OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 2 of 3 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 facility in 07/2025 with diagnoses including inguinal hernia, skin carcinoma, and hyperlipidemia. Resident 2’s clinical record was reviewed, including the current service plan, dated 01/08/26, and progress notes and temporary service plans, dated 12/02/25 through 03/02/26. Observations of the resident were made, and interviews with staff were conducted. The service plan was not reflective or did not provide clear instructions to staff in the following areas: * Transfers; * Nutrition and hydration; * Catheter care; and * Behaviors; The service plan lacked information regarding transfers for Resident 2. In an interview on 03/03/26 at 11:15, Staff 12 (CG) stated the resident required assistance from one person with a gait belt for transfers. On 03/04/26 at 12:50 pm, the need to ensure service plans were reflective of residents’ current care needs and provided clear direction to staff was discussed with Staff 1 (ED/LPN) and Staff 2 (RN). They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2020 with diagnoses including type 2 diabetes and osteoarthritis. Resident 1’s clinical record was reviewed, including the current service plan dated 02/16/26 and temporary service plans dated 02/14/26 through 03/01/26. Observations and staff interviews were conducted. The service plan was not reflective of the resident’s current needs and did not provide clear direction to staff in the following areas: * Foley catheter care and management, including daily catheter and perineal care and changing the nighttime drainage bag to the daytime leg bag; * Behavioral needs, including a description of the resident’s behaviors, and non-drug interventions for staff to implement in response to the behaviors; * Pain status, including the location of the resident’s pain and pharmaceutical and non-pharmaceutical interventions; and * Evacuation ability, including staff assistance with wheelchair use during emergency evacuation. Observations of the resident and staff interviews conducted from 03/02/26 through 03/04/26 identified the resident had a foley catheter and required staff assistance with wheelchair use. On 03/04/26 at 3:00 pm, the need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED/LPN) and Staff 2 (RN). They acknowledged the findings.

Resident 2's service plan, dated 01/08/2026 was not reflective or did not provide clear direction to staff in the following areas: *Transfers; *Nutrition and hydration; *Catheter care; *Behaviors; and *Fall interventions. Provider's Plan of Correction: 1. Resident 2's service plan was reviewed and updated to ensure it accurately reflects the resident's current needs and provides clear direction to staff. Updates included the following: *Clarified that the resident requires an escort using a wheelchair or walker when going to the dining room. *Transfer status clarified and documented as independent. *Dietary likes and dislikes updated, including fluid preferences to support nutrition and hydration. *Catheter care instructions added, including AM and PM peri-care and switching of the catheter from the day bag to the night bag. *Specific behaviors were added with appropriate staff interventions. *Fall prevention intervention added to ensure the restroom area remains free of rugs or other tripping hazards. 2. To prevent recurrence, all service plans will be reviewed for completeness and clarified by the Community Nurse and/or Executive Director before completing and posting to ensure they accurately reflect the resident's needs and provide clear direction. 3. Service plans will be reviewed quarterly, with any significant change of condition, or as needed to ensure accuracy and completeness. In addition, the Community Nurse and/or Executive Director will conduct periodic audits of service plans to ensure required care areas are clearly addressed. 4. Community Nurse and Executive Director Resident 1's service plan, dated 02/16/2026 was not reflective of the resident's current needs and did not provide clear direction to staff in the following areas: *Foley catheter *Behavioral needs *Pain status *Evacuation ability Provider's Plan of Correction: 1. Resident 1’s service plan was reviewed and updated to accurately reflect the resident’s current needs and provide clear direction to staff. The following updates were made: * Foley catheter care and management instructions were added, including daily catheter and perineal care and procedures for changing the nighttime drainage bag to the daytime leg bag. *Behavioral needs were added, including a description of the resident’s behaviors and appropriate non-pharmacological interventions for staff to implement. *Pain status was updated to include the location of the resident’s pain and both pharmacological and non-pharmacological interventions for staff to implement. *Evacuation ability was clarified to include staff assistance required for wheelchair use during an emergency evacuation. 2. To prevent recurrence, all service plans will be reviewed for completeness and accuracy by the Community Nurse and/or Executive Director prior to completing and posting to ensure the plans reflect the resident’s current needs and provide clear direction to staff. 3. Service plans will be reviewed quarterly, with any significant change in condition, or as needed, to ensure continued accuracy and completeness. The Community Nurse will also conduct periodic audits of service plans to ensure all required care areas are addressed. 4. Community Nurse and Executive Director.

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)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 1 of 1 sampled resident (#1) who had orders for daily weights. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2020 with diagnoses including type 2 diabetes and osteoarthritis. Resident 1’s MARs, dated 02/01/26 through 03/02/26, and active signed physician orders dated 01/27/26 were reviewed. The following was identified: Resident 1 had a physician order for daily weights, with instructions documented, “Please do weights prior to eating. Notify RN if there is a two-pound weight gain in a day or five pounds in a week.” Review of the MARs showed the resident’s weight was documented on 02/01/26, 02/02/26, 02/04/26, 2/05/26, 02/13/26 and 02/28/26. There was no documented evidence the resident’s weight was obtained daily on the on the remaining days as ordered. During an interview on 03/04/26 at 1:20 pm, Staff 1 (ED/LPN) and Staff 2 (RN) confirmed the resident weights were not obtained daily as ordered. The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 and Staff 2 on 03/04/26 at 3:00 pm. They acknowledged the findings.

