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' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 4 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including diastolic congestive heart failure, tremors and chronic obstructive pulmonary disease (COPD). During the acuity interview on 06/16/26, Resident 4 was identified as receiving hospice services at the time of admission. Observations were made of the resident's care on 06/17/26 and 06/18/26. Interviews with the resident, hospice providers and facility staff were conducted, and the service plan, dated 05/06/26, was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with activities of daily living; * Instructions on signs and symptoms of depression and anxiety to report while on anti-depressant therapy; * Instructions for staff as to how the side rails were to be used, monitored for safety, and to whom to report any malfunctions; * Oxygen equipment precautions, instructions for proper maintenance, including when to add distilled water, how to charge a portable oxygen tank, and how to monitor for safety; * Instructions on what types of skin impairments to report and to whom; and * Incorrect reference to the resident as using a bilevel positive airway pressure (BiPAP) ventilation device or continuous positive airway pressure (CPAP) therapy device. Staff 9 (Care Partner) was interviewed on 06/17/26 at 2:19 pm and stated Resident 4 spent most of the time in bed and “when [Resident 4]’s hand tremors get worse, [s/he] needs help with everything around the room.” Staff 9 added, “I always check side rails while changing bedding because they [side rails] get loose often.” The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 1:57 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2025 with diagnoses including chronic kidney disease and hypertension. The resident’s 03/08/26 to 06/16/26 clinical record was reviewed, interviews with staff and resident were conducted, and observations were made. The service plan, dated 05/27/26, was not reflective of the resident’s current care needs or lacked clear instructions to staff in the following areas: * Instructions regarding how the side rails were to be used, monitored for safety, and to whom to report any malfunctions; * Instructions regarding level of assistance needed for management of oxygen; * Incorrect reference to the resident as using a bilevel positive airway pressure (BiPAP) ventilation device or continuous positive airway pressure (CPAP) therapy device; * Instructions regarding bowel movements including supplies needed, bowel status and modifications of the briefs; * Preferences regarding where to eat meals; * Skin conditions including what to apply following brief changes; * Frequency of providing safety checks; * Ability to reposition in bed; * PRN psychotropic medication including reason for use and what to do when exhibiting; * Frequency of taking weight and which wheelchair to use; and * Diabetic status. During an observation on 06/16/26 at 1:45 pm, Resident 2 had two quarter length side rails on the hospital bed, preferred the side straps of briefs removed prior to use, and relied on staff to assist with his/her oxygen needs. Resident 2 indicated s/he used a BiPAP, not CPAP, machine at night and was not diabetic. During an interview on 06/18/26 at 12:55 pm, Staff 6 (Care Partner) indicated Resident 2 was continent of his/her bowels, was unsure if the resident had a PRN medication for anxiety or which wheelchair the resident used to obtain his/her weight and had two types of ointment to apply following a brief change and believed the “thicker one” was applied at night. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 2:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) Resident #4's service plan were immediately reviewed and revised to reflect the number of staff needed to provide assistance, safety interventions for depression medication, equipment, and reporting instructions for staff. b) Resident #2's service plan were immediately reviewed and revised to reflect equipment instructions, level of assistance, resident preferences, safety interventions, and physician orders. 2. The system will be corrected so that the violation will not occur by: a) The community will implement a service plan review process requiring service plans to be reviewed and updated upon admission, within 30 days, quarterly, and with a significant change of condition followed by a service plan audit checklist to verify all required care instructions, equipment, interventions, resident preferences, and safety measures are accurately documented. 3. The area needing correction will be evaluated by the Licensed Nurse and/or Administrator by completing weekly service plan audits to ensure compliance. Any areas of non-compliance will be addressed immediately. 4. The Administrator, Resident Care Coordinator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

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, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible for administering for 2 of 4 sampled residents (#2 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2025 with diagnoses including chronic kidney disease and hypertension. The resident's 03/08/26 to 06/16/26 clinical record and 06/01/26 through 06/16/26 MAR were reviewed and noted the following: a. On 06/04/26 Novolog 100 U/ml insulin sliding scale for hyperglycemia was ordered for administration before each meal three times daily based on Resident 2's blood glucose level while taking prednisone. Based on review of the MAR, an incorrect dose of insulin was administered on two occasions. Additionally, there was no documented evidence how many units of insulin had been administered based on the resident’s blood glucose level on three occasions. The administration of incorrect dose had no negative outcome to Resident 2. b. A physician’s order on 05/14/26 instructed staff to obtain weights twice weekly on Tuesday and Friday and notify the PCP for a weight gain of five pounds or more. Based on review of the MAR, the resident was not weighed on 06/04/26, 06/09/26 and 06/12/26. c. The following orders were not transcribed to the 06/01/26 through 06/16/26 MAR: * Pantoprazole (for acid reflux) 40 mg daily; and * Glucose (for low blood sugar) 15 grams as needed for blood sugar less than 70. The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 2:30 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 04/2025 with diagnoses including diastolic congestive heart failure, tremors and chronic obstructive pulmonary disease (COPD). During the acuity interview on 06/16/26, Resident 4 was identified receiving hospice services at the time of admission. Resident 4's MARs from 06/01/26 through 06/16/26 were reviewed. Interviews with facility staff were conducted. During the review of the resident’s chart on 06/16/26 at approximately 2:30 pm, it was noted there was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the medications and treatments that the facility was responsible to administer. Signed physician orders dated 06/16/26 were received by the survey team on 06/17/26 at 11:03 am. During an interview on 06/17/26 at 9:45 am, Witness 1 (Hospice RN) confirmed the facility asked for a copy of the hospice orders on 06/16/26 and they were faxed as requested. The need to ensure written, signed or other legally recognized practitioner orders were documented in the resident’s facility record for all medications and treatments that the facility was responsible to administer was reviewed with Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 1:57 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) Resident #2's physician orders and medication records were immediately audited. All medications and treatments were verified to accurately reflect current physician orders. b) Resident #4's physician orders were immediately obtained. A facility-wide audit of active physician orders was completed to ensure all medications and treatments have corresponding signed practitioner orders within the resident record. 2. The system will be corrected so that the violation will not occur by: a) The community implemented a Physician Order Reconciliation Process requiring all new physician orders to be reviewed for completeness, entered into the electronic record, and verified against the MAR/TAR prior to implementation by the Med Tech's, Care Coordinator and RN. 3. The area needing correction will be evaluated by the Licensed Nurse weekly. Any areas out of compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

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 complete, update and review the Acuity Based Staffing Tool (ABST) evaluation for each resident before a resident moved in and no less than quarterly and corresponding with resident service plan updates for 3 of 4 sampled residents (#s 2, 3 and 4). Findings include, but are not limited to: The ABST data was captured on 06/16/26 at 10:41 am. a. On 06/18/26 at 12:30 pm, Staff 1 (ED) confirmed Resident 3 moved into the facility on 04/30/26. The resident’s ABST evaluation was not created until 05/26/26. b. Resident 2’s most recent service plan was dated 05/27/26. The resident’s ABST evaluation was last reviewed on 02/13/26. c. Resident 4’s most recent service plan was dated 05/06/26. The resident’s ABST evaluation was last reviewed on 02/12/26. The need to ensure resident ABST evaluations were completed prior to move-in and no less than quarterly and corresponding with resident service plan updates, was reviewed with Staff 1 and Staff 3 (RCC) on 06/18/26 at 12:30 pm and with Staff 1 and Staff 4 (Regional Director of Operations) on 06/18/26 at 3:05 pm. They acknowledged the ABST evaluations had not been created or reviewed as required.

1. The actions that will be taken to correct the rule are: a) Resident #'s 2, 3 and 4 had their ABST evaluations updated to actively reflect current service plan needs. 2. The system will be corrected so that the violation will not occur by: a) The community will implement an ABST Review Process audit requiring completion upon admission, 30 days, quarterly and significant changes of condition. A monthly evaluations log is created to monitor for upcoming due dates and completed reviews. 3. The area needing correction will be evaluated by the Administrator weekly for four weeks and then monthly therafter to ensure evaluations remain current. 4. The Administrator and Resident Care Coordinator will be responsible to ensure that corrections are completed and monitored.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct and document fire drills per Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records were reviewed on 06/17/26. The following was identified: a. The facility was not conducting fire drills at different times of the day, evening and night shifts. The facility conducted drills on day, and evening shifts every other month, but the last drill conducted on night shift was 09/30/25. b. The facility had one first floor wing of resident rooms, and two second floor wings of resident rooms: rooms 201 – 221 and 222 – 238. Fire drills conducted between 07/18/25 and 05/31/26 indicated fires were simulated on the first floor and on the second-floor wing for rooms 222 – 238. No drills were conducted for the residents in the 201 – 221 wing. c. The facility did not document any follow up regarding the residents who resisted or failed to participate in the fire drills in order to ensure the facility was capable of evacuating the building in an emergency. The need to ensure fire drills were conducted and documented per the OFC was reviewed with Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 3:05 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) Leadership responsible for conducting fire drills received re-education regarding required drill frequency, documentation elements, staff participation, resident participation and evacuation expectations. 2. The system will be corrected so that the violation will not occur by: a) A Fire Drill Documentation Checklist has been implemented to ensure all required Oregon Fire Code elements are documented for each drill. Fire drills will be scheduled throughout varying shifts to ensure staff participation across all work hours. Completed documentation will be reviewed by the Executive Director prior to filing to ensure compliance with regulatory requirements. 3. The area needing correction will be evaluated by the Administrator following each fire drill and monitored monthly. 4. The Administrator and Maintenance Director will be responsible to ensure that corrections are completed and monitored.