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 evaluation contained all required elements specified in the rule and quarterly evaluations described the resident’s physical health status for 2 of 5 sampled residents (#s 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into to the facility in 12/2025 with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, and history of diverticulitis. Review of the resident’s move-in evaluation indicated the following elements were not addressed: * Routines: eating and bathing; * Cultural preferences and traditions; * Grooming ability; * Transfer ability; and * Non-pharmacological interventions for pain. The information lacking from the move-in evaluation was reviewed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 12:45 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 07/2022 with diagnoses including dementia, depression, and hypertension. The resident's quarterly evaluation, dated 11/14/25, was reviewed, and staff were interviewed. The evaluation was not reflective of his/her current physical health status in the following areas: * Transfer status; * Pain, including pharmacological and non-pharmaceutical interventions; and * Skin condition. The need to ensure the quarterly evaluation was reflective of the resident’s current physical health status was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:25 pm. The findings were acknowledged.

Resident #3 Routines and non-pharmacological interventions for pain were reviewed with resident on 1/20/26 Resident #2 evaluation was reviewed and updated with current physical health status to include pharmacological and non-pharmaceutical interventions 1/20/26 Current resident evaluations will be reviewed and updated by 3/09/26 Associates who complete the evaluations at move in and after were educated on the form and policy on 1/23/26 Health and Wellness Director or designee will monitor the move in and scheduled evaluations for person centeredness during weekly collarborative care review with no end date Executive Director or designee will monitor completion of audits 3 times a month for 60 days. Health and Wellness Director or designee will review plan of correction at monthly quality assurance for 180 days.

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:

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 provided clear direction regarding the delivery of services for 1 of 1 sampled resident (# 5) who resided in the memory care unit. Findings include, but are not limited to: Resident 5 moved into the memory care unit in 07/2025 with diagnoses including dementia. The resident's clinical record was reviewed, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff in the following areas: * Showers pertaining to when the resident required full assistance, stand-by assistance, and when Resident 5 requested additional showers; * Bathroom assistance and when it was needed; * How the resident exhibited behaviors and direction to staff on what precautions to take; * Increased fall risk when Resident 5 exhibited behaviors; * Ability to communicate needs and wants; * Dressing assistance needs and the use of underwear or briefs; and * Personal preference of assistance with hair brushing. The need to ensure service plans provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 1:24 pm. They acknowledged the findings.

Service plan for resident # 5 was reviewed and updated with person centered instruction and interventions on 1/21/26 Service plans will be reviewed and updated for person centered instruction by 3/09/2026 Associates who create service plans received additional training on person centered approach and behavioral supports on 1/16/2026- 1/23/2026 Additional Service plan reviews will be completed during weekly collaborative care reviews Executive Director or designee will audit completion three (3) times a month for 60 days Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days

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 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order for 3 of 3 sampled residents (#s 2, 3, and 5) with documented medication refusals. Findings include, but are not limited to: 1. Resident 5 moved into the memory care unit in 07/2025 with diagnoses including hypertension, atrial fibrillation, and dementia. The resident's 12/01/25 through 01/05/26 MARs and 09/24/25 physician's orders were reviewed. The records showed that Resident 5 refused medications on the following days: * 12/21/25: Amiodarone (for heart failure), carvedilol (for hypertension), vitamin D (supplement), furosemide (for blood pressure), potassium (supplement), apixaban (for atrial fibrillation), and buspirone (for anxiety); and * 12/28/25: Atorvastatin (for cholesterol), carvedilol, irbesartan (for hypertension), memantine (for Alzheimer's disease), apixaban, and buspirone. On 01/06/26 at 12:25 pm, Staff 11 (Director of Clinical Services) confirmed the physician was not notified of the 12/21/25 and 12/28/25 medication refusals. The need to notify the physician or other practitioner when a resident refused to consent to an order was reviewed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 on 01/08/26 at 1:24 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 07/2022 with diagnoses including dementia, depression, and hypertension The resident's 12/01/25 through 01/05/26 MARs and progress notes and temporary service plans dated 10/05/25 through 01/05/26 were reviewed and revealed the resident refused to consent to orders for the following medications: * Gabapentin 300mg capsule at bedtime for neuropathic pain on three occasions; * Trazodone 50mg tablet at bedtime for trouble sleeping on three occasions; * Acetaminophen 500mg, take 2 tablets two times a day for pain, on three occasions; * Carboxymethylcellulose 0.5% eye drops twice a day for eye irritation on three occasions; and * Nystatin mouth/throat suspension 100000 unit/ml four times a day for infection of oropharynx on 19 occasions. There was no documented evidence the prescriber was notified after each refusal of the medications. In an interview on 01/07/26 at 10:00 am, Staff 7 (Health and Wellness Coordinator) acknowledged the lack of provider notification and stated they are continuing to educate MTs to write progress notes and fax the provider for each refusal. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:25 pm. The findings were acknowledged. No further documentation was provided. 3. Resident 3 moved into the facility in 12/2025 with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, and history of diverticulitis. The resident’s MAR, dated 12/01/25 to 01/05/26, was reviewed, and the following was noted: * The resident was prescribed acetaminophen 500 mg tablet – two tablets TID for pain; * The MAR indicated the resident refused the medication 21 of 93 times it was to be administered; and * There was no documented evidence the facility notified the prescriber of the refusals. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 12:45 pm. They acknowledged the findings.

Physician contacted for resident 2, 3, 5 for refusal trends on 1/20/2026. Upon receipt of physican review, orders will be updated Medication Tech and nurses trained on physician notification policy and resident rights on 1/20/2026 Medications refusals will be reviewed to verify notifications per physican order will be completed in clinical review at least 5 days a week for 3 months Health and Wellness Director or designee will track and trend pattern of refusals and notify physician for medication need and/or expected notification Executive Director or designee will monitor audit completion 3 times a month for 60 days Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to keep an accurate MAR for all medications that were ordered by a legally-recognized provider and administered by the facility for 3 of 5 sampled residents (#s 1, 2, and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 12/2025 with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, and history of diverticulitis. The resident’s MARs, dated 12/01/25 through 01/05/26, were reviewed, and the following was noted: The resident had orders from the hospice provider for PRN haloperidol (for hallucinations and agitation), PRN lorazepam (for anxiety or difficulty breathing), and PRN morphine (for pain and difficulty breathing). Each medication order included instructions that the facility “May give without trying nonpharmacological interventions first.” The morphine order had additional instructions to “Call hospice if ineffective or if patient receives [three] hourly doses.” * The instructions were not transcribed to the MAR for the three medications noted above. The need to ensure the MAR was accurate was reviewed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 12:45 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2023 with diagnoses including fibromyalgia, chronic pain, chronic fatigue syndrome, and constipation. The resident’s MAR, dated 12/01/25 to 01/05/26, was reviewed, and the following was noted: There was no documented evidence of medication-specific instructions for administration of the following PRN medications by unlicensed staff: * Metoprolol succinate ER (extended release) 25mg (for atrial fibrillation); * Flecainide acetate 100mg (for atrial fibrillation); and * Denta 5000 plus dental cream 1.1%. In an interview with Staff 11 (Director of Clinical Operations) on 01/07/26, she confirmed that there were no medication-specific orders for the three medications. The need to ensure that medication-specific instructions were included with each medication was discussed with Staff 1(ED), Staff 2 (Associate ED), Staff 3, Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:05 pm. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2022 with diagnoses including dementia, depression, and hypertension. The resident's 12/01/25 through 01/05/26 MARs and current physician orders were reviewed, and the following inaccuracies were noted: On 12/20/25, a treatment for Resident 2’s pressure ulcer was added to the MAR which directed MTs to complete during the evening shift. On 01/07/26 at 3:10pm, Staff 13 (MT) acknowledged she had never performed the resident’s treatment. On 01/07/26 at approximately 3:15pm, Staff 18 (CG), confirmed that she had performed the treatment for the resident on several occasions. A review of the resident’s MAR showed the treatment was initialed by Staff 13 on 11 occasions. The need to ensure MARs were initialed by the person who completed the treatment was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:25 pm. The findings were acknowledged.

Electronic Medication Administration Record ( EMAR) reviewed for resident 1: instructions were verified and transcribed to the medication administration record for the three medications noted on 1/08/26 and 1/21/26 Resident 2, treatment orders were reviewed and verified with instruction on 1/09/26 Resident 3, hospice orders were verified and transcribed to medication administration record on 1/21/26 EMAR accuracy and documentation will be reviewed, clarified and corrected as needed by 2/13/2026. Medication Technition and Nurses were trained on the policy for medication administration documentation, PRN administration on 1/20/2026 Nurse or designee will reconcile written physician orders in conjuction with order transcription review process during clinical review at least 5 days a week for 3 months. Executive Director or designee will monitor audit completion 3 times a month for 60 days. Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days.

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated quarterly and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#1) who was reviewed for self-administration of medications. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2023 with diagnoses including fibromyalgia, chronic pain, chronic fatigue syndrome, and constipation. Resident 1's signed physician orders, dated 09/03/25, and MAR, dated 12/01/25 through 01/05/26, were reviewed during the survey and indicated the following: * During the MAR review, it was discovered that the resident was prescribed the following medications and administering them him/herself, as indicated by “unsupervised self-administration” noted on the MAR for each medication: - Miralax Oral Powder 17gm/scoop (for constipation); - Vit D3 oral capsule 1000 units (a supplement); - Lubiprostone oral capsule 8mcg (for Parkinson’s related constipation); - Colace oral capsule 100mg (for constipation); - Senna oral tablet 8.6mg (for constipation); and - Zinc oral tablet (a supplement). * There was no documented evidence the facility had obtained signed written orders of approval for the resident to self-administer the medications. During an interview with Staff 3 (Health and Wellness Director) on 01/05/26, she confirmed that there was not an order for self-administration of medications. There was no documented evidence that self-medication evaluations were being completed on a quarterly basis. The evaluations provided were completed on 03/26/25 and 01/05/26. The need to ensure residents who choose to self-administer their medications were evaluated quarterly and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medication was discussed with Staff 1(ED), Staff 2 (Associate ED), Staff 3, Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:05 pm. They acknowledged the findings.

Self Administration evaluation completed for resident 1 on1/5/26 An audit for the other residents who self-administer medication was completed on 1/20/2026 Associates who complete self-administration audits were trained on policy on 1/23/2026 Service plan team will review required evaluation forms during care conference for completion Health and Wellness Director or designee will audit completion of quarterly evaluations per service plan schedule or changes in condition during collaborative care review weekly for 90 days Executive Director or designee will monitor audit completion 3 times a month for 60 days Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. 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 PRN psychotropic medications, administered to treat a resident's behavior, must have written, resident-specific parameters, for 1 of 1 sampled resident (#3) who was administered PRN psychotropic medications. Resident 3 was admitted to the facility in 12/2025 with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, and history of diverticulitis. The resident had orders from the hospice provider for: * PRN haloperidol (for hallucinations and agitation); and * PRN lorazepam (for anxiety or difficulty breathing). There were no parameters for unlicensed staff which described how Resident 3 exhibited hallucinations, agitation, and anxiety to guide the staff in administering the medications. The need to ensure PRN psychotropic medications to treat a resident's behavior had written, resident-specific parameters was reviewed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 12:45 pm. They acknowledged the findings.

Review of residents on PRN psychotropic medications was completed on 1/09/2026 and 1/20/26 Diagnosis clarification and/or individualized parameters will be completed by 1/31/2026 Associates were trained on PRN medications and treatment policy on 1/20/2026 PRN Psychotropics and other PRN medications orders will be reviewed during clinical review at least 5 days a week for three months. Executive Director or designee will monitor audit completion 3 times a month for 60 days Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days.

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 411-057-0160(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: Please refer to: C 260 and C 305.

Refer to plan of correction for C252, C260, C305, C310, C325, and C330.

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: