OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained all required elements and was dated for 1 of 1 sampled residents (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 05/2026 with diagnoses including an upper extremity fracture. Resident 1’s move-in evaluation was reviewed, and the following was identified: a. The document failed to address the following required elements: * Pronouns and gender identity; * Personality, including how the person copes with change or challenging situations; * Memory, orientation, and confusion; * Communication and sensory abilities, including vision, speech, and the ability to understand and be understood; * Activities of daily living: toileting, bowel and bladder management, bathing, and transfers; * List of treatments – type, frequency, and level of assistance needed; * Indicators of nursing needs, including potential for delegated nursing tasks; * Recent losses; and * Smoking. b. The evaluation was not dated. The need to ensure the initial evaluation contained information addressing all required elements and was dated was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (Director of Clinical Services) on 07/16/26 at 2:22 pm. They acknowledged the findings.

1. A new Resident Evaluation was completed for Resident #1 which addresses the required elements. 2. The current Resident Evaluation for existing residents will be reviewed to verify that the required elements are completed. 3. For the next 90 days, the Resident Care Coordinator and Health & Wellness Director will review the resident evaluations completed weekly for new admissions, reassessments and residents with change of condition to verify the required elements were completed. Executive Director or designee will monitor audit completion 3 times a month for 90 days and then monthly thereafter. 4. Executive Director, Health & Wellness Director, and Area RN or designee

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 were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 6 sampled residents (#s 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2025 with diagnoses including type 2 diabetes mellitus, congestive heart failure, and chronic atrial fibrillation. S/he was subsequently admitted to hospice services on 07/03/26, with an admitting diagnosis of congestive heart failure. Observations were made of the residents’ care on 07/14/26 and 07/15/26. Interviews with the resident and facility staff were conducted, and the service plan, dated 07/03/26, was reviewed. Resident 4's service plan was not reflective of the residents’ current needs and lacked clear instructions to staff in the following areas: * Instructions for proper maintenance of blood glucose monitor on right upper extremity and how to monitor for malfunctions; * Instructions to staff for blood glucose monitoring protocol when resident slept late and skipped meals; * Pacemaker precautions, instructions for proper maintenance, and how to # malfunctions; * Instructions for signs and symptoms of anxiety to report while on anti-anxiety therapy; * Instructions for peri and skin care; * Instructions for Foley leg bag and night bag placements; * Incorrect reference to resident being on anticoagulation therapy; * Instructions for specific changes of condition to report to hospice; * Instructions for fall prevention; * Two electric wheelchair equipment precautions and instructions for proper maintenance; and * Incorrect reference to resident not requiring assistance with dressing. During an interview on 07/14/26 at 11:27 am, Resident 4 stated s/he needed one-person assistance with dressing and switching placement of his/her Foley bag. Staff 12 (CG), interviewed on 07/15/26 at 11:07 am, confirmed Resident 4 “starts calling for assist at 6:30 am to help with dressing, Foley bag…” and other ADLs for which s/he required one-person assistance. Review of the MARs confirmed the resident was taking sertraline (for anxiety) daily and Eliquis (blood thinner) was discontinued upon admission to hospice on 07/03/26. Observation of a transfer in the dining room from dining chair to electric wheelchair on 07/13/26 at 1:28 pm confirmed Resident 4 required one-person assistance. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Health Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 07/16/26 at 3:05 pm. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 04/2023 with diagnoses including Parkinson’s disease with dyskinesia (uncontrollable body movements, tremors), dementia, and adult failure to thrive. During the acuity interview on 07/13/26, Resident 6 was identified as receiving hospice services. Observations were made of the resident's care on 07/15/26 and 07/16/26. Interviews with facility staff were conducted, and the service plan, dated 05/19/26, was reviewed. Resident 6's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions for safe use and monitoring of a shoulder harness used to facilitate an upright seated posture; * Instructions for communicating with a non-verbal resident who used gestures and other bodily movements for communicating with staff; * Instructions for aspiration precautions and interventions while choking; * Incorrect reference to resident diet texture; * Instructions regarding to whom weight gain or loss and changes in appetite to be reported; * Instructions for peri and skin care; * Instructions for signs and symptoms of anxiety to report while on anti-anxiety therapy; * Instructions for signs and symptoms of depression to report while on antidepressant therapy; and * Instructions for specific changes of condition to report to hospice. Staff 8 (MT) was interviewed on 07/15/26 at 2:21 pm and stated Resident 6 was on pureed texture diet since “about four months ago.” However, the service plan available to staff stated the resident’s diet was regular and the MARs listed the diet as mechanical soft. During the meal observation on 07/16/26, Resident 6 was observed to have been served a mechanical soft texture diet and regular texture during the lunch meal. Staff 8 also stated that while eating meals, Resident 6’s “nose runs and [s/he] coughs…” Review of the MARs confirmed the resident was taking lorazepam (for anxiety) daily at midnight and sertraline (for depression) daily. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services/RN) on 07/16/26 at 3:05 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 02/2026 with diagnoses including mild cognitive impairment and depression. Observations of staff assisting Resident 5 and interviews with the resident and facility staff were conducted during the survey, from 07/13/26 to 07/16/26. Resident 5's service plan, dated 05/22/26, was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed for transfers; * Level of assistance needed for toileting, bathing, and dressing; * Level of assistance needed for grooming and hygiene; * Ambulation ability and fall risk; and * Instructions for meals and nutritional supplements. The need to ensure service plans were reflective and provided instructions for staff was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 07/16/23 at 3:00 pm. They acknowledged the findings.

1. The service plans for resident #4, #5 and #6 have been updated to reflect the residents' current needs and to provide person centered instruction and interventions. 2. The service plans for existing residents will be reviewed to verify service plans are reflective of current needs and to provide clear direction to staff on how to provide and deliver services. 3.Quarterly audits will be completed by HWD and RCC to verify compliance. Executive Director or designee will monitor audit completion 3 times a month for 60 days, then monthly thereafter. 4. Executive Director, Health & Wellness Director, and Area RN or designee will ensure compliance.

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 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, service plans were updated, actions or interventions were determined and communicated to staff on all shifts, and failed to monitor the changes, with weekly progress noted through resolution, for 3 of 6 sampled residents (#s 3, 4, and 5) with changes of condition. Resident 5 had ongoing severe weight loss. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 2/2026 with diagnoses including mild cognitive impairment and depression. a. A review of the resident's clinical record, including weight records from 04/01/26 through 07/13/26, the most recent service plan and evaluation dated 05/22/26, 07/01/26 through 07/13/26 MAR, and 04/13/26 through 07/13/26 charting notes, interviews with staff, a witness, the resident, and observations of the resident were completed between 07/13/26 and 07/15/26. Weight records indicated the resident weighed: * 04/01/26: 131.0 pounds; * 05/05/26: 134.0 pounds; * 06/02/26: 132.6 pounds; * 06/05/26: 134.0 pounds; * 06/24/26: 125.0 pounds; * 06/28/26: 121.2 pounds; and * 07/13/26: 112.4 pounds (taken during the survey). The “Weight and Vitals Summary” documented Resident 5 experienced an 11.4-pound weight loss between 06/02/26 and 06/28/26, or 8.6 % of his/her total body weight, in one month, which constituted a significant change of condition. There was no documented evidence the resident's weight loss was evaluated, and actions or interventions were determined, documented, and communicated to staff on all shifts. A “Provider Progress Note” dated 07/09/26 documented Resident 5’s Nurse Practitioner identified “abnormal weight loss,” recorded “06/05/26 135 lbs [sic] to 06/24/26 125 lbs [sic],” and signed an order for “High calorie shakes three times a day at mealtime for nutritional supplementation.” Review of Resident 5’s record showed no documented evidence the high calorie shakes that were ordered were added to the MAR, the service plan, or the kitchen “Diet type report” of nutritional orders. There was no documented evidence the shakes were given or consumed. On 07/13/26, the surveyor requested Resident 5’s current weight, and it was measured at 112.4 pounds. Resident 5 had lost an additional 8.8 pounds, or 7% of his/her total body weight, since the significant weight loss identified on 06/28/26. This represented a severe loss of over 10% in two months. Meal observations on 07/13/26 through 07/16/26 revealed Resident 5 could eat independently, but often refused meals, with approximately 20% intake during one observation of drinking a high calorie shake. Multiple interviews with staff throughout the survey indicated the resident sometimes received high calorie shakes but often refused meals and confirmed there was no documented monitoring of intake or refusal and no service plan updates regarding the weight loss. The facility failed to evaluate, determine interventions, and monitor Resident 5’s significant weight loss, and s/he continued to lose weight. b. Resident 5’s most recent quarterly evaluation, dated 05/22/26, documented “one complex wound AND [sic] wound care is to be provided by the community.” Resident 5’s most recent service plan, dated 05/22/26, documented, “Resident has a wound on [his/her] right lower extremity.” A home health RN note dated 06/08/26 documented, “reason for visit: wound care” and “R shin progressing, .4 x .5 open with dried bloody drainage.” There was no documented evidence the wounds were monitored until resolution, with progress noted weekly by the facility. The need to ensure changes of condition were identified, evaluated, and monitored was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 07/16/23 at 3:00 pm. They acknowledged the findings. Kathy 2. Resident 3 was admitted to the facility in 11/2022 with diagnoses including multiple sclerosis. Resident 3's 04/23/26 through 07/12/26 clinical record and charting notes were reviewed and revealed the following: The resident experienced short-term changes without documented monitoring at least weekly until resolution in the following areas: * New medications/antibiotics on 06/03/26 and 06/11/26 for urinary tract infections. Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's condition at least weekly until resolution. The need to ensure short-term changes of condition were monitored at least weekly until resolution was discussed with Staff 1 (ED) and Staff 13 (District Director of Operations) on 07/15/26 at 3:05 pm. They acknowledged the findings. Example 3: Elena 3. Resident 4 was admitted to the facility in 12/2025 with diagnoses including type 2 diabetes mellitus, congestive heart failure, and chronic atrial fibrillation. S/he was subsequently admitted to hospice services on 07/03/26, with an admitting diagnosis of congestive heart failure. Resident 4’s clinical records from 04/13/26 through 07/13/26 and current service plan, dated 07/03/26, were reviewed. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident and/or monitored the resident through resolution of the condition for effectiveness and adverse effects: * On 04/13/26, Resident 4 returned to the facility after a visit to the emergency department related to anxiety. S/he was started on lorazepam as needed for anxiety and panic attack. There was no documented evidence staff had been provided monitoring instructions for the resident upon return from the hospital or that the resident’s condition had been monitored through resolution; * On 04/25/26, Resident 4 returned to the facility after a visit to the emergency department related to shortness of breath. There was no documented evidence the resident’s condition had been monitored through resolution; * Resident 4 was hospitalized from 05/01/26 through 05/06/26 related to fluid overload and heart failure. There was no documented evidence staff had been provided monitoring instructions or the resident’s condition had been monitored through resolution for any complications following hospitalization; * On 05/26/26 Resident 4 was hospitalized related to a urinary tract infection and subsequently transferred to the skilled nursing facility. There was no documented evidence the resident’s condition had been monitored through resolution for any complications following hospitalization upon his/her return on 06/12/26; * On 07/03/26, Resident 1 was admitted to hospice and multiple medications were discontinued. There was no documented evidence staff had been provided monitoring instructions for the resident for new medications or that the resident’s condition had been monitored through resolution; and * On 07/12/26, morphine sulfate (for pain or shortness of breath) was increased from 7.5 mg every hour as needed to 15 mg every hour as needed. There was no documented evidence the medication change had been monitored through resolution. The need to ensure the facility determined what resident-specific action or intervention was needed for the resident for short-term changes of condition and monitored the resident’s condition through resolution for effectiveness and adverse effects was discussed with Staff 1 (ED), Staff 2 (Health Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 07/16/26 at 3:05 pm. They acknowledged the findings.

1. The records for resident #3, #4 and #5 have been reviewed and documentation updated to reflect short term changes of condition and closure to resolved issues. 2. Current medication technicians were re-educated on changes of condition, Temporary Service Plan development and alert charting documentation policies on 7/29/26. 3. Documentation for residents with changes in condition will be reviewed by the HWD and RCC in conjunction with clinical meeting three times per week to verify the changes have been addressed. 4. Executive Director, Health & Wellness Director and Area RN or designee will ensure compliance.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. 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 interview and record review, it was determined the facility failed to ensure the RN assessed a significant change of condition, failed to develop interventions based on the results of the assessment, and failed to update the service plan for 1 of 1 sampled residents (#5) who experienced significant changes of condition related to severe weight loss and a fracture. Resident 5 had ongoing severe weight loss. Findings include, but are not limited to: Resident 5 was admitted to the facility in 02/2026 with diagnoses including mild cognitive impairment and depression. A review of the resident's clinical record, including weight records from 02/25/26 through 07/13/26, the most recent service plan and evaluation, 07/01/26 through 07/13/26 MAR, and 04/13/26 through 07/13/26 charting notes, interviews with staff, a witness, and the resident, and observations of the resident were completed between 07/13/26 and 07/15/26. a. Weight records indicated the resident weighed: * 04/01/26: 131.0 pounds; * 05/05/26: 134.0 pounds; * 06/02/26: 132.6 pounds; * 06/05/26: 134.0 pounds; * 06/24/26: 125.0 pounds; * 06/28/26: 121.2 pounds; and * 07/13/26: 112.4 pounds (taken during the survey). Resident 5 experienced an 11.4-pound weight loss between 06/02/26 and 06/28/26, or 8.6 % of his/her total body weight, in one month, which constituted a significant change of condition for which an RN assessment was required. On 07/13/26, the surveyor requested Resident 5’s weight. It was measured at 112.4 lb. Resident 5 had lost an additional 8.8 pounds, or 7% of his/her total body weight, since the significant weight loss noted on 06/28/26. This represented a severe loss of over 10% in two months. There was no documented evidence the facility RN had completed a significant change of condition assessment for the weight loss, which included documented findings, resident status, and interventions made as a result of an assessment or had updated the service plan until 07/13/26. The facility failed to ensure an RN assessment was completed for Resident 5’s significant weight loss, and s/he continued to lose weight. The need to ensure a timely RN assessment was completed for a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 07/16/26 at 3:00 pm. They acknowledged the findings. Refer to C270. b. Resident 5 was hospitalized from 05/15/26 to 05/22/26 after a fall with wrist fracture. Resident 5 returned to the facility with their dominant right hand in a hard cast. A progress note by Staff 16 (Resident Care Coordinator) documented, “Resident 5 has increased care needs due to her/his mental status and broken wrist.” Multiple CG interviews confirmed Resident 5 required increased care with ADLs after returning from the hospital. The fracture, hospitalization, and decreased self-care ability upon return constituted a significant change of condition for which an RN assessment was required. There was no documented evidence of an RN assessment until 06/11/2026, 20 days after the resident returned from the hospital. The need to ensure a timely RN assessment was completed for a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 07/16/23 at 3:00 pm. They acknowledged the findings.

1. The RN evaluated weight loss for resident #5. Resident #5's service plan and medication record were updated with interventions. Such documentation is reflected in the resident record. 2. The Area RN has been re-educated on community process for weight tracking and assessment of weight changes. Remaining residents will be reviewed to identify weight changes in need of RN assessment and to complete documentation that is reflective of the change and intervention. 3. Clinical meeting will occur no less than 3 times per week to review residents with changes in condition. During the meeting, the team will review to confirm that the Area RN or designee has been notified of significant changes. The Area RN or designee will document the interventions and monitoring through resolution or until a new baseline is established. 4. Executive Director and Area RN or designee

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 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers, ensuring the facility management or licensed nurse were notified of the services provided and that staff were informed of new interventions, the service plan was adjusted if necessary, and reporting protocols were in place for 1 of 1 sampled resident (# 6) who was receiving outside services. Findings include, but are not limited to: Resident 6 was admitted to the facility in 04/2023 with diagnoses including Parkinson’s disease with dyskinesia (uncontrollable body movements, tremors), dementia, and adult failure to thrive. During the acuity interview on 07/13/26, Resident 6 was identified as receiving hospice services. Review of the clinical record from 04/14/26 through 07/10/26 noted the following: * The hospice provider changed in 03/2026. The current hospice provider provided orders for medication; however, there was no documented evidence of a plan of care; * During the period from 04/2026 to 07/2026, the resident’s recorded weight fluctuated from 113.8 pounds to 133 pounds. There was no documented evidence the facility communicated the weight changes to the hospice provider; and * Multiple hospice visit notes completed by a hospice nurse stated, “…Continue following the plan of care” or “…Continue with current plan of care.” There was no documented evidence the facility received the hospice plan of care and incorporated it into the resident’s service plan. The need to ensure the facility coordinated on-site health services with outside service providers such as hospice, and the facility management or licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, the service plan was adjusted if necessary, and reporting protocols were in place was reviewed with Staff 1 (ED), Staff 2 (Health Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 07/16/26 at 3:05 pm. They acknowledged the findings.

1. Resident #6 Hospice plan of care has been obtained and placed in chart. Service plan has been updated to reflect current hospice provider and current plan of care information. 2. The records of remaining residents receiving hospice services will be reviewed to verify the hospice plan of care is reflected in their community service plan. 3. The Hospice plan of care will be reviewed in conjunction with the order review process in conjunction with clinical meeting no less than 3 times weekly. The Executive Director or designee will conduct random audits of resident records 3 times per month for 60 days and monthly thereafter. 4. Executive Director, Health & Wellness Director, Area RN or designee

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 3 of 5 sampled residents (#s 4, 5, and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2025 with diagnoses including type 2 diabetes mellitus, congestive heart failure, and chronic atrial fibrillation. S/he was subsequently admitted to hospice services on 07/03/26, with an admitting diagnosis of congestive heart failure. Resident 4's legally authorized prescriber orders, hospice legally authorized prescriber orders, and MARs from 04/01/26 through 07/13/26 were reviewed. Interviews with facility staff were conducted. The following was identified: a. The legally authorized prescriber orders, dated 04/28/26, contained the following orders: * Monitor for new signs and symptoms fluid overload; and * Follow up with determining current pacemaker monitoring provider. There was no documented evidence the orders were followed. b. The legally authorized prescriber orders, dated 06/09/26 and 07/03/26, contained the orders for metoprolol succinate ER [extended release] 100 mg one tablet orally in the morning for heart failure, hold for systolic blood pressure less than 100 or heart rate less than 55. There was no documented evidence the facility was checking the resident’s heart rate. During an interview on 07/15/26 at 11:30 am, Staff 10 (MT) confirmed the facility was checking the resident’s blood pressure prior to the administration of the medication and not the heart rate as ordered. 2. Resident 6 was admitted to the facility in 04/2023 with diagnoses including Parkinson’s disease with dyskinesia (uncontrollable body movements, tremors), dementia, and adult failure to thrive. During the acuity interview on 07/13/26, Resident 6 was identified as receiving hospice services. Resident 6's hospice physician orders, dated 07/02/26, and MARs from 07/01/26 through 07/13/26 were reviewed. Interviews with facility staff were conducted. The following orders were noted: * Administer carbidopa-levodopa 25-100 mg one tablet by mouth four times daily “for Parkinsons, check BP [blood pressure] the first and fourth dose prior to giving.” There was no documented evidence the facility was checking the blood pressure prior to administration. In an interview on 07/15/26 at 2:21 pm, Staff 8 (MT) stated the facility checked the resident’s heart rate prior to the administration of medication. Staff 7 (MT) confirmed on 07/16/26 at 9:35 am, “We [the facility] used to check the blood pressure but now are checking the heart rate.” * Administer morphine 15 mg half-tablet by mouth every two hours as needed for pain or shortness of breath. There was no documented evidence the order was transcribed to the resident’s MAR. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Health Wellness Director/LPN), Staff 3 (RN), Staff 14 (District Director of Clinical Services/RN), and Staff 13 (District Director of Operations) on 07/16/26 at 3:05 pm. They acknowledged the findings. Brian 3. Resident 5 was admitted to the facility in 02/2026 with diagnoses including mild cognitive impairment and depression. Resident 5’s 07/01/26 to 07/13/26 MAR and most current signed physician’s orders were reviewed. On 07/09/26, Resident 5’s Nurse Practitioner identified “abnormal weight loss” and ordered “high calorie shakes three times a day at mealtime for nutritional supplementation.” Review of Resident 5’s 07/01/26 through 07/13/26 MAR, 05/22/26 service plan, and kitchen “Diet type report” showed no documented evidence the high calorie shakes had been administered and/or monitored by the facility. The need to ensure physician’s orders were followed was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (RN), Staff 13 (District Director of Operations), and Staff 14 (Director of Clinical Services) on 07/16/26 at 3:00 pm. They acknowledged the findings.

1. Resident #4 medication administration record was updated to reflect heartrate oring for Metoprolol. Hospice has been contacted and orders received for pacemaker and fluid overload monitoring. Resident #5 protein supplement has been added to the Medication Administration Record (MAR). Resident #6 orders for Carbidopa/Levodopa has been clarified with hospice and medication administration record updated., The medication administration record has been updated to reflect current orders for Morphine. 2. Remaining resident orders will be reviewed to identify any that may require further nursing clarification or clarification with the provider. Medication technicians will be re-educated on order transcription, reviewing orders in MAR during med pass, supplemental documentation and provider notification. 3. Orders will be reviewed in conjunction with the transcription review process during the clinical meeting three times per week. Executive Director or designee will conduct random audits three times a month for 60 days, then monthly thereafter. 4. Executive Director, Health & Wellness Director and Area RN or designee

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 possess written, signed physician or other legally recognized practitioner orders for all medications administered by the facility for 1 of 2 sampled residents (#8) whose prescriber orders were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 8 moved into the facility in 02/2026 with diagnoses including Parkinson’s disease without dyskinesia and major depressive disorder. Resident 8’s signed practitioner orders for medications were requested on 10/05/26 and none were provided. On 10/06/26 at 10:15 am, Staff 1 (ED) stated the facility did not possess written, signed physician or other legally recognized practitioner orders for Resident 8’s medications. The need to possess written, signed physician or other legally recognized practitioner orders for Resident 8’s medications was reviewed with Staff 1, Staff 2 (Health and Wellness Director) and Staff 3 (Area RN) on 10/06/26 at 10:25 am. They acknowledged the findings.

C303 1. The orders for Resident #8 have been reviewed and signed by provider and reconciled with the Medication Administration Record (MAR). 2. Remaining resident records have been reviewed to identify any medications that need physician review. The Health & Wellness Director and Area RN have been re-educated on regulatory requirements regarding physician orders. 3. Faxes pending provider response and new orders will be reviewed in conjunction with the transcription review process during the clinical meeting three times per week. Executive Director or designee will conduct random audits twice weekly for 30 days and once weekly for 30 day and then monthly thereafter. 4. Executive Director, Health & Wellness Director and Area RN or designee

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 maintain an accurate MAR for all medications ordered by a legally recognized prescriber and administered by the facility for 3 of 5 sampled residents (#s 2, 4, and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including chronic respiratory failure with hypoxia and mild intermittent asthma. The resident was prescribed the following PRN medications to treat shortness of breath: * Albuterol sulfate HFA aerosol solution 108 (90 base) MCG/ACT – inhale 2 puffs orally every 4 hours; and * Levalbuterol tartrate inhalation aerosol 45 MCG/ACT – inhale 2 puffs orally every 6 hours. The MAR lacked instructions for unlicensed staff as to which medication to administer first when the resident exhibited symptoms of shortness of breath. In an interview on 7/15/26 at 11:10 am, Staff 14 (District Director of Clinical Services) confirmed the lack of parameters for the two medications and acknowledged there should be parameters instructing staff which medication to administer first. The need to maintain an accurate MAR was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), Staff 3 (Area RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 7/16/26 at 2:20 pm. They acknowledged the findings. Example #2: Elena 2. Resident 4 was admitted to the facility in 12/2025 with diagnoses including type 2 diabetes mellitus, congestive heart failure, and chronic atrial fibrillation. S/he was subsequently admitted to hospice services on 07/03/26, with an admitting diagnosis of congestive heart failure. Resident 4's MAR, from 04/01/26 through 07/13/26, and physician orders were reviewed and revealed the following: a. The following PRN medications lacked instructions for sequential order of use: * Acetaminophen 325mg (for pain); * Acetaminophen suppository 650mg (for pain); * Lidocaine gel (for pain); * Diclofenac sodium 1% gel (for pain); * Morphine 15mg (for pain or shortness of breath); * Glycerin laxative (for constipation); * Senna 8.6mg (for bowel care); * Polyethylene Glycol 3350 (for constipation); * Sodium phosphates rectal enema (for constipation); * Ativan 0.5mg (for anxiety or agitation); and * Haloperidol 2mg/ml (for anxiety, agitation, hallucinations, nausea, vomiting). b. The following PRN medications and treatment lacked resident-specific parameters for use: * Daily weights; * Haloperidol 1 mg (for anxiety, agitation, hallucinations); and * Ativan 0.5 mg (for anxiety or agitation). c. The legally authorized prescriber orders, dated 07/03/26, contained the order for miconazole nitrate 0.02 mg/mg topical powder to apply three times daily for rash, redness, and moisture. There was no documented evidence the order was transcribed to the resident’s MAR. 3. Resident 6 was admitted to the facility in 04/2023 with diagnoses including Parkinson’s disease with dyskinesia (uncontrollable body movements, tremors), dementia, and adult failure to thrive. During the acuity interview on 07/13/26, Resident 6 was identified as receiving hospice services. Resident 6's MAR, from 07/01/26 through 07/13/26, and physician orders were reviewed and revealed the following: * There was a physician’s order to administer morphine 15 mg half-tablet by mouth every two hours as needed for pain or shortness of breath. There was no documented evidence the order was transcribed to the resident’s MAR. The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (Health Wellness Director), Staff 3 (RN), Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 07/16/26 at 3:05 pm. They acknowledged the findings.

1. The medication administration records for Resident #2, #4 and #6 have been updated to reflect nursing clarification and instructions for use. 2. The Area RN will be re-educated on regulatory requirements for providing specific parameters for the administration of as needed medications by unlicensed medication technicians. Remaining resident as needed medication orders will be reviewed and updated as necessary. Medication technicians have been re-educated on the review of nursing parameters, following sequential instructions for medications ordered for the same reason, and as needed medication documentation. This training was completed on 7/29/26. 3. New orders will be reviewed in conjunction with clinical meeting three times week as part of the transcription review process to assure nursing instruction is present. Executive Director or designee will monitor audit completion three times a month for 60 days, then monthly thereafter. 4. Executive Director, Health & Wellness Director and Area RN or designee

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, observation and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility for 1 of 2 sampled residents (# 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 9 moved into the community in 04/2024 with diagnoses including respiratory bronchiolitis-interstitial lung disease and Crohn’s disease. Resident 9's MARs from 09/01/26 through10/05/26 were reviewed and revealed the following: Resident 9 had two PRN medications for pain with no sequential order of administration: * Acetaminophen rectal suppository 650 mg, insert one suppository rectally every 6 hours as needed for pain or fever; and * Morphine sulfate oral solution 20 mg/5ml, give 0.25 ml by mouth every 1 hour as needed for pain or shortness of breath. Resident 9 had not been administered any PRN medications for pain from 09/01/26 through 10/05/26. During an interview on 10/06/26 at 9:26 am, Staff 7 (MT) reviewed the electronic MAR with this surveyor and acknowledged the lack of instructions for which medication to take first for pain. When asked how she would know which medication to use first, she stated it would be “based on my experience.” The need to ensure medications on the MARs included instructions and resident-specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (Area RN) on 10/06/26 at 10:25 am. They acknowledged the findings.

C310 1. The medication administration record (MAR) for Resident #9 was updated to reflect parameters and instruction as provided by Hospice on 10/6/2026. 2. Remaining resident as needed medication orders will be reviewed and updated as necessary. The Area RN will be re-educated on regulatory requirements for providing specific parameters for the administration of as needed medications by unlicensed medication technicians. Medication technicians will be provided additional education by 10/29/2026 on ability to reference sequential instructions and nursing parameters within the eMAR application. 3. New orders will be reviewed in conjunction with clinical meeting three times week as part of the transcription review process to assure nursing instruction is present. Executive Director or designee will conduct random audits twice weekly for 30 days and once weekly for 30 day and then monthly thereafter. 4. Executive Director, Health & Wellness Director and Area RN or designee

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 evaluate residents who chose to self-administer their medications upon move-in to assure ability to safely self-administer medications for 1 of 1 sampled residents (#1) who was recently admitted and who self-administered his/her medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 05/2026 with diagnoses including fracture of upper end of left humerus, unsteadiness on feet, and sciatica. Review of the record indicated Resident 1 had physician orders to self-administer his/her medications. Interviews with Staff 2 (Health and Wellness Director) and Staff 4 (RCC) on 07/13/26 at 9:30 am, and with the resident on 07/14/26 at 10:18 am, confirmed Resident 1 self-administered his/her medications. On 07/14/26 at 11:25 am, Staff 3 (Area RN) provided the resident’s “Self-Administration of Medications Review.” The evaluation was dated 07/13/26, which was seven weeks after the resident moved into the facility. Staff 3 confirmed the evaluation had been completed 07/13/26 and no other evaluation of the resident’s ability had been completed at admission. The facility failed to evaluate Resident 1’s ability to safely self-administer medications upon move-in as required. The need to ensure residents who chose to self-administer their medications were evaluated at move-in to ensure they could safely do so was reviewed with Staff 1 (ED), Staff 2, Staff 3, Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 7/16/26 at 2:20 pm. They acknowledged the findings.

1. Resident #1 was evaluated for ability to self-administer medications before surveyors exited the community. 2. An audit has been completed for existing residents who self administer their own medications to confirm their current self medication evaluation is present. Self-medication evaluations will be reviewed in conjunction with the service plan review process. 3. Monthly audits of self-med residents will be completed and checked for accuracy by HWD and Area RN. Executive director or designee will conduct random audits three times a month for 60 days, then monthly thereafter. 4. Executive Director, Health & Wellness Director and Area RN or designee

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 evaluate residents who chose to self-administer their medications upon move-in to assure ability to safely self-administer medications for 1 of 1 sampled residents (#7) who was recently admitted and who self-administered his/her medications. This is a repeat citation. Findings include, but are not limited to: Resident 7 was admitted to the facility in 08/2026 with diagnoses including thrombocythemia. Review of the record indicated Resident 7 had physician orders to self-administer his/her medications. Interviews with Staff 2 (Health and Wellness Director) and Staff 17 (RCC) on 10/05/26 at 10:30 am, and with the resident on 10/05/26 at 11:41 am, confirmed Resident 7 self-administered his/her medications. On 10/05/26 at 12:35 pm, Staff 3 (Area RN) provided the resident’s “Self-Administration of Medications Review.” The evaluation was dated 10/05/26, which was approximately 8 weeks after the resident moved into the facility. Staff 3 confirmed the evaluation had been completed on 10/05/26 and stated the facility “had done an audit, but they somehow had this one slip through the cracks”. The facility failed to evaluate Resident 7’s ability to safely self-administer medications upon move-in as required. The need to ensure residents who chose to self-administer their medications were evaluated at move-in to ensure they could safely do so was reviewed with Staff 1 (ED), Staff 2, and Staff 3 on 10/06/26 at 10:25 am. They acknowledged the findings.

C325 1. Resident #7 evaluation was reviewed for accuracy. 2. An audit has been completed for current residents who self-administer their own medications to confirm their current self-medication evaluation is present. Self-medication evaluations will be reviewed in conjunction with the service plan review process. Executive Director and Health & Wellness Director have been provided additional education on scheduling forms completion within Point Click Care. 3. HWD, Executive director or designee will conduct random audits twice weekly for 30 days and once weekly for 30 day and then monthly thereafter. 4. Executive Director, Health & Wellness Director and Area RN or designee

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval Temporary rule language in effect until 02/05/2027 (2) The facility must not interfere with a good faith disclosure of information by an employee, volunteer concerning abuse or other action affecting a resident’s safety or welfare, as described in OAR 411-054-0028(4). (3) The Department must visit and inspect every licensed facility to determine whether the facility is maintained and operated in accordance with these rules. (a) The Department must inspect every facility at a minimum: (A) No less than 90 days and no more than 120 days after an initial license is issued or after a change of ownership of a facility. (B) Upon receipt of a license renewal application fee. (C) For each year during which a facility does not have a full survey, the Department must conduct an in-person inspection of the kitchen and other areas where food is prepared for residents. (b) Inspections may be conducted at other times as determined by the Department. (c) Facilities not in compliance with these rules must submit a plan of correction that satisfied the Department, within 10 business days of receipt of the inspection report. (d) Facilities must correct deficiencies within timeframes outlined in the accepted plan of correction. (e) Failure to be in substantial compliance upon reinspection may result in regulatory action to compel compliance. (f) Achieving substantial compliance is ultimately the facility’s responsibility, whether or not a plan of correction was followed. (g) The Department may impose sanctions for failure to comply with these rules. (4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to correct deficiencies within timeframes outlined in the accepted plan of correction. Findings include but are not limited to: Refer to C303, C310 and C325.

see POC for C303, C310, and C325

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate residents who chose to self-administer their medications upon move-in to assure ability to safely self-administer medications for 1 of 1 sampled residents (#1) who was recently admitted and who self-administered his/her medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 05/2026 with diagnoses including fracture of upper end of left humerus, unsteadiness on feet, and sciatica. Review of the record indicated Resident 1 had physician orders to self-administer his/her medications. Interviews with Staff 2 (Health and Wellness Director) and Staff 4 (RCC) on 07/13/26 at 9:30 am, and with the resident on 07/14/26 at 10:18 am, confirmed Resident 1 self-administered his/her medications. On 07/14/26 at 11:25 am, Staff 3 (Area RN) provided the resident’s “Self-Administration of Medications Review.” The evaluation was dated 07/13/26, which was seven weeks after the resident moved into the facility. Staff 3 confirmed the evaluation had been completed 07/13/26 and no other evaluation of the resident’s ability had been completed at admission. The facility failed to evaluate Resident 1’s ability to safely self-administer medications upon move-in as required. The need to ensure residents who chose to self-administer their medications were evaluated at move-in to ensure they could safely do so was reviewed with Staff 1 (ED), Staff 2, Staff 3, Staff 13 (District Director of Operations), and Staff 14 (District Director of Clinical Services) on 7/16/26 at 2:20 pm. They acknowledged the findings.

Refer to plan of correction for C252.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (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. This Rule is not met as evidenced by: