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 change of ownership survey, conducted 08/17/26 through 08/20/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the severity of citations. A situation was identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. An immediate plan of correction was requested in the following area: OAR 411-054-0025: Reasonable Precautions. The facility put an immediate plan of correction in place during the survey. Refer to deficiencies in the report.

C150 OAR 411-054-0025 (1) Facility Administration: Operation Reference OAR 411-054-0025: Reasonable Precautions The facility put an immediate plan of correction in place during the survey, Refer to deficiencies in the report.

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 health, safety, or welfare of residents for 2 of 2 sampled residents (#s 6 and 7) who had dysphagia (difficulty swallowing). The residents’ prescribed diets were not administered by the facility, placing them at risk of aspiration, choking, and/or death. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 10/2024 with diagnoses including dysphagia (difficulty swallowing) and aphasia (difficulty speaking). During the acuity interview on 08/17/26 at 11:45 am, Resident 6 was identified to be on a mechanical soft diet. Resident 6's clinical record dated 05/27/26 through 07/17/26 was reviewed, and the following was identified: A physician’s order, dated 05/27/26, indicated the resident’s diet texture was “Level 6: soft and bite sized (mechanical soft) and thin liquids.” According to the International Dysphagia Diet Standardization Initiative (IDDSI), Level 6 food should be soft, tender, and moist throughout, with pieces no larger than 1.5 cm by 1.5 cm. Food should be easily mashed with a fork. The service plan, dated 06/01/26, documented that Resident 6 was “a chok[ing] risk and needs to eat in the dining room” and “was on a mechanical soft diet for choking.” On 07/13/26, staff documented in an incident report Resident 6 had a choking episode and required the Heimlich maneuver. An interim service plan (ISP) instructed staff to ensure Resident 6’s food was cut up to bite-sized pieces and to eat at a dining counter near staff. During a lunch observation, 08/18/26 at 12:00 pm, Resident 6 was served the following food items: * Fried chicken, chopped up in a food processor; * String beans approximately 3 cm in length; and * Cubed potatoes, approximately 1.5 cm diced. The chicken was not covered with a sauce or gravy. Resident 6 was observed removing pieces of the chicken from his/her mouth and stated at that time that the pieces were “bone and cartilage.” The resident was observed coughing intermittently throughout the meal. During interviews, on 08/18/26 at 12:30 pm, Staff 7 (MT) and Staff 14 (CG) reported Resident 6 had a prior choking episode and required the Heimlich maneuver. After the choking incident, the facility provided a food processor for direct care staff to modify the diet. When asked if they were provided with training on how to prepare a mechanical soft texture, Staff 14 stated she was instructed to use the food processor to prepare Resident 6’s food. During dinner observation, on 08/18/26 at 5:00 pm, Resident 6 was served the following food items: * A whole slice of casserole with a congealed, solid mass of cheese of top; and * A salad with shredded lettuce (not an acceptable food on a Level 6 diet). During an interview at 08/18/26 at 5:00 pm Staff 11 (CG) stated he did not know what diet texture the resident was supposed to be receiving. The facility failed to ensure Resident 6 received the prescribed diet order of IDDSI Level 6 and failed to ensure staff had been trained on the prescribed diet texture, which placed the resident at risk for choking and aspiration. An immediate plan of correction was requested from Staff 1 (Administrator) on 08/18/26 at 6:10 pm. The initial plan of correction was received and accepted by the survey team on 08/18/26 at 8:30 pm. However, a revision to the plan of correction was requested on 08/19/26 8:40 am and the revised plan of correction was accepted at 12:06 pm. During a lunch observation, on 08/19/26 at 12:30 pm, Resident 6 was served the following food items: * Diced pork chops with gravy; * Cut pasta; and * Cut up vegetables. The pork chop was not fork-mashable, the pieces were larger than 1.5 cm, and not the Level 6 diet texture as prescribed. During a dinner observation, on 08/19/26 at 5:00 pm, Resident 6 was served the following food items: * Cut up fish; * Mashed potatoes: and * Cut up vegetables. There was no sauce or gravy on the food. The facility failed to provide the correct diet texture to the resident, and the facility failed to implement their immediate plan of correction and continued to place the resident at risk for choking and aspiration. On 08/20/26 at 10:00 am, the survey team directed Staff 1 to have a licensed dietitian on site prior to the next meal service, to ensure that the modified diets were prepared correctly and to provide training for staff. Documentation was received on 08/20/26 at 3:13 pm, indicating the licensed dietitian had observed the lunch prep, meal service, and provided training to seven staff members. Staff 1 also stated the facility would have a licensed dietitian on site for dinner service. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1, Staff 2 (ED Skilled Nursing Facility), Staff 3 (RN), Staff 4 (Wellness Nurse/LPN), and Staff 5 (RCC) on 08/20/26 at 4:15 pm. They acknowledged the findings. 2. Resident 7 moved into the assisted living facility in 06/2026 with diagnoses including stroke and dysphagia (difficulty swallowing) and was identified in the acuity interview on 08/17/26 at 11:45 am as being on a mechanical soft diet. The resident’s service plan dated 06/11/26, interim service plans (ISPs) from 07/15/26 and 07/30/26, an outside provider note from the HH speech pathologist dated 06/30/26, and signed prescriber orders dated 07/13/26 were reviewed, observations of the resident were made, and interviews of the resident and staff were conducted. The following was identified: The resident had a signed physician’s order for “bite/soft foods.” An ISP dated 07/15/26 indicated Resident 7’s diet was changed to “small bite/soft foods/mechanical soft.” During a dinner observation on 08/18/26 at 5:20 pm, Resident 7 was served the following food items: * A whole slice of casserole with a congealed, solid mass of cheese of top; and * Pears cut in pieces. The casserole was not in bite-sized pieces as prescribed. During an interview on 08/18/26 at 5:20 pm, Staff 12 (CG) stated she was not aware of any modified diet texture orders for Resident 7. The facility failed to provide the correct diet texture, placing the resident at risk for choking and aspiration. An immediate plan of correction was requested from Staff 1 (Administrator) on 08/18/26 at 6:10 pm. The initial plan of correction was received and accepted by the survey team on 08/18/26 at 8:30 pm. However, revision to the plan of correction was requested on 08/19/26 8:40 am and the revised plan of correction was accepted at 12:06 pm. During a lunch observation 08/19/26 at 12:20 pm, Resident 7 was served the following food items: * Pasta; * Orzo salad with cut vegetables; and * Diced pork chops with gravy. Resident 7 stated at the time of the observation, “it’s tough,” referencing the pork, and demonstrated s/he was unable to cut through the pieces. During an interview at 12:20 pm on 08/19/26, Staff 1 acknowledged the consistency of the meat was not soft per prescribed diet order. The facility failed to provide the correct diet texture to the resident, and the facility failed to implement their immediate plan of correction and continued to place the resident at risk for choking and aspiration. On 08/20/26 at 10:00 am, the survey team directed Staff 1 to have a licensed dietitian on site prior to the next meal service, to ensure that the modified diets were prepared correctly and to provide training for staff. Documentation was received on 08/20/26 at 3:13 pm, indicating the licensed dietitian had observed the lunch prep, meal service and provided training to seven staff members. Staff 1 also stated the facility would have a licensed dietitian on site for dinner service. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1, Staff 2 (ED Skilled Nursing Facility), Staff 3 (RN), Staff 4 (Wellness Nurse/LPN), and Staff 5 (RCC) on 08/20/26 at 3:53 pm. They acknowledged the findings.

C160 OAR 411-054-0025 (4) Reasonable Precautions 1. Actions taken to correct this rule violation as follows: a. Resident #5: The resident's current diet order was reviewed and clarified. The MAR, and service plan were updated to accurately reflect the resident's prescribed Level 6 Soft & Bite-Sized diet. Direct care and dietary staff were educated regarding the resident's prescribed diet, including appropriate food size, texture, moisture requirements, and appropriate IDDSI testing methods. Staff responsible for meal preparation and service demonstrated understanding of the resident's diet requirements. b. Resident #7: The resident's current diet order was reviewed and clarified. The MAR and service plan were updated to accurately reflect the resident's prescribed bite size / soft foods. Direct care and dietary staff were educated regarding preparation and service of the resident's prescribed bite / soft foods diet. c. The Licensed Nurse / RCC / Dietary Manager and Licensed Dietitian reviewed resident's modified -texture diet orders to verify that current provider orders are accurate. The MAR's and service plans and dietary information are available to staff. Any discrepancies were corrected. 2. The system will be corrected so this violation will not happen again by: a. All new and changed diet orders will be reviewed upon receipt and communiciated to staff responsible for preparing and serving meals prior to the resident's next meal. The Licensed Nurse / RCC will verify that the resident's current diet order is accurately reflected on the MAR, and service plan, and dietary communication tools. b. All direct care and dietary staff responsible for preparing or servicing modified-texture diets will receive training regarding modified-texture diets, including applicable IDDSI requirements, and appropriate testing methods. c. Newly hired staff responsible for preparing or serving modified -texture diets will receive training prior to independently preparing or serving these diets. 3. The area needing correction will be evaluated as follows: a. The Licensed Nurse, RCC, Dietary Manager, Administrator, and / or designee will conduct meal observations of residents receiving modified-texture diets weekly for four weeks and monthly for three months to verify that meals served are consistent with the resident's current prescribed diet texture. b. New or changed diet orders will be reviewed upon receipt to ensure the order has been accurately communicated and incorporated into the resident's MAR, service plan and dietary information. c. Results of audits and meal observations will be reviewed through the facility's Quality Improvement process. Any identified concerns will be corrected immediately and additional staff education provided as indicated. 4. The Facility Administrator, Licensed Nurse, RCC, & Dietary Manager will ensure corrections are completed & monitored.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. 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 treated with dignity and respect for 2 of 6 sampled residents (#s 3 and 5) and multiple unsampled residents who received meal services. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 05/2026 with diagnoses including chronic obstructive pulmonary disorder and nondisplaced fracture of the sacrum (tailbone). On 08/17/26 at 3:35 pm, Resident 3 stated s/he had a fish allergy and would order a chef’s salad as an alternate meal when fish was served as the main entrée. Resident 3 did not like iceberg lettuce and had requested the kitchen have romaine lettuce on hand to use in the chef’s salad when fish was on the menu. On one occasion, the resident was told by kitchen staff there was no romaine lettuce for the chef’s salad, and s/he would need to choose something else from the alternate menu. When Resident 3 stated s/he did not want anything else from the alternate menu, the kitchen staff stated the resident should “go buy [his/her] own romaine lettuce.” Resident 3 stated s/he no longer had any direct contact with the kitchen and had care staff phone in his/her requests. S/he also stated s/he had attended resident council meetings to voice his/her concerns over how the kitchen staff treated the residents, but “nothing ever happens. They don’t care about us.” On 08/18/26 at 1:50 pm, Staff 13 (CG) stated about one week ago she had called the kitchen on Resident 3’s behalf to order a chef’s salad for dinner and was informed the kitchen did not have romaine lettuce. The cook told the CG to tell the resident s/he needed to “buy [his/her] own lettuce if [s/he] wanted a specific kind.” A review of resident council notes from 05/19/26 documented resident requests for romaine lettuce for salads and inclusion of cheese, meats, and tomatoes, “not just lettuce.” The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (Administrator), Staff 2 (ED Skilled Nursing Facility), Staff 3 (RN), Staff 4 (Wellness Nurse/LPN), and Staff 5 (RCC) on 08/20/26 at 3:53 pm. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 10/2024 with diagnoses including dysphagia (difficulty swallowing) and aphasia (difficulty speaking). Observations were conducted during meal service from 08/17/26 through 08/20/26. The following concerns were identified: On 08/19/26 at 12:30 pm Resident 6 was served lunch which included diced pork chops with gravy. Resident 6 notified Staff 16 (CG) and Staff 8 (MT) that the pork chop was tough. Both Staff 8 and Staff 16 did not acknowledge the resident. After a few minutes surveyor intervened and asked both staff what they would do with that information. Staff 16 then called the kitchen. According to Staff 16, the kitchen staff answered the phone and told the CG the kitchen would bring another plate for Resident 6 “if there was any left.” On 08/19/26 at 5:00 pm, Resident 6 commented to staff that the fish served was dry. Staff 11 (CG) did not acknowledge the resident. The need to ensure residents were treated with dignity and respect during meal service was discussed with Staff 1 (Administrator) Staff 2 (ED Skilled Nursing Facility) Staff 3 (RN) Staff 4 (Wellness Nurse/LPN) and Staff 5 (RCC), on 08/20/26 at 4:15 pm. They acknowledged the findings. 3. Throughout the survey period of 08/17/26 through 08/20/26, multiple unsampled residents approached the survey team with reports of being disrespected by primarily kitchen staff. The following issues were repeated by residents: * “We were told the kitchen wouldn’t be providing condiments anymore, we had to buy our own ketchup and mayonnaise...the buildings aren’t given enough condiments to go around so some of us get them and some of us don’t”; * “Half the time, when I order a hamburger for lunch, they tell me they’re out of patties. The other half the time, they tell me they’re out of buns.” The unsampled resident who made this complaint was observed not eating lunch on 08/18/26 because s/he stated the CG was told the facility was out of hamburger patties for that meal; * “I tried to have a discussion with the Dietary Manager the one time he attended our Resident Council meeting. We ended up getting into a screaming match and he walked out and told me I didn’t know what I was talking about”; * Multiple sampled and unsampled residents voiced concern over the frequency with which CGs were quitting, resulting in an increased reliance by the facility on agency CGs. One unsampled resident stated he used a urinal, which required staff assistance to empty. He stated, “I once filled two urinals to the top and still had to ask one of the agency caregivers to empty them, they just walk right by and don’t help at all. It’s like they don’t know what they’re supposed to do for us”; * Review of resident council minutes from 05/19/26, 06/16/26, and 07/2026 indicated residents were reporting poor communication between the main kitchen and the building kitchenettes (“caregivers calling kitchen and no one answering,” “being told many times that they don’t have the supplies in the building and the kitchen won’t answer”), lack of foods in the individual building kitchenettes (“want things like toast,” “still no bread being brought in,” “kitchens running out of stock and not being replenished in a decent time period”), and lack of variety and availability of menu options (“ensure every caregiver is trained to take orders for lunches and dinners on a daily basis offering the alternative menu,” “bored with alternative menu”); and * On 08/20/26 at 3:00 pm, an unsampled resident stated s/he was diabetic and had an episode of low blood sugar. S/he requested a sandwich and the staff in the unit stated there was no bread to make the sandwich. The staff and the resident called the kitchen and the kitchen declined to provide the bread. Because the caregiver was the only staff in the building at that time, the resident had to then leave the unit and propelled his/her wheelchair to the kitchen, which in the skilled nursing facility approximately 150 feet away. S/he stated, “I told them I wasn’t leaving until they gave me the bread.” On 08/20/26 at 1:50 pm, Staff 1 (Administrator) stated when the facility was made aware of a resident concern, the quality assurance policy directed him to address it with the head of the department with which the concern was identified. He stated he was aware of resident dissatisfaction and was working directly to improve communication between the kitchen and care staff in each building by purchasing new phones, increasing the kitchen budget, and training for care staff and kitchen staff. The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (Administrator), Staff 2 (ED Skilled Nursing Facility), Staff 3 (RN), Staff 4 (Wellness Nurse/LPN), and Staff 5 (RCC) on 08/20/26 at 3:53 pm. They acknowledged the findings.

C200 OAR 411-054-0027 (1) Resident Rights and Protection- General 1. Actions taken to correct the rule violation are as follows: Resident #3 a. The residents dietary preferences and aversions have been updated in the service plan as well as the dietary log and is available for all staff to reference. b.The community has a new dietary manager. c. All kitchen staff have received coaching and training on respectful communication and resident rights. Resident #6 a. The residents specific diet plan has been reviewed; staff have been provided education and training on diet orders (see C160) b. The resident diet order has been updated to include always providing a side of gravy or sauce or premixing the gravy / sauce. Staff have received training on serving resident specific diet. 2.The system will be corrected so this violation will not happen again by: a.Continued education for all staff on resident rights; focused on respectful communication and treating each resident with dignity and respect. b.The community implemented an updated system for communication of concerns. The administrator reviewed the updated system with 100% of residents 1 on 1 to ensure each resident understands the process and ability to express concerns anonymously if desired. 3.The area needing correction will be evaluated daily (M-F) by checking the comments / suggestion box, monthly with the resident town hall and food committee meetings. 4.The Administrator, Licensed Nurse, Dietary Manager, and / or designee will be responsible to ensure the corrections are completed and monitored.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation was completed before the resident moved into the facility for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the assisted living facility in 06/2026 with diagnoses including type 2 diabetes mellitus and congestive heart failure. Resident 1’s move-in evaluation was reviewed and the following was identified: * The resident’s evaluation was completed one day after move-in, not before as required by rule. The need to ensure the initial resident evaluation was completed prior to move-in was reviewed with Staff 1 (Administrator), Staff 2 (ED Skilled Nursing Facility), Staff 3 (RN), Staff 4 (Wellness Nurse/LPN), and Staff 5 (RCC) on 08/20/26 at 3:53 pm. They acknowledged the findings.

C252 OAR 411-054-0034 (1-6) Resident Move-In & Evaluation: Res Evaluation 1. Actions taken to correct the rule violation as follows: a. The community has implemented the use of a paper word document to be utilized to complete any new pre-admission evaluation during the initial evaluation completed no less than 24 hours prior to an admission to the community. b. The community has received and participated in education, and will continue to receive education regarding the move in process including but not limited to the evaluation requirements prior to admission. 2. The system will be corrected so this violation will not happen again by ensuring the initial move-in evaluation will be completed in it's entirety prior to a resident's move-in to ensure all required elements are addressed and timely completion per the OAR. 3. The area needing correction will be evaluated as follows with each initial move-in. a. All admissions will be reviewed to ensure completion of all required components prior to admit date. 4. The Administrator, Licensed Nurse, or designee will be responsible to ensure the corrections are completed and monitored.

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 significant change of condition assessments, which included documented findings, resident status and interventions made as a result of the assessment, were completed by a facility RN in a timely manner, for 1 of 3 sampled residents (#5) reviewed for a significant change of condition. Findings include, but are not limited to: Resident 5 was admitted to the facility in 05/2026 with diagnoses including diabetes with polyneuropathy, depression and lymphedema. During the acuity interview on 08/17/26 at 11:45 am, staff reported that the resident had pressure ulcer (open wound) and was receiving HH services. Review of Resident 5’s clinical record from 05/06/26 through 08/17/26 revealed the following: Resident 5 was identified on 05/08/26 to have a multiple scattered stage two pressure ulcers to buttock region by HH RN. The stage two pressure ulcer constituted a significant change in condition for which an RN assessment was required. There was no documented evidence the facility RN performed an assessment of the resident’s significant change in condition until 07/06/26, 59 days after the pressure ulcer was identified. On 08/20/26 at 4:15 pm, Staff 1 (Administrator), Staff 3 (RN) and Staff 4 (Wellness Nurse/LPN) acknowledged the lack of timely RN assessment. The need to ensure RN assessments were completed timely by a facility RN in a timely manner was discussed with Staff 1, Staff 2 (ED Skilled Nursing Facility), Staff 3, Staff 4, and Staff 5 (RCC), on 08/20/26 at 4:15 pm. They acknowledged the findings.

C280 OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services 1. Actions taken to correct the rule violation as follows: a. Resident #5; the community RN & LN completed a thorough review of the resident chart and care needs. The clinical team ensured a treatment plan was in place with clear direction to care staff. The team had determined the resident wound needs were Skilled Care Appropriate; the resident has transitioned to St. Helens Post Acute for complex wound care as of 8/19/26. 2. The system will be corrected so this violation does not happen again by: a. All resident changes are reported and documented via the 24-hour reporting system. b. The Facility RN will assess the resident and condition change in a timely manner to determine any need for further monitoring. c. Facility RN will complete a weekly nursing assessment until the resident is back at their baseline health status, or a new baseline can be established. 3. The area needing correction will be evaluated on a daily, weekly, and monthly basis. Change of condition identified will be discussed daily in daily stand up meeting to trigger oversight and follow up by RN 4. The Facility RN or designee will be responsible to ensure the corrections have been completed and monitored.

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 interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site outside providers were communicated to staff and the service plan was adjusted if necessary for 1 of 1 sampled resident (#1) who received outside therapy services. Findings include, but are not limited to: Resident 1 moved into the assisted living facility in 06/2026 with diagnoses including type 2 diabetes mellitus and congestive heart failure. Staff reported in the acuity interview on 08/17/26 the resident received HH therapy services. Review of outside provider notes from 06/15/26 to 07/22/26 identified the following recommendations: * On 06/24/26, a HH PT note recommended “Frequent position changes, limit sitting one hour. During one hour offload every 15 minutes. Alternate lying down, up in chair for pain relief. Sit up after meals minimum 20-30 min before lying down”; * On 06/25/26, a HH OT documented “Patient with [approximate] 30-point systolic BP drop following standing activity. 134 to 105. Symptomatic. Left in bed [with] legs elevated, aide notified”; * On 07/02/26, a HH OT documented “adding compression hose to plan of care, on day, off PM”; * On 07/08/26, a HH RN recommended “1) Monitor [blood pressure] or increased dizziness, 2) Wear compression socks and shoes”; and * On 07/22/26, a HH OT recommended “Wheelchair to 90-degree angle to toilet during toilet transfers to reduce fall risk. [N]ote was left in [Resident 1’s] bathroom.” There was no documented evidence the facility communicated these recommendations to direct care staff or that the service plan was adjusted to ensure continuity of care. The need to ensure information and interventions provided by on-site outside providers were communicated to staff and service plans were adjusted if necessary was reviewed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), Staff 4 (Wellness Nurse/ LPN), and Staff 5 (RCC) on 08/20/26 at 3:53 pm. They acknowledged the findings.

C290 OAR 411-054-0045 (2) Res Hlth Srvc: On-Off Site Health Srvc 1. Actions taken to correct the rule violation are as follows: a. Resident #1; The service plan was updated via ISP to reflect all recommendations for changes of care. Corrections were completed 9/3/26. 2. The system will be corrected so this violation does not happen again by: a. All documentation received by on - off site services are processed through the triple check system to ensure staff are informed of new interventions, that the service plan is adjusted if necessary and any interventions are implemented per outside provider recommendation. b. Each house has an outside provider binder that is housed in the nursing office. All outside providers have been notified to place the outside provider form in the specific house binder, the Licensed Nurse or designee takes the outside provider binder to clincal meeting daily and ensures each is processed. 3. The area needing correction will be evaluated on a daily basis in clinical meeting. System will be reviewed monthly through continous quality improvement program. 4. The Licensed Nurse, Administrator or designee will be responsible to ensure 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 observation, interview, and record review, it was determined the facility failed to ensure orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 2) whose prescriber orders were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living facility in 06/2026 with diagnoses including type 2 diabetes mellitus and congestive heart failure. Resident 1’s clinical record from 06/03/26 to 08/17/26 was reviewed and revealed the following: The resident had a signed physician’s order, dated 06/03/26 for “Diet: IDDSI [Level] 6.” According to the International Dysphagia Diet Standardization Initiative (IDDSI), Level 6 food should be soft, tender, and moist throughout, with pieces no larger than 1.5 cm by 1.5 cm. Food should be easily mashed with a fork. Resident 1 was observed during lunch and dinner on 08/18/26 being served a regular diet. On 08/19/26 at 3:35 pm, Staff 4 (Wellness Nurse) confirmed the facility had not reviewed the resident’s diet order when s/he was admitted. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (ED Skilled Nursing Facility), Staff 3 (RN), Staff 4, and Staff 5 (RCC) on 08/20/26 at 3:53 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2022 with diagnoses including high blood pressure. The residents’ 07/01/26 through 08/17/26 MARs, current prescriber orders, and clinical records were reviewed. The following was identified: Resident 2 had an order dated 07/17/26 for metoprolol succinate extended release 25 mg tablet, hold for systolic blood pressure less than 90 or heart rate less than 60. There was no documented evidence staff were checking the heart rate prior to administering the medication. On 08/18/26 at 12:10 pm Staff 4 (Wellness Nurse/LPN) acknowledged the heart rate was not documented. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (ED Skilled Nursing Facility), Staff 3 (RN), Staff 4, and Staff 5 (RCC) on 08/20/26 at 4:15 pm. They acknowledged the findings. No additional information was received

C303 OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders 1. Actions taken to correct the rule violation are as follows: a. Resident #1; The diet order was updated to reflect physician prescribed order. The resident was re-evaluated by SLP and determined to be IDDSI level 7 regular no modifications needed. The resident MAR, service plan and dietary log have been updated to reflect the accurate diet. b. Resident #2; The resident MAR was updated to reflect the required components; corrections completed 8/18/26. 2. The system will be corrected so this violation will not happen again by: a. Ensuring all physician orders go through the triple check process where the orders are initially processed by the receiving med tech / RCC, to ensure no delay in treatment. Second check is the next oncoming med tech / RCC to verify orders are accurate, and appropriate directions and parameters for staff to follow are in place. Nursing to be the final check to verify all components are in place, and to make updates as indicated. b. All resident diets / medications and treatments will be reconciled to ensure accurancy, c. Facility will complete a parameter audit at least bi-weekly to ensure accurate administration and to identify medication-errors. 3. The area needing correction will be evaluated daily, weekly and monthly basis with triple check, MAR audits, and monthly continous quality improvement program to ensure MAR's are accurate, including residents diets and specific parameters and instructions for medications. All orders will be reconciled quarterly prior to physician orders sent to MD for review. 4. The Administrator, Licensed Nurse, RCC or trainined designee will be responsible to ensure the correction 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 ensure the acuity-based staffing tool (ABST) was updated and reviewed whenever there was a significant change of condition for 2 of 3 sampled residents (#s 1 and 3) who experienced a significant change of condition. Findings include, but are not limited to: Clinical records, including service plans and ABST evaluations, were reviewed, and the following was identified: The ABST evaluations were not updated and reviewed following a significant change of condition for Resident 1, who experienced a significant change of condition on 07/25/26, and Resident 3, who experienced a significant change of condition on 07/05/26. Neither residents’ ABST evaluations were updated after 06/15/26. The need to update and review residents’ ABSTs whenever there was a significant change of condition was reviewed with Staff 1(Administrator), Staff 2 (ED Skilled Nursing Facility), Staff 3 (RN), Staff 4 (Wellness Nurse/LPN), and Staff 5 (RCC) on 08/20/26 at 3:53 pm. They acknowledged the findings.

C363 OAR 411-054-0037 (4-6) Acuity Based Staffing Tool-Updates & Staffing Plan 1. Actions taken to correct this rule violation is as follows: a. Resident #1; The RCC and RN reviewed and updated the ABST on 8/20/26. The community RN completed a new evaluation and service plan on 8/25/26 including a thorough review and update of the ABST on 8/26/26 b. Resident #3; The RCC and RN reviewed and updated the ABST on 8/20/26. The community RN completed a new evaluation and service plan on 9/2/26 including a thorough review and update of the ABST on 9/3/26 2. The system will be corrected so this violation does not happen again by: a. The Administrator. Licensed Nurse or designee will update the ABST records immediate after completion / update of resident's service plan prior to move-in, 30 days, quarterly and with a signifcant changes of condition. 3. The area needing corrections will be evaluated daily during clinical stand up, upon resident admission, with 30 days of move-in, quarterly and with significant changes of condtion. 4. The Administrator and Licensed Nurse will be responsible for ensuring corrections are completed and monitored.

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: The assisted living facility consisted of three separate buildings, Building B, C, and D. Each building contained a large common area, which opened to a kitchenette and dining room. One hallway extended from the common area to an exit door and another hallway extended from the common area and encircled the kitchenette before rejoining the dining room. During a tour of the assisted living facility on 08/17/26 at 2:40 pm the following was identified: * The main doors to Buildings B, C, and D had three full-thickness holes in the bottom corner of approximately one half inch in diameter; * Handrails throughout the hallways in Building B, C, and D were sanded to bare wood, making them uncleanable; * Multiple resident and exit doors were scraped and discolored in Buildings B, C, and D; * Carpets in common areas and hallways outside multiple resident rooms were discolored; * Multiple upholstered armchairs in each of the buildings’ common areas were discolored and/or torn; and * The toilet seat in the common resident bathroom in Building C hallway was not fully attached, which increased the potential of a resident injury. The areas in need of cleaning and repair were shown to and discussed with Staff 1 (Administrator), Staff 2 (ED Skilled Nursing Facility), and Staff 6 (Maintenance Director) on 08/18/26 at 2:30 pm. They acknowledged the findings.

C613 OAR 411-054-0300 (4)(d-i) General Building: Doors, Walls. Cleanable 1. The action taken to correct the rule violation are as follows: a. The main doors to Buildings B.C, & D with three full thickness holes in the bottom corner of approximately one half inch diameter will be repaired. b. Handrails throughout the hallways in Building B,C, & D will be resanded and sealed to be a cleanable surface. c. Multiple resident doors and exit door with scrapes and discoloration in Buildings B, C & D will be cleaned and repainted. d. Carpet in common areas and hallways outside mulitple residents room with discoloration will be cleaned and or replaced if discoloration is unable to be cleaned. e. Multiple upholstered armchairs in each buildings' common areas with discoloration with be cleaned and all torn armchairs will be disposed of in the dumpster. f. The toilet seat in common resident bathroom in Building C hallway has been repaired. 2. The system will be corrected so this violation will not happen again by: a. All staff will have additional training on reporting maintenance concerns / issues via the use of the maintenance log. b. The maintenance director will review the maintenance log daily during stand up and ensure timely resolution. 3. The area needing correction will be evaluated by: The Administrator, Maintenance Director and / or RCC will conduct interior walk throughs of the community daily, weekly, monthly and will discuss concerns with IDT during daily stand up meetings, as well as during quality improvement meetings. 4. The Facility Administrator, Maintenance Director and / or designee are responsible to ensure the corrections are completed and monitored.