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’ needs and provided clear direction to staff regarding the delivery of services for 2 of 6 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living facility in 07/2025 with diagnoses including congestive heart failure and osteoporosis. The resident was identified in the acuity interview on 08/10/26 as having a recent fall resulting in a fractured humerus (shoulder). The resident’s clinical record, including the 08/04/26 service plan, was reviewed, interviews with staff and the resident were conducted, and observations were made. Resident 1's service plan was not reflective of the resident's current needs and lacked clear directions to staff in the following areas: * Instructions to staff regarding fall interventions; * Instructions to staff regarding non-pharmaceutical pain interventions; * The resident’s preference to sleep in his/her recliner; and * The resident’s preference to have bathing and toileting assistance provided by a female caregiver. The need to ensure residents’ service plans were reflective of their care needs and provided clear direction to staff was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 2:25 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 04/2019 with diagnoses including congestive heart failure and arthritis. The resident’s clinical record, including the 05/28/26 service plan, was reviewed, interviews with staff and the resident were conducted, and observations were made. Resident 3's service plan was not reflective of the resident's current needs and lacked clear direction to staff in the following areas: * Assistance required for hair and oral care; * The resident’s bowel and bladder continence status and toileting needs; * The resident’s status of visual assistive devices; and * Accommodations required for the resident’s hearing impairment when staff entered his/her room. The need to ensure residents’ service plans were reflective of their care needs and provided clear direction to staff was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1.What a actions will be taken to correct the rule violation for each example/resident? a. Resident #1 service plan will be reviewed by the RN and updated to include a. Instructions to staff regarding fall interventions. b. Instructions to staff regarding non-pharmacological pain interventions. c. The resident’s preference to sleep in his/her recliner; and d. The resident’s preference to have bathing and toileting assistance provided by a female caregiver. b. Resident #3 service plan will be reviewed by the RN and updated to include; a. Assistance required for hair and oral care. b. Resident’s bowel and bladder continence status and toileting needs c. The residents’ status of visual assistive devices; and d. Accommodation required for the residents hearing impairment when staff entered his/her room. 2. How will the system be corrected so this violation will not happen again? a. All current residents will have their service plans reviewed and updated by the RN to ensure specific instructions are present on each identified need. b. RN and RCC will complete service plans collaboratively to ensure adequate instruction is provided and all needs are captured. c. ED will review each service plan prior to signing the service plan. 3. How often will the area needing correction be evaluated? a. All service plans will be evaluated for content quarterly during the required review process and care conference to ensure appropriate instruction is included. 4.Who will be responsible for seeing that the corrections are completed/monitored? a. ED will review each service plan prior to signature for instructional content and provide feedback as needed.

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 interview and record review, it was determined the facility failed to determine, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition and ensure weekly progress was noted until the condition was resolved for 1 of 3 sampled residents (# 1) who experienced falls. Findings include, but are not limited to: Resident 1 moved into the assisted living facility in 07/2025 with diagnoses including congestive heart failure and osteoporosis. The resident was identified in the acuity interview on 08/10/26 as having recently fallen, resulting in a left humerus (shoulder) fracture. Resident 1’s clinical records from 05/13/26 through 08/10/26 and current service plan, dated 08/04/26, were reviewed, and interviews with the resident and staff were conducted. There was no documented evidence the facility determined and documented what resident-specific actions or interventions were needed for the resident, communicated the action or intervention to staff, and/or monitored the following changes of condition through resolution: * 07/24/26: Unwitnessed fall without injury; and * 08/03/26: Unwitnessed fall resulting in left humerus (shoulder) fracture. On 08/12/26 at 8:35 am, Resident 1 was observed in her recliner with legs elevated. The resident stated s/he was very independent prior to the fall but now was afraid to get up on her own, as s/he didn’t feel sure of his/her balance. On 08/12/26 at 12:30 pm, Staff 2 (RN) confirmed she had not determined new fall interventions following Resident 1’s fall with injury, as the standard interventions were always in place: ensure the resident was wearing non-skid footwear and paths were well lit and uncluttered and encourage the resident to use the call pendant for help when transferring. The need to determine, document, and communicate to staff what resident-specific actions or interventions were needed for the resident following a change of condition and ensure weekly progress was noted until the condition was resolved was reviewed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 08/13/26 at 2:25 pm. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1. What action will be taken to correct the rule violation for each example/resident? a. Resident #1 records will be reviewed by the RN, and a current change of condition will be completed by the RN to include the most recent changes to the resident including new fall interventions and recent shoulder fracture. b. Changes will be communicated to the staff in the form of a written Interim Service Plan. c. The residents’ service plan will be updated following assessment to reflect the new changes. d. The resident will remain on monitoring until the changes are resolved or become a new baseline. This will be reflected in the service plan. e. The RN will enter weekly chart notes until the resident returns to baseline. f. RN will review entire resident census for changes of condition and will address any unidentified changes of condition at that time with new assessments, COC chart note, service plan update, physician notification, and weekly RN notes until baseline is established. 2. How will the system be corrected so this violation will not happen again? a. RN will review all observation notes and communication binders daily when in the community and look for any changes that may constitute a change of condition and will see those residents timely to determine if there is a change of condition. b. Change of condition interpretive guidelines and regulations will be reviewed with the RN, RCC and ED to ensure complete understanding of changes of condition, regulatory compliance, and expectation. c. Care staff will be trained in reporting changes noted during care and daily interactions with residents. d. All ER visits, SNF stay, Hospital stay discharge summaries will be reviewed by the RN upon return to identify any change of condition that may have occurred because of illness, medical emergency or treatment. 3. How often will the area needing correction be evaluated? a. A census review and COC update will be completed weekly during ED and RN one on one meetings. 4. Who will be responsible for seeing that the corrections are completed/monitored? a. ED will monitor the completion of COC process during weekly one on one meetings with the RN.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#4) whose weights were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 09/2025 with diagnoses including mild cognitive impairment. Weight records, dated 04/08/26 through 08/12/26, and progress notes, dated 05/28/26 through 07/29/26, were reviewed and showed the following: * A 4.8-pound weight gain between 04/08/26 and 04/20/26 (90.6 to 95.4 pounds), which constituted a 5.29% significant gain in less than one month. * A 7.6-pound weight loss between 04/20/26 and 07/15/26 (95.4 to 87.8 pounds), which constituted a 7.96% significant weight loss in less than three months. * A 4.8-pound weight loss, between 06/02/26 and 07/02/26 (92.6 to 87.8 pounds), which constituted a 5.18% significant weight loss in one month. The current weight obtained at the time of survey on 08/12/26 was noted as 90.6 pounds. This was a 2.8-pound increase from 07/15/26. The service plan, dated 06/26/26, indicated the resident was independent with meals. The resident was provided with regular textures with some cut up items for easy chewing and swallowing. S/he could eat and drink on his/her own and would select what specific items s/he wanted for each meal. The resident rarely ate in the dining room and took most of his/her meals in his/her apartment. The resident routinely refused the high protein health shakes staff offered. The resident also intermittently refused weights. The resident was noted with some confusion and memory impairment but could complete some ADLs on his/her own, call staff for assistance, and direct his/her care. The resident was known to use the call light frequently, but when staff came to assist him/her the resident would deny ever using the call light and get agitated with staff bothering him/her. Multiple observation attempts were made near meal delivery times for two lunches, breakfast, and dinner. The resident’s meal intake appeared to be between 50% and 75% when the resident allowed entrance and observation. The resident did not attend any meals in the dining room during survey. The resident’s kitchenette had a variety of snacks available for him/her to obtain on their own throughout the day. Interviews with staff and the resident between 08/10/26 and 08/13/26 identified the following: Resident 4 indicated s/he received plenty to eat and drink. The resident stated s/he ate whatever they wanted and whenever s/he wanted and could do so on his/her own without any help. The staff would take the resident’s order and then the meal was delivered to him/her. The resident further indicated s/he did not have any concerns about what s/he ate or his/her weight. Staff 11 (CG) indicated the resident rarely attended meals in the dining room. S/he preferred to spend his/her time in the apartment. The resident could make his/her needs known and call staff for assistance. The staff obtained the resident’s meal selections each day for all three meals. Once staff delivered the order the resident could eat without further assistance. The resident loved bacon and wanted as much as s/he could get and would order it for every meal if s/he could and ate it very well. Staff 13 (MT) indicated the resident ate the majority of his/her meals in his/her apartment. The resident could make needs known, call for assistance as needed, and directed his/her own care. The resident required staff assistance with ADLs but could eat and drink independently. Staff 13 further indicated the resident had good intake and selected the meal items s/he wanted for each meal. The resident previously had health shakes in place due to weight changes, but s/he refused to take them, so they were discontinued. Staff 2 (RN) indicated the resident rarely came out of his/her apartment, refused to drink the health shakes and many times to be weighed at all. Staff 2 stated she notified the resident’s physician when the first weight changes were identified, but the physician had no concerns and wanted nothing additional done. Staff 2 did not complete an assessment after the physician declined any additional interventions. There was no documented evidence an RN assessment was completed for the resident’s significant weight changes, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (ED) and Staff 2 (RN) on 08/11/26 and 08/12/26. The staff acknowledged the findings.

OAR 411-054-0045 (1) (a-f) (A) (C-F) Resident Health Services 1. What action will be taken to correct the rule violation for each example/resident? a. Resident #4 chart, assessment and service plan will be reviewed by the RN, and a new assessment will be completed with a new service plan for change of condition and interventions for weight loss. A COC weight focused chart note will be completed. b. The physician will be notified of ongoing weight fluctuations. c. Residents will be weighed monthly ensuring her right of refusal to be weighed is honored where appropriate. d. Residents will have a consultation with the Dining Services Director to identify favorite foods and available options to encourage increased meal intake. 2. How will the system be corrected so this violation will not happen again? a. Weights for all residents will be monitored monthly, and the RN will conduct a weight variance review from the ALIS reports monthly to identify significant weight loss. b. All weight variances greater than 3% monthly will be reported to the physician and a new change of condition assessment and service plan will be completed with new interventions put in place. c. Physicians will be notified of any refusals by residents for weight monitoring. Refusals will be included in the service plan. 3. How often will the area needing correction be evaluated? a. Weekly during ED/RN one on one meetings. 4. Who will be responsible for seeing that the corrections are completed/monitored? a. The ED will monitor for compliance monthly during weight review discussions that occur during weekly one on one meetings with the RN.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 residents (#s 3 and 6) who required assistance with ADL care. /toileting/incontinence care. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 04/2019 with diagnoses including congestive heart failure and arthritis. In the acuity interview on 08/10/26, the resident was identified as requiring assistance with transfers and ADL care. On 08/12/26 at 11:22 am, the surveyor entered the resident’s room and with permission observed Staff 12 (CG) assist the resident to the toilet. Staff 12 helped the resident to doff his/her soiled incontinence brief without gloves on, then donned gloves, applied barrier cream to the resident’s buttocks, applied a clean brief and removed her gloves. She obtained ice from the resident’s freezer and put it in his/her drink, took the resident’s socks off, placed a blanket on him/her, took the trash with the soiled incontinence brief to the laundry room, then entered the kitchen to return the resident’s dirty dishes, all without performing hand hygiene between dirty and clean tasks. The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to residents who required assistance with ADL care/toileting/incontinence care was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 2:55 pm. They acknowledged the findings. 2. Resident 6 moved into the assisted living facility in 03/2026 with diagnoses including atrial fibrillation and dementia. The resident was identified in the acuity interview on 08/10/26 as requiring staff assistance with transfers and ADLs. On 08/13/26 at 11:35 am, the following was observed: The surveyor entered the resident’s room with permission and observed Staff 12 (CG) assist Resident 6 to the toilet. Staff 12 assisted Resident 6 with removal of a soiled brief and pants and put on a clean brief and clean pants. Throughout the observation, Staff 12 neither donned gloves nor performed hand hygiene between clean and dirty tasks. The need to ensure infection prevention and control practices were followed during personal care was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 2:25 pm. They acknowledged the findings.

OAR 411-054-0050 (1-5) Infection Prevention and Control 1. What actions will be taken to correct the rule violation for each example/resident? a. All staff will be trained in proper handwashing techniques with competency. b. All staff will be trained in universal precautions. c. All staff will be trained in care sequences for washing hands with a competency. 2. How will the system be corrected so this violation will not happen again? a. RN/RCC will schedule ongoing biannual training on hand hygiene and universal precautions will be scheduled. b. RN/RCC will conduct spot checks for proper hand hygiene during cares with appropriate resident permissions. c. RN/RCC will observe appropriate hand hygiene while aiding care staff. 3. How often will the area needing correction be evaluated? a. Biannually with refresher training and competency. 4. Who will be responsible for seeing that the corrections are completed/monitored? a. RN/RCC will provide biannual competencies outcomes to the ED for review. ED has completed Infection Prevention training through OHCA

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 5 sampled residents (#s 2 and 3) who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 07/2023 with diagnoses including early Alzheimer’s dementia and unintended weight loss. Resident 2's clinical record from 05/12/26 through 08/04/26 and MARs from 07/01/26 through 08/10/26 were reviewed, and the following was identified: Staff documented Resident 2 refused Med Pass 2.0 (a nutritional supplement) on 10 separate occasions. In an interview on 08/13/26 at 10:40 am, Staff 2 (RN) stated she could not find documentation the providers were notified of the refusals. When their software was changed to ALIS, MD refusal notification preferences were not entered in the MAR. The need to notify the physician/practitioner when a resident refuses to consent to orders was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 08/13/26 at 2:55 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 04/2019 with diagnoses including congestive heart failure and arthritis. Resident 3's clinical record from 05/12/26 through 08/10/26 and MARs from 07/01/26 through 08/10/26 were reviewed, and the following was identified: Staff documented Resident 3 refused the following medications/treatments on one or more occasions: * Aspirin; * Carvedilol (for blood pressure and/or heart failure); * Docusate sodium (stool softener); * Duloxetine (antidepressant); * Entresto (for heart failure); * Furosemide (diuretic); * Gabapentin (pain relief); * Metformin (for diabetes); * Multivitamin; * Secura (protective skin cream); * Senna/docusate (laxative/stool softener); * Symproic (for opioid induced constipation); and * Vitamin D. In an interview on 08/13/26 at 10:40 am, Staff 2 (RN) stated she could not find documentation that the providers were notified of the refusals. When their software was changed to ALIS, MD refusal notification preferences were not entered in the MAR. The need to notify the physician/practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 08/13/26 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0055 (1) (j-k) Systems: Resident Right to Refuse. 1. What actions will be taken to correct the rules violation for each example/resident? a. Resident #2 review of MARs by RN to determine refusals of medications or treatments. b. Communication will be sent to the provider listing refusal dates and medications or treatments refused. c. Resident #3 review of MARs by RN to determine refusals of medication sor treatments. d. Communication will be sent to the provider listing refusal dates and medications or treatments refused. 2. How will the system be corrected so this violation will not happen again? a. A form has been developed for physician notification preferences of medications and treatment refusals that supports broader notification preferences. b. This form will be sent to each provider for each resident to identify the provider preference for refusal notifications. c. The completed form will be maintained in the resident chart and not purged. d. The RCC will review the med exception report daily when in the community and identify medication refusals. e. The RCC will ensure notification to the physician has been sent and confirmation will be kept in the resident record. f. RN will discuss with physicians discontinuing medications or treatments that are frequently refused. g. RN will assess for and service plan medication refusals. 3. How often will the area needing correction be evaluated? a. The RCC will collaborate with the RN on med refusals weekly. b. RN will review refusal communications daily. 4. Who will be responsible for seeing that the corrections are completed/monitored? a. RN will be responsible for ensuring communications with the physicians are completed.

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 resident MARs were accurate, including resident-specific parameters and instructions for medications, for 4 of 6 sampled residents (#s 1, 2, 3, and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living facility in 07/2025 with diagnoses including congestive heart failure and osteoporosis. Residents 1's 07/01/26 through 08/10/26 MAR was reviewed, and the following was identified: a. There were no resident-specific instructions for multiple PRN pain medications, including sequence of administration. b. The following medications lacked a reason for use: * Furosemide; * Kerendia; * Potassium chloride; * Tizanidine; * Acetaminophen/codeine; * Acetaminophen; and * Oxycodone-acetaminophen. The need to ensure an accurate MAR was kept of all medications the facility was administering was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 2:25 pm. They acknowledged the findings. 2. Resident 6 moved into the assisted living facility in 03/2026 with diagnoses including atrial fibrillation (irregular heartbeat) and dementia. Resident 6’s 07/01/26 through 08/10/26 MAR was reviewed, and the following was identified: The following medications lacked a reason for use on the MAR: * Omega-3 geltab; * Pravastatin sodium; * Preservision AREDS; and * Propylthioracil. The need to ensure an accurate MAR was kept of all medications the facility was administering was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 2:25 pm. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2023 with diagnoses including early Alzheimer’s dementia and unintended weight loss. Resident 2's 07/01/26 through 08/10/26 MAR was reviewed, and the following was identified: a. There were no resident-specific instructions for two PRN cough medications, including sequence of administration. b. The following medications lacked a reason for use: * Loperamide; * Med Pass 2.0; * Multivitamin; and * Preservision AREDS. The need to ensure an accurate MAR, including the reason for use for each medication and resident-specific parameters for PRN medications, was kept of all medications the facility was administering was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 2:55 pm. They acknowledged the findings. 4. Resident 3 moved into the facility in 04/2019 with diagnoses including congestive heart failure and arthritis. Residents 3's 07/01/26 through 08/10/26 MAR was reviewed, and the following was identified: The following medications lacked a reason for use: * Docusate sodium; * Entresto; * Furosemide; * Gabapentin; * Metformin; * Nortriptyline; * Potassium; * Symproic; and * Lidocaine patch. The need to ensure an accurate MAR, including the reason for use for each medication, was kept of all medications the facility was administering was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration 1. What action will be taken to correct the rule violation for each example/resident. a. Resident # 1, 2, 3, 6 MAR will be reviewed by the RN/RCC and corrected to include reason for use, instructions for PRNs and sequencing of like PRN medications used for the same purpose. b. All resident med orders will be reviewed and audited for reason for use, parameters and instructions for multiple PRN medications given for the same purpose including sequencing. 2. How the system will be corrected so this violation will not happen again. a. All new medication orders received will be faxed to the pharmacy for profiling into the EHR system. b. During the order approval process, each order will be reviewed to ensure a reason for use, full instruction, parameters for PRN Medications if appropriate and sequencing of like PRN medications given for the same reason is present. c. Training for RCC regarding order approval process and the areas of the steps of order approval to ensure all elements are addressed before approving the order. d. Will meet with the pharmacy regarding ensuring reason for use are carried over when entering order refills. e. Order approval will be a 3-part system with each order being reviewed by Med Tech, RCC and RN. 3. How often will the area needing correction be evaluated? a. Quarterly pharmacy audits will include ensuring reason for use, PRN parameters, instructions and sequencing is present on all PRN orders given for the same reason. b. Pharmacy audit results will be sent to the RN, RCC, and ED for review. c. RN will ensure any identified deficiencies are corrected in the EHR. 4. Who will be responsible for seeing that the corrections are completed/monitored? a. ED will review pharmacy audit results with RN quarterly during one-on-one meetings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 6 sampled residents (#s 1 and 6) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living facility in 07/2025 with diagnoses including congestive heart failure and osteoporosis. Observations of the resident, interviews with staff, review of the 08/04/26 service plan, and review of Resident 1’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Dressing and undressing; * Toileting, bowel and bladder management; * Transfers; * Repositioning; * Escorting to or from meals or activities; and * Safety checks. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (ED) on 08/12/26 at 12:05 pm. She acknowledged the findings. 2. Resident 6 moved into the assisted living facility in 03/2026 with diagnoses including atrial fibrillation (irregular heartbeat) and dementia. Observations of the resident, interviews with staff, review of the 07/26/26 service plan, and review of Resident 6’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Personal hygiene; * Grooming; * Dressing and undressing; * Toileting, bowel and bladder management; * Bathing; * Transfers; * Ensuring non-drug interventions for behaviors; * Assisting with leisure activities, assisting with social and recreational activities; * Assisting with assistive devices for hearing and vision; and * Safety checks. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (ED) on 08/12/26 at 12:05 pm. She acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time 1. What actions will be taken to correct the rule violation for each example/resident are as follows: a. Resident # 1- the following areas have been updated to reflect accurte time: Dressing and undressing;Toileting, bowel and bladder management;Transfers;Repositioning;Escorting to or from meals or activities; and Safety Checks b. Resident #6- the following areas have been udated to reflect accurate time: Personal hygiene;Grooming; Dressing and undressing; Toileting, bowel and bladder management; Bathing; Transfers; Ensuring non-drug interventions for behaviors; Assisting with leisure activities, assisting with social and recreational activities; Assisting with assistive devices for hearing and vision; and Safety checks c. ABST time will be reviewed for all current residents d, staff schedule and staffing plan will be updated to reflect current need. 2. How will the system be corrected so this violation will not happen again are as follows: a. ABST training with the Executive Director, RN, and Resident Care Coodinator completed regarding accuracy of time entered. 3. How often will the area needing corrected be evaluated is as follows: Per OAR: a.Before a resident moves in. b Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). c No less than quarterly and corresponding with resident service plan updates, updating as required by OAR 411-054-0034. 4. Who will be responsible to see that the corrections are completed/monitored: a. Executive Director with support from the clinical team such as RN and Resident Care Coordinator

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated and reviewed before move-in, whenever there was a significant change of condition, and no less than quarterly at the same time the residents’ service plans were updated for 3 of 6 sampled residents (#s 1, 5, and 6) and one unsampled resident. Findings include, but are not limited to: Clinical records, including service plans and ABST evaluations, were reviewed, and the following was identified: The ABST evaluations were not completed, updated, and reviewed before move-in, following a significant change of condition, or no less than quarterly, corresponding with resident service plan updates, for Residents 1, 5, and 6. One unsampled resident was listed in the “Archive Residents” and not the “Current Residents” and, therefore, was not included in the ABST report. The need to ensure the ABST evaluation for each resident was updated and reviewed according to the required schedule was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/13/26 at 4:40 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan 1. What actions will be taken to correct the rule violation for each example/resident is as follows: a. ABST evaluations will be updated for residents 1, 5, and 6. b. Unsampled resident has been moved from archive. c. ABST will be reviewed for all current residents. d. staffing schedule and staffing plan will be updated to reflect accurate need. 2. How will the system be corrected so this violation will not happen again is as follows: a. Training provided to Executice Director, RN, and RCC regarding ABST OAR. 3. How often will the area needing correction be evaluated is as follows: Per OAR: a. Before a resident moves in. b. Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). c. No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. 4. Who will be responsible to see that the corrections are completed/monitored: a. Executive Director with support from the clinical team such as RN and Resident Care Coordinator

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and reinstructed at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) on 08/13/26. There was no documentation that residents were consistently provided fire training within 24 hours of admission and again at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. The need to ensure fire and life safety instruction was provided to residents upon admission and at least annually was discussed with Staff 1 on 08/13/26 at 1:30 pm. She acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents 1. What actions will be taken to correct this rule violation for each example/resident is as follows: a. Annual Fire and Life Safety training will be documented for all current residents. b. Training of Fire and Life Safety provided to ED, ED Designee, and Maintenance Director by VP of Operations. 2. How will the system be corrected so this violation does not happen again is as follows: a. Automatic calendar prompt set up based off residents move in date and annual anniversary that will be sent to ED, Maintenance Director and Regional Team 3. How often will the area needing correction be evaluated is as follows: a. With each new move in b. prior to each residents annual anniversary 4. Who will be responsible to see that the corrections are completed/monitored is as follows: a. Maintenance Director b. Executive Director or Desginee

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and access to the ALF’s common-use areas, entrance, and exit ways were smooth and maintained in good repair. Findings include, but are not limited to: The exterior of the building was toured on 08/11/26. The following was identified: The wrap-around deck off the main entrance and the dining room had boards across the length of the decking that were uneven, pulling apart, and lifting, creating multiple fall hazards. A walkthrough of the deck and review of the findings was discussed with Staff 9 (Maintenance Supervisor) on 08/13/26 at 10:30 am, and the findings were discussed with Staff 1 (ED) on 08/13/26 at 1:30 pm. They acknowledged the findings.

OAR 411-054-0300 (3)(a-h) General Building Exterior 1. What actions will be taken to correct the rule violation for each example/resident is as follows: a. wrap around deck boards have been secured and or replaced to ensure fall hazard is not present. 2. How will the system be corrected so this violation will not happen again is as follows: a. daily walk of wrap around deck will be completed by Maintenance Director or designee 3. How often will the area needing correction be evaluated is as follows: a. Daily when working by Maintenance Director or Designee b. Weekly when working by Executive Director 4. Who will be responsible to see that corrections are completed/monitored is as follows: a. Maintenance Director or Designee b. Executive Director