Resident 1 had a physician order for daily weights - there was no documented evidence the resident’s weight was obtained daily as ordered: Providers Plan of Correction: 1. Resident 1's order format was updated to separate weight documentation from other vital signs such as blood pressure and pulse. This change allows staff to accurately document when a resident refuses to be weighed rather than selecting “N/A.” Staff were instructed to document refusals appropriately and provide supporting chart note documentation when a resident declines weight monitoring. 2. The vital sign documentation format has been revised to ensure staff are able to accurately document resident weights and refusals. This change ensures weight monitoring documentation is clear, accurate, and reflective of the resident’s status. One-on-one training was completed with all medication technicians regarding proper documentation of resident refusals and the requirement to complete a chart note when a resident declines weight monitoring. 3. The Community Nurse and/or Executive Director will review documentation during routine record audits to ensure weights and refusals are documented appropriately and that required chart notes are completed. 4. Community Nurse and Executive Director.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

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 interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications, including over-the-counter medications that were ordered by a legally recognized prescriber and administered by the facility for 2 of 3 sampled resident (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to 1. Resident 2 was admitted to the facility 07/2025 with diagnoses including inguinal hernia, skin carcinoma, and hyperlipidemia. Review of Resident 2’s MAR, dated 02/01/26 through 03/02/26, identified the following: a. The MAR included a prescription for routine acetaminophen 500 mg 2 tablets by mouth 3 times daily. There were also two different strengths of PRN acetaminophen. These were 500 mg caplets and 325 mg caplets. The acetaminophen instructions stated, “not to exceed 3000 mg in 24 hours”. Therefore, no PRN doses could be administered without exceeding 3000 mg. b. The MAR showed two dosages of loperamide 2 mg capsules. One entry instructed “Give 1 capsule orally for loose stool,” and the other “Give 2 capsules orally for loose stool.” There were no instructions for determining sequential order of use. On 03/04/26 at 12:50 pm, the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (ED/LPN) and Staff 2 (RN). They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2020 with diagnoses including type 2 diabetes and osteoarthritis. Resident 1’s MARs dated 02/01/26 through 03/02/26 were reviewed. The following was identified: Resident 1 had a physician order for hydroxyzine 10 mg, one tablet by mouth three times daily as needed for anxiety. The MAR did not include resident-specific parameters or instructions to guide staff on when to administer the PRN hydroxyzine. During an interview on 03/04/26 at 1:20 pm, Staff 1 (ED/LPN) and Staff 2 (RN) acknowledged the MAR did not include resident specific parameters or instructions for administration of the PRN hydroxyzine. On 03/04/26 at 3:00 pm, the need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 and Staff 2. They acknowledged the findings.

Review of Resident #2’s MAR dated 02/01/2026 through 03/02/2026 identified unclear medication instructions. The MAR included routine acetaminophen 500 mg, two tablets by mouth three times daily, along with two different strengths of PRN acetaminophen (500 mg and 325 mg) with instructions not to exceed 3000 mg in 24 hours, which would prevent administration of PRN doses without exceeding the maximum dose. The MAR also listed two separate orders for loperamide 2 mg capsules without clear direction for use: Plan of Correction: 1. Resident #2’s medication orders were reviewed with the prescribing provider and pharmacy. The acetaminophen orders were clarified to ensure that the total daily dose does not exceed the prescribed maximum amount and to provide clear direction regarding routine versus PRN administration. The loperamide orders were also clarified to ensure clear instructions for staff regarding the appropriate dosage and administration for loose stool. The MAR was updated to reflect the clarified physician orders. 2. To prevent recurrence, the Community Nurse and/or Executive Director will review all new and updated medication orders and MAR entries for clarity, duplication, and potential medication dosing conflicts prior to implementation. Medication technicians were educated on the importance of identifying unclear, duplicate, or conflicting medication orders and the requirement to notify the Community Nurse, pharmacy, or prescribing provider for clarification before administering medications. 3. The Community Nurse and/or Executive Director will conduct routine MAR audits to ensure medication orders are clear, complete, and accurately transcribed, and that potential medication conflicts are identified and clarified promptly. 4. Community Nurse and Executive Director. Resident 1 had a physician order for hydroxyzine 10 mg, one tablet by mouth three times daily as needed for anxiety. The MAR did not include resident-specific parameters or instructions to guide staff on when to administer the PRN hydroxyzine: Plan of Correction: 1. The PRN hydroxyzine order was reviewed with the prescribing provider and clarified to include resident-specific parameters and clear guidance for staff regarding indications for administration. The MAR was updated to reflect these instructions to ensure safe and appropriate PRN use. 2. To prevent recurrence, the Community Nurse and/or Executive Director will review all new and updated PRN medication orders to ensure that each includes resident-specific parameters, indications, and administration guidance before being placed on the MAR. Medication technicians were trained on the importance of following PRN parameters as indicated on the MAR and verifying unclear orders with the Community Nurse or prescribing provider prior to administration. 3. The Community Nurse and/or Executive Director will perform routine audits of PRN medication documentation to ensure that orders are clear, complete, and include resident-specific administration parameters. 5. Community Nurse and Executive Director.

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: