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 status and care needs and provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the MCC in 10/2024 with diagnoses including Alzheimer’s disease and anxiety disorder. The resident’s current service plan was reviewed, staff were interviewed, and observations of the resident were made. The service plan was not reflective of the resident’s current status and care needs and/or did not provide clear direction to staff regarding the delivery of services in the following areas: * When protein shakes should be offered; * PRN psychotropic medications and non-pharmacological interventions; * Use of fall mat; * Sleeping patterns; * Use of tab alarm in bed, wheelchair, and recliner; and * Tilt wheelchair. The need to ensure service plans were reflective of the resident’s current status and care needs and provided clear direction to staff was discussed with Staff 1 (ED) on 07/17/25 at 1:05 pm. She acknowledged the findings. 2. Resident 1 moved into the MCC in 04/2025 with diagnoses including type 2 diabetes mellitus and unspecified dementia. The resident’s record, including progress notes dated 04/22/25 through 07/14/25, were reviewed. Observations of the resident were made, and staff were interviewed. The following was identified: A review of Resident 1’s service plan dated 05/22/25 was completed. The service plan was not reflective of the resident’s needs, did not provide clear direction to staff, and/or was not being implemented as instructed in the following areas: * Non-pharmaceutical interventions for pain; * Use of a gait belt during transfers; and * When protein shakes should be offered. The need to ensure service plans were reflective of the residents’ current status and care needs, provided clear direction to staff, and were being implemented as instructed was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Vice President of Operations) on 07/17/25 at 10:00 am. They acknowledged the findings.

Heritage House of Woodburn will implement the following: 1. The Executive Director reviewed and is updating all residents Evals to the new version to ensure all care needs are being transferred over. RN will also review and sign Eval/SP Resident 2: Protein Shakes were added to the MAR, Interventions were added to MAR and supplemental documentation was added. TSP’s were added for Fall mat, Tab alarm and bed alarm. RN did a restraint eval for the recliner and Tilt wheel chair was discontinued and she has a regular Wheel chair. Resident 1: Service plan change was made taking out the gait belt. Francisca doesn't get protein shakes. 2. Caregivers will be responsible for reviewing, signing and following the care plans. They will also be trained on signing off on the tasks after they have completed them. 3. All staff will receive additional training at the next in- service on how to read the care plans and to notify management if any of the residents care needs have changed. 4. The Executive Director and/or Nurse will review and monitor to ensure that the care plans are being reviewed and signed and that the proper care is being delivered. The Executive Director and/or Assistant Executive Director will pull reports to ensure that tasks are signed off each week and be responsible to see that corrections are completed and monitored.

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:

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 an RN assessment was completed in a timely manner for a significant change of condition for 1 of 1 sampled resident (#2) reviewed with weight loss. Resident 2 continued to lose weight. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2024 with diagnoses including Alzheimer’s disease. During the acuity interview on 07/14/25, staff indicated Resident 2 was on hospice and had experienced significant weight loss within the last 90 days, The resident’s progress notes and temporary service plans (TSPs), dated 04/15/25 through 07/09/25, were reviewed, as well as weight loss records from 01/03/25 through 07/04/25. Observations were made of the resident, and staff were interviewed. The resident’s weight records indicated the following: * 01/03/25 – the resident weighed 141.5 pounds; * 06/03/25 – the resident weighed 114.5 pounds; and * 07/04/25 – the resident weighed 110.4 pounds. Between 01/03/25 and 06/03/25, the resident lost 27 pounds, or 19.08% of his/her total body weight, in five months. This constituted a severe weight loss and a significant change of condition. There was no documented evidence a significant change of condition assessment was completed by the RN. The resident continued to lose weight. A temporary service plan (TSP) dated 06/04/25 instructed staff to “encourage and assist with meals as needed or tolerated. Staff are to encourage a protein shake with all meals.” There was no documented evidence staff were providing protein shakes to the resident with meals. Between 06/03/25 and 07/04/25, the resident lost another 4.1 pounds. This was a total loss of 31.1 pounds between 01/03/25 and 07/04/25, or 21.97% of his/her total body weight. This constituted a severe weight loss. In an interview on 07/15/25 at 7:50 am, Staff 1 (ED) reported the RN had “overlooked” the need for a significant change of condition assessment after being notified when the resident’s weight loss was first identified on 06/04/25. Further weight loss was identified on 07/04/25, the RN was notified, and a significant change of condition assessment was completed and signed on 07/10/25. In that assessment, the RN incorrectly documented the resident had gained 4.1 pounds in one month. Survey requested the resident be weighed on 07/15/25. At 8:10 am, the resident’s weight was documented as 114.1 pounds, a gain of 3.7 pounds since 07/04/25. During the survey the resident was observed to begin eating lunch independently on 07/14/25. The resident was able to take a few bites but then appeared to be unable to cut up the food, at which time Staff 5 (MT/CG) began to assist the resident with eating. Resident 2 ate 100% of his/her lunch with staff assistance. In interviews on 07/14/25 and 07/15/25, Staff 4 (MT) and Staff 9 (MT/CG) indicated they had noticed Resident 2 losing weight in the last few months based on how his/her clothing fit. On 07/15/25 at 1:25 pm, Staff 4 (MT) reported Resident 2 ate 100% of his/her breakfast and approximately 75% of his/her lunch. When asked if the resident was provided with a protein shake after lunch, Staff 4 stated she was unsure if there were protein shakes for the resident. She indicated protein shakes were not on the resident’s MAR. The resident experienced severe and ongoing weight loss, with no documented evidence staff were assisting the resident with meals or providing protein shakes as noted in the 06/04/25 TSP. The RN significant change of condition assessment was completed and signed six days after the second identified severe weight loss. The need for all significant changes of condition to be assessed by an RN in a timely manner was discussed with Staff 1 (ED) on 07/16/25 at 1:05 pm and with Staff 1 and Staff 3 (VP of Operations) on 07/17/25 at 8:32 am. Staff acknowledged the findings.

Heritage House of Woodburn will implement the following: 1. The Executive Director and RN will be trained to look at all weights the day they take the weight and Executive Director will get a re-weights if needed and Report to RN 2. The Executive Director will work with the nurse as weights are taken to ensure and monitor there is no change of condition. review all weights. Will also communicate on the nurses Corner Board. 3. Executive Director and /or Assistant Executive will check monthly and do a progress note. 4. Executive Director and Assistant will be responsible to see that 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:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 2 sampled residents and multiple unsampled residents related to dining services and 1 of 2 sampled residents (# 2) who were dependent on staff for ADL care. Findings include, but are not limited to: 1. Lunch service was observed on 07/14/25 at 12:11 pm. a. Staff were observed serving meals and beverages, touching residents and various surfaces in the dining room and kitchen, and assisting residents with feeding without changing their gloves or performing hand hygiene. b. Direct care staff were observed serving food to residents without donning a protective barrier over potentially contaminated clothing. On 07/17/25 at 10:00 am, the need to maintain infection prevention and control protocols was reviewed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Vice President of Operations). They acknowledged the findings. 2. Resident 1 moved into the MCC in 04/2025 with diagnoses including type 2 diabetes mellitus and unspecified dementia. On 07/15/25 at 12:06 pm Staff 6 (MT/CG) was observed providing feeding assistance for Resident 1. Staff 6 was not observed wearing hand or clothing protection while feeding Resident 1. During the meal, Staff 6 paused assisting the resident, walked to the kitchen, and retrieved food for another resident. Staff 6 resumed assisting Resident 1 without performing hand hygiene. When Staff 6 finished feeding the resident, she began gathering soiled dishes and was observed with the right thumb of her right hand on the plate surface of a soiled plate. Staff 6 brought the plate to the kitchen and poured a glass of juice and handed it to a an unsampled resident without performing hand hygiene. The need to maintain infection prevention and control protocols was discussed with Staff 1 (ED) on 07/16/25 at 2:15 pm. She acknowledged the findings. 3. Resident 2 was admitted to the MCC in 10/2024 with diagnoses including Alzheimer’s disease and anxiety disorder. S/he was identified in the acuity interview as dependent on staff for all ADL care. Incontinence care for Resident 2 was observed on 07/14/25 at 12:06 pm. Staff were observed to wear the same gloves throughout incontinence care, not changing them between clean and dirty tasks. Staff removed their gloves when the incontinence care was completed, but they did not perform hand hygiene after removing the gloves. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) on 07/16/25 at 1:05 pm. She acknowledged the findings. 4. On 07/14/25 at 12:30 pm, a staff member was observed to enter the kitchen area, run her hands under water, turn the water off, shake their hands once, remove a fork from a drawer, and leave the kitchen to provide meal assistance to a resident in the dining room. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) on 07/16/25 at 1:05 pm. She acknowledged the findings.

Heritage House of Woodburn will implement the following: 1. All staff will take another infection prevention and Control class and a hands on training will be given to all staff. OCP Hand hygiene class will be assigned for all staff to do. We retrained staff and watch the staff daily. 2.Daily- Laminated signage will be posted in every room and restroom to remind staff to wash hands 3.Daily by Executive Director and or person in charge 4. The Executive Director and Assistant will be responsible for monitoring the corrections to be sure they are completed.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure there were written, resident-specific parameters for PRN psychotropic medication and failed to document non-pharmacological interventions as ineffective prior to administering a PRN psychotropic for 1 of 1 sampled resident (#2) who was prescribed PRN psychotropics. Findings include, but are not limited to: Resident 2 was admitted to the MCC in 10/2024 with diagnoses including Alzheimer’s disease and anxiety disorder. The resident’s 07/01/25 through 07/14/25 MAR and physician orders were reviewed, and staff were interviewed. The resident had two PRN psychotropic medication prescriptions: * Haloperidol lactate 2 mg/ml solution, 2.5 ml every two hours as needed for anxiety, agitation, and restlessness; and * Lorazepam 1 mg tablet, one tablet every two hours as needed for agitation, anxiety, and restlessness not relieved by haloperidol. There were no resident-specific parameters related to how the resident exhibited anxiety, agitation, and restlessness, nor were there non-pharmacological interventions listed on the resident’s MAR. There was no documented evidence staff had attempted non-pharmacological interventions and documented them as being ineffective prior to administering the PRN psychotropic medications. In an interview on 07/15/25 at 8:15 am, Staff 1 (ED) verified there were no resident-specific parameters or non-pharmacological interventions for the two PRN psychotropic medications on the MAR. Staff 1 stated the non-pharmacological interventions had been on the MAR in the past, but had not been re-entered when a new prescription was entered on the MAR by the RN. The need to ensure all PRN psychotropics on the resident’s MAR included resident-specific parameters and non-pharmacological interventions to attempt prior to administering the PRN psychotropic was discussed with Staff 1 (ED) on 07/16/25 at 1:05 pm. She acknowledged the findings.

Heritage House of Woodburn will implement the following: 1.Correct interventions were placed in EMAR for staff to sign and in the care plan with detailed steps to try before use of behavioral medication. 2. Staff will be retrained on correct documentation with use of medication, and supplemental documentation was added and that will trigger for interventions to be charted before giving medication. 3. Executive Director and Assistant Executive Director and Nurse will review weekly for PRN use to ensure it is being used correctly and documentation is correct. 4.Executive Director And Assistant Executive Director will be responsible for weekly monitoring of PRN use.

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

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure an RN, PT, or OT had conducted a thorough assessment of all supportive devices with restraining qualities for 1 of 1 sampled resident (#2) who had a supportive device. Findings include, but are not limited to: Resident 2 was admitted to the MCC in 10/2024 with diagnoses including Alzheimer’s disease and anxiety disorder. The resident’s clinical record was reviewed, observations of the resident were made, and staff were interviewed. The following was identified: * The resident’s current service plan, most recently updated on 07/10/25, indicated the resident used a tilt back wheelchair; * The resident was observed to be escorted to and from meals in the tilt back wheelchair. There was no documented evidence a thorough assessment of the tilt back wheelchair had been conducted by an RN, PT, or OT. In an interview on 07/16/25 at 9:05 am, Staff 1 (ED) reported the tilt back wheelchair was no longer being tilted back when the resident was using it and verified there was no assessment of the tilt back wheelchair completed by an RN, PT, or OT. The need for an RN, PT, or OT to thoroughly assess all supportive devices with restraining qualities was discussed with Staff 1 on 07/16/25 at 1:05 pm. She acknowledged the findings. Staff 1 provided an assessment of the tilt back wheelchair completed by the RN on 07/16/25, and stated she had ordered a new, non-tilt back wheelchair for the resident which was to be delivered later that day.

Heritage House of Woodburn will implement the Following: 1. The Executive Director will ensure we are making sure when a restraint device is delivered we are to communicate with RN for an assessment to be done. The tilted wheelchair got removed due to the resident not using it. 2. Executive Director and Nurse will check residents, rooms and areas to be sure no residents are using any kind of restraining things per OAR. All Staff were trained on what are considered restraints. 3.Weekly by nurse and Director. 4.The Executive Director and Assistant is responsible to ensure correction is completed and monitored

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident during the overnight shifts, based on resident acuity. Findings include, but are not limited to: During the acuity interview at 9:45 am on 07/14/25 and other staff interviews throughout the survey, the following was noted: * The facility was a licensed MCC with a current census of 15 residents; * Two residents required a two-person assist to transfer; * Observations of the community, conducted from 07/14/25 to 07/17/25, revealed multiple sampled and unsampled residents used wheelchairs for mobility; and * Seven residents required two-person assist for behavioral symptoms. Review of staffing schedules from 07/07/25 through 07/13/25 revealed the facility staffed two Universal Workers on the overnight shifts from 07/07/25 through 07/13/25. The overnight shift staffing from 07/07/25 through 07/13/25 was insufficient to meet the unscheduled needs for multiple sampled and unsampled residents based on their acuity. The need to have a sufficient number of direct care staff to meet the scheduled and unscheduled needs of the residents was discussed with Staff 1 (ED) on 07/17/25 at 10:15 am. She acknowledged the findings.

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 in fire and life safety procedures at lease annually. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 07/14/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities at least annually. The need to ensure residents were instructed in fire and life safety procedures at least annually, was discussed with Staff 1 (ED) on 07/16/25 at 2:15 pm. She acknowledged the findings.

Heritage House of Woodburn will implement the following: 1. Fire Safety/Evacuation form including review of safety/procedures will be done on all residents yearly in August. 2. Staff will ensure that the evacuation evaluation is completed each admit, as needed and August of every year . 3. The Executive Director will be checking this with each move in and quarterly. 4. The Executive Director and Assistant will be responsible to see that this is 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:

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure all individuals had the right to freedom from restraints. Findings include, but are not limited to the following: Refer to C340.

Refer to C340

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C295, C360, and C422.

Refer to C280

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C280, C330, and C340.

Refer to C260, C280, C330, and C340.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individualized activity plan based on their activity evaluation, for 1 of 2 sampled residents (# 2) whose records were reviewed. Findings include, but are not limited to: Resident 2’s activity evaluation and service plan were reviewed. Though the activity evaluation offered some information about the residents’ past and current interests and included activities that could be used as behavioral interventions, the facility had not evaluated the resident’s: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; and * Adaptations necessary for participation. There was no individualized activity plan developed for the resident based on their activity evaluation which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities. The need to complete an activity evaluation which addressed all required elements and for an individualized activity plan to be developed from the evaluation for each resident was discussed with Staff 1 (ED) on 07/17/25 at 1:05 pm. She acknowledged the findings.

Heritage House of Woodburn will implement the Following: 1. The Executive Director updated all activity assessments and added personalized activities for all shifts including night shift. Resident 1: Reviewed activity assessment and edited adding the current abilities and skills, Emotional and social needs and patterns, Physical abilities and limitations; and adaptations necessary for participation. 2. In the company system for each resident all questions will be answered for more individualized activities for all shifts 3. Activities will be monitored three times a week 4. The Executive Director and assistant will be responsible for monitoring.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: