and revealed the following: * Resident 1 had no documented evidence the ABST data had been updated upon move-in; * Resident 2 had no documented evidence the ABST data had been updated following a significant change of condition; and * Fourteen unsampled residents had no documented evidence the ABST data had been updated quarterly. The need to ensure residents’ ABST data was updated following a significant change of condition, no less than quarterly, and/or upon move in was reviewed with Staff 1 (Regional Director of Operations), Staff 2, and Staff 3 on 04/09/26 at 11:03 am. They acknowledged the findings.

Elderwise Adminstrator Consultant provided inservice to AHSD and RCC on ABST Provider Training on 4/22/26 Residents #1, 2, 3 ABST has been updated to reflect resident care needs. ABST updates were completed for all 14 unsampled residents whose quarterly updates were overdue. The posted staffing plan was reviewed and updated to reflect the corrected ABST totals for each shift. The facility implemented a three-point ABST update tracking system: (1) Prior to Move In: ABST completion is now a required item on the new resident move-in checklist, to be completed by the RCC prior to move-in. (2) Significant change of condition: When RN Consultant documents a significant change of condition assessment, the RCC is notified to update the ABST within 48 hours. (3) Quarterly: A perpetual quarterly ABST review calendar was created listing each resident's next due date. The RCC reviews the calendar weekly to identify upcoming and overdue updates. The posted staffing plan will be reviewed and updated by the Executive Director/Administrator whenever ABST totals change materially, and no less than quarterly. The RCC reviews the quarterly ABST update calendar weekly. The Executive Director/Administrator reviews the ABST tracking log and posted staffing plan monthly to confirm all updates are current and the staffing plan accurately reflects ABST requirements. The RDHS reviews ABST data monthly as part of the clinical audit process. The RCC is responsible for completing timely ABST updates and maintaining the tracking calendar. The RN Consultant triggers ABST updates following significant changes of condition. The Executive Director/Administrator is responsible for monthly oversight and ensuring the posted staffing plan reflects current ABST data.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were provided with fire and life safety training every other month and to document all required fire drill elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 03/2026 was reviewed on 04/07/26. The following was identified: 1. There was no documented evidence all staff were consistently provided with fire and life safety training every other month. 2. Fire drill documentation did not include one or more of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. In an interview on 04/07/26 at 2:05 pm, Staff 9 (Maintenance Director) reported he took over as Maintenance Director for the campus and had not had a consistent maintenance staff for the building since the change of ownership in 10/2025. He reported there was no documented evidence fire and life safety training had been completed other than March 2026. The need to provide fire and life safety training to all staff on opposite months of fire drills, as well as the need to address all required elements in fire drill documentation, was discussed with Staff 1 (Regional Director of Operations) on 04/09/26 at 11:35 am. He acknowledged the findings.

1.The Maintenance Director will be educated on regulations by the Regional Director of Operations/Regional Environmental person on policy and regulations regarding fire drills being performed according to the Oregon Fire Code by 5/6/26 2. MD/designee will conduct fire drills and staff education per policy and regulation. 3. Documentation will be maintained in TELS system by the MD/designee. The fire drill system will be audited by the Executive Director or designee monthly x 3 months. The result of the audit will be discussed at the monthly continuous quality improvement meeting. 4. ED/designee will ensure corrections are completed and monitored

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission. Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 03/2026 was reviewed on 04/07/26. In an interview on 04/07/26 at 2:05 pm, Staff 9 (Maintenance Director) was unable to provide documentation that residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the facility within 24 hours of admission for Resident 1, who recently moved into the facility. The need to provide fire and life safety instruction to residents within 24 hours of admission was discussed with Staff 1 (Regional Director of Operations) on 04/09/26 at 11:35 am. He acknowledged the findings.

MD completed Fire and life safety instruction to Resident 1: The content of the training included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside/outside the building. The training was documented with the date, content covered, and notation in the resident's file. To be completed by 5/8/26 All current residents' records were reviewed to identify any others admitted since the change of ownership (10/2025) for whom fire safety instruction was not documented. Any identified residents received or are scheduled to receive documented fire and life safety instruction by MD by 6/8/26 Resident fire and life safety instruction within 24 hours of admission is now a required item on the facility's admission checklist. The Maintenance Director or a trained designee is responsible for completing and documenting the instruction. The completed form is placed in the resident's file. The admission checklist is reviewed by the Executive Director/Administrator at each new admission to confirm the instruction was completed. Resident fire safety training is provided at each admission (within 24 hours) and re-provided annually for all residents. The Executive Director/Administrator reviews the admission checklist monthly to confirm fire safety instruction was completed and documented for each new admission. Annual re-instruction for all residents is tracked on the facility's life safety calendar. The Maintenance Director (or trained designee) is responsible for providing and documenting resident fire and life safety instruction at admission and annually. The Executive Director/Administrator is responsible for monthly review of admission checklists to confirm completion and for ensuring the annual re-instruction schedule is maintained.