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 preferences and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted into the facility in 09/2025 with diagnoses including developmental delay. The resident’s 05/31/26 through 08/31/26 clinical record was reviewed, observations of the resident were made, and staff were interviewed. The service plan dated 8/20/26 was not reflective the resident’s current care needs or preferences and did not provide clear direction to staff in the following areas: * Bed repositioning schedule; * Bed height; * Wearing heel protection boots while in bed; and * Door being opened or closed when the resident was in his/her room. Observations of Resident 1 from 08/31/26 through 09/02/26 identified the following: Resident 1’s bed was in lowered and raised positions and the door to the resident’s unit was opened and closed. On 08/31/26 at 2:50 pm, Staff 6 (CG) stated Resident 1 wore heel protection boots while in bed and was assisted with repositioning every two hours. The need to ensure resident service plans were reflective of current care needs and preferences and provided clear direction to staff was discussed with Staff 1 (Administrator) on 09/02/26 at 11:15 am. He acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2023 with diagnoses including stroke. Staff reported in the acuity interview on 08/31/26 the resident used alcohol daily to the point of intoxication and was evaluated as independent with smoking. The resident’s 05/31/26 through 08/31/26 clinical record was reviewed, observations of the resident were made, and staff were interviewed. The 07/01/26 service plan was not reflective of the resident’s needs in the following: * History of cigarette/lighter burn and interventions staff should attempt when the resident was intoxicated and smoking. Staff documented in an incident report on 06/02/26 the resident had burned his/her fingers while lighting a cigarette while intoxicated. The resident refused staff assistance in lighting his/her cigarettes. Observations made on 08/31/26 and 09/01/26 showed the resident in the facility parking lot, drinking beer and smoking. The need to ensure the service plan was reflective of the resident’s needs was discussed with Staff 1 (Administrator) at 10:59 am on 09/02/26. He acknowledged the findings.

PLAN OF CORRECTION 1. Corrective Action for Residents Affected by the Deficient Practice The service plans for Residents 1 and 2 were immediately reviewed and updated to ensure that the residents’ current needs, preferences, safety concerns, and required services are clearly identified and communicated to caregivers. Resident 1: The service plan was updated on 9/17/2026 to provide specific caregiver direction regarding: • Repositioning while the resident is in bed; • Appropriate bed height for resident safety; • When heel protection and boots are to be applied while the resident is in bed; and • The resident’s preference regarding keeping the door open or closed. Resident 2: The service plan was updated on 9/17/2026 to reflect the resident’s current care needs. Clinical staff added specific direction regarding the assistance and supervision required with smoking when the resident is intoxicated due to the resident’s history of cigarette/lighter burns and associated safety risk. Clinical staff will review all current resident service plans to ensure that resident preferences, care needs, safety concerns, and caregiver instructions are accurately and clearly documented. 2. Systemic Changes to Prevent Recurrence The facility will implement a process to ensure that temporary service plans and/or changes in resident needs that occur after the most recently completed service plan are incorporated into the resident’s permanent/current service plan at the time of the next scheduled review or sooner when there is a significant change in condition, needs, preferences, or services. Clinical staff will review the resident’s current service plan and any temporary service plans, physician/clinical recommendations, and identified changes in condition to ensure that all applicable instructions are incorporated into the service plan. Service plan updates will contain clear, specific, and measurable directions for caregivers so that staff understand the services to be provided, safety precautions to be followed, and resident preferences to be honored. 3. Monitoring and Quality Assurance The Administrator or designee will be responsible for implementation and ongoing monitoring of this Plan of Correction. The Administrator or designee will conduct periodic audits of resident service plans to verify that: 1. Current resident needs and preferences are accurately reflected; 2. Safety risks and required interventions are clearly documented; 3. Temporary service plans and changes in condition have been incorporated into the current service plan when applicable; and 4. Caregiver directions are sufficiently clear to ensure consistent delivery of services. Any identified discrepancies will be corrected promptly, and additional staff education or follow-up will be provided as necessary. The Administrator or designee will continue monitoring compliance to ensure that the corrective actions are sustained and that the identified deficient practice does not recur.

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 actions or interventions were determined, documented, and communicated to staff with weekly progress noted to resolution for 1 of 1 sampled resident (#1) who experienced significant weight loss. Resident 1 continued to lose weight. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2025 with diagnoses including developmental delay. During the acuity interview on 08/31/26, Resident 1 was identified as having had weight loss, required meal assistance, and had orders for a pureed diet. The resident’s clinical record from 04/20/26 to 08/31/26 was reviewed, observations of the resident were made, and interviews with staff were conducted. The resident’s service plan, dated 08/20/26, indicated s/he had orders for a pureed diet with thin liquids and required full feeding assistance from care staff due to dysphagia (difficulty swallowing) and pocketing of food (holding food in parts of the mouth instead of swallowing it). Resident 1 required a wheelchair escort to and from the dining room for meals. Staff documented the following weights: * 05/05/26- 134 pounds; * 06/05/26- 133 pounds; * 07/05/26- 129 pounds; * 08/05/26- 122 pounds; and * 09/01/26- 120.4 pounds (taken during survey). Between 07/05/26 and 08/05/26, the resident lost seven pounds, or 5.19% of his/her total body mass. There was no documented evidence the facility determined actions or interventions needed for the weight loss, communicated those actions or interventions to staff, monitored Resident 1 for continued weight loss, or documented weekly progress through resolution. During survey, the following was observed: * On 09/01/26 for lunch, the resident was assisted by Staff 5 (CG) to eat approximately 30% of the pureed vegetable soup, 100% of the vanilla pudding cup, and 80% of the strawberry yogurt cup served, and drank 100% of the apple juice provided. Staff 5 removed the resident’s food once s/he stated, “I’m done, I want to go to my room.” * On 09/02/26 for breakfast, Resident 1 was provided hand-over-hand assistance to eat approximately 10% of the cream of wheat and 100% of the cup of applesauce served. S/he drank 100% of the glass of apple juice and glass of orange juice provided. The CG removed Resident 1’s food once s/he confirmed s/he did not want any more to eat. The facility failed to ensure the resident’s significant weight loss was evaluated, actions and interventions were determined, and the condition was monitored for progress at least weekly through resolution, and the resident continued to lose weight. On 09/02/26 at 12:40 pm, Staff 1 (ED) confirmed the facility had not documented what interventions were needed for the resident, communicated the interventions to staff, or documented weekly progress through resolution regarding Resident 1’s ongoing significant weight loss. The need to ensure the facility determined and documented what action or intervention was needed for the resident, communicated the action or intervention to staff on all shifts, and monitored the resident consistent with their evaluated needs at least weekly through resolution was reviewed with Staff 1 on 09/02/26 at 12:45 pm. He acknowledged the findings.

PLAN OF CORRECTION 1. Corrective Action for Residents Affected by the Deficient Practice An RN assessment was completed to evaluate Resident 1’s current condition and weight loss. The resident’s nutritional status and meal intake were reviewed. On 9/2/2026, the physician ordered Carnation protein supplementation three times daily when meal intake is less than 25%. On 9/4/2026, the RN recommended a milkshake between meals to provide additional calories and support the resident’s nutritional needs. Beginning 9/6/2026, the resident’s meal intake has been continuously monitored. Weekly weights were initiated beginning 9/4/2026 to monitor the resident’s weight and response to nutritional interventions. The resident’s service plan was reviewed and updated on 9/3/2026 and 9/17/2026 to provide clearer and more specific instructions regarding the resident’s current nutritional needs, interventions, and monitoring requirements. 2. Systemic Changes to Prevent Recurrence Facility staff will review resident vital signs and weights monthly and as needed to identify significant changes in condition. When a resident demonstrates unexpected or abnormal vital signs, significant weight loss, or other indicators of a change in condition, an RN assessment will be completed timely, or sooner when clinically indicated. Appropriate interventions will be initiated and clearly documented in the resident’s service plan and/or clinical record. A weekly focused Licensed Nurse assessment will be completed for residents experiencing significant weight loss or other identified nutritional concerns until the condition is resolved or the resident’s status is determined to be stable. Clinical staff will monitor the effectiveness of interventions, including meal intake, nutritional supplementation, and weight trends, and will communicate significant changes to the physician and other appropriate members of the care team as indicated. 3. Responsibility for Implementation and Monitoring The Administrator/Designee will be responsible for ensuring that this corrective action plan is implemented and maintained. The Administrator/Designee will monitor compliance through periodic review of resident weights, meal intake records, nursing assessments, and service plans to ensure that identified changes in condition are appropriately assessed, addressed, documented, and monitored. Any identified concerns or gaps in compliance will be addressed promptly through corrective action, follow-up, and staff education as appropriate.

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 all residents with a significant change of condition, including documentation of findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 1) who experienced significant weight loss and a pressure ulcer. Resident 1 continued to lose weight. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2025 with diagnoses including developmental delay. Staff reported in the acuity interview on 08/31/26 the resident had a pressure ulcer and had experienced weight loss. The resident’s clinical record from 04/20/26 to 08/31/26 was reviewed, and the following was identified: a. Between 07/05/26 and 08/05/26, the resident lost seven pounds, or 5.19% of his/her total body mass, in one month. This constituted a significant change of condition which required an RN assessment. There was no documented evidence the facility RN had completed a significant change of condition assessment for the weight loss, which included findings, resident status, and interventions made as a result of the assessment. On 09/01/26 at 9:37 am, Staff 2 (RN) stated the facility had recognized Resident 1 was losing weight but had not completed an RN assessment for the significant weight loss. The facility currently did not have a system for identifying when a resident required an assessment for weight loss. The facility failed to ensure an RN assessment was completed for Resident 1’s significant weight loss, and s/he continued to lose weight. The need to ensure an RN assessment was completed for all residents with a significant change of condition was reviewed with Staff 1 (ED) on 09/02/26 at 11:30 am. He acknowledged the findings. Refer to C270. b. On 04/29/26, Staff 3 (RN) documented in a nursing note, “[Resident 1] was discharged from [the hospital] where [s/he] was admitted with pneumonia. Resident [1] was also noted with hospital acquired wounds - [s/he] came back with stage 2 wound on [his/her] hip, stage 2 wounds on right and left heels and another one on [his/her] left great toe.” The stage 2 wounds constituted a significant change of condition for which an RN assessment documenting findings, resident status, and interventions made as a result of the assessment was required. There was no documented evidence the RN completed an assessment. On 09/01/26 at 2:58 pm, Staff 3 confirmed there was no RN assessment completed for Resident 1’s return from the hospital with wounds. The need to ensure an RN assessment was completed for all residents with a significant change of condition was reviewed with Staff 1 (ED) on 09/02/26 at 11:30 am. He acknowledged the findings.

PLAN OF CORRECTION 1. Corrective Action for Residents Affected by the Deficient Practice An RN assessment was completed to evaluate Resident 1’s current skin condition and weight loss. The resident’s nutritional status, meal intake, and skin condition were reviewed. On 9/2/2026, the physician ordered Carnation protein supplementation three times daily when meal intake is less than 25%. On 9/4/2026, the RN recommended a milkshake between meals to provide additional calories and support the resident’s nutritional needs. Beginning 9/6/2026, the resident’s meal intake has been continuously monitored. Weekly weights were initiated beginning 9/4/2026 to monitor the resident’s weight and response to nutritional interventions. Wound care orders were reviewed, and new wound care orders were implemented on 9/10/2026. Weekly skin assessments are being completed to provide ongoing monitoring of the resident’s skin condition and to ensure that physician-ordered wound care interventions are implemented as directed. The resident’s service plan was reviewed and updated on 9/3/2026 and 9/17/2026 to provide clearer and more specific instructions regarding the resident’s current skin care needs, nutritional needs, interventions, and monitoring requirements. 2. Systemic Changes to Prevent Recurrence The facility’s Registered Nurse will complete and document an RN assessment for all new residents upon admission and for any resident experiencing a significant change in condition timely, or sooner when clinically indicated. The RN assessment will include review of the resident’s current condition, skin integrity, nutritional status, weight trends, meal intake, and other relevant clinical indicators as applicable. When a change in condition is identified, appropriate interventions will be initiated promptly and clearly documented in the resident’s clinical record and service plan. Physician notification and new or revised orders will be obtained as clinically indicated. Licensed nursing staff will continue to monitor the resident’s response to interventions and will communicate any further changes in condition to the RN, physician, and other appropriate members of the care team. 3. Responsibility for Implementation and Monitoring The Administrator/Designee will be responsible for ensuring that this corrective action plan is implemented and maintained. The Administrator/Designee will conduct periodic reviews of RN assessments, resident service plans, wound care documentation, nutritional monitoring records, and other applicable clinical documentation to verify that identified changes in condition are appropriately assessed, addressed, documented, and monitored. Any identified concerns or gaps in compliance will be addressed promptly through corrective action, follow-up, and staff education as appropriate. The facility will maintain ongoing monitoring to ensure that corrective measures are sustained and that similar deficient practices do not recur.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure infection prevention and control protocols were maintained for multiple unsampled residents who received catheter care. Findings include, but are not limited to: Observations were made from 08/31/26 through 09/02/26 of multiple unsampled residents whose catheter bags and tubing were hung from their wheelchairs in a manner that allowed them to contact the floor. The catheter bags were not covered or otherwise protected from contamination. On 09/02/26 at 10:01 am, an unsampled resident was observed sitting in his/her wheelchair in the hallway with care staff, catheter tubing dragging along the floor. The need to ensure infection prevention and control protocols were maintained was reviewed with Staff 1 (ED) on 09/02/26 at 11:30 am. He acknowledged the findings.

PLAN OF CORRECTION 1. Corrective Action for Residents Affected by the Deficient Practice The facility purchased Foley catheter bag covers on 9/3/2026 and provided them to residents who have Foley catheters to promote privacy and dignity. Staff training on Foley catheter care was completed on 9/5/2026 and will be ongoing. Training included proper placement and positioning of the catheter drainage bag, infection prevention and control practices, maintaining proper catheter care, and appropriate covering of the catheter bag to promote resident dignity and privacy. 2. Systemic Changes to Prevent Recurrence Clinical staff will provide clear instructions regarding Foley catheter care through each resident's service care plan. The care plan will include instructions related to infection prevention and control, proper catheter and drainage bag placement, maintaining the drainage bag below bladder level, promoting resident privacy and dignity, and ongoing monitoring of catheter care. Staff will follow the resident's service care plan and report any concerns related to catheter placement, drainage, infection prevention, skin integrity, or resident dignity to the appropriate clinical personnel. 3. Monitoring and Responsibility The Administrator or designee will be responsible for monitoring and ensuring implementation of this Plan of Correction. The Administrator or designee will monitor staff compliance with Foley catheter care practices, including proper drainage bag placement, infection prevention measures, and appropriate use of catheter bag covers to promote resident dignity and privacy. Any identified concerns or areas of non-compliance will be addressed promptly through corrective action, additional staff education, and follow-up monitoring.

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for all treatments the facility was responsible to administer for 1 of 1 sampled resident (#1) who had orders for wound care and a nutritional supplement. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2025 with diagnoses including developmental delay. Staff reported in the acuity interview on 08/31/26 the resident had a pressure ulcer and had experienced weight loss. The resident’s 04/20/26 to 08/31/26 clinical record was reviewed and revealed the following: a. Resident 1 had orders dated 05/15/26 for “food supplement (high protein) drink, take 237 mL twice a day.” There was no documented evidence the facility provided the resident the nutritional supplement as prescribed after 07/24/26. On 09/01/26 at 2:58 pm, Staff 3 (RN) stated the resident’s insurance had denied coverage of the supplement in July. She confirmed the resident had not been given the supplement twice per day as prescribed since 07/24/26. b. Resident 1 had wound care orders dated 04/28/26 for a left hip wound, “change dressing every other day, cleanse with NS, pat dry, apply [gauze] to wound bed to manage bacteria, cover with sacral foam dressing.” Documentation on the resident’s MAR from 04/28/26 to 08/31/26 indicated staff changed the wound’s dressing on 04/29/26, 05/01/26, and 05/04/26. On 09/01/26 at 2:58 pm, Staff 3 (RN) stated the home health nurses had been providing wound care for the resident in addition to the weekly skin checks and wound care provided by the facility nurses. However, based on review of outside provider notes and the facility’s wound care log, there was no documented evidence the resident received dressing changes every other day as prescribed. The need to ensure the facility carried out treatment orders as prescribed was reviewed with Staff 1 (ED) on 09/02/26 at 11:30 am. He acknowledged the findings.

PLAN OF CORRECTION 1. Corrective Action for Residents Affected by the Deficient Practice. Facility staff provided care coordination with present provider and advocated for Resident 1's nutritional needs with the hospice team. Hospice subsequently ordered Carnation Protein Mix, one packet by mouth three times daily with meals when meal intake is less than 25%. In addition, facility nursing implemented an intervention on 9/4/2026 to provide a milkshake between meals to support the resident's nutritional intake. Resident 1's wound care coordination was subsequently completed with the hospice provider. New wound care orders were received on 9/3/2026 and 9/10/2026, including PRN wound care orders, and the orders were implemented by facility staff as indicated. 2. Systemic Changes to Prevent Recurrence The facility will strengthen its process to ensure that physician and provider orders are followed, communicated, and appropriately documented when services are provided by an outside provider. Staff will continue to use outside provider visit notes and communications as a means of care coordination between the facility and the outside provider. Information received from outside providers will be incorporated into the resident's clinical record through the appropriate progress note/documentation process. Clinical staff will review outside provider documentation daily or within 24 hours of receipt to ensure that changes in the resident's condition, treatment recommendations, and new or revised orders are identified and addressed timely. When staff identify that an outside provider's schedule or availability has changed in a manner that may impair the resident's ability to receive ordered care, staff will promptly notify the appropriate provider and obtain a PRN order, when clinically appropriate, to allow facility staff to provide the necessary care based on the resident's current assessment and the provider's orders. Staff will implement and document all applicable orders and interventions in accordance with the resident's plan of care and the facility's policies and procedures. 3. Monitoring and Responsibility The Administrator or designee will be responsible for monitoring and ensuring implementation of this Plan of Correction. The Administrator or designee will monitor compliance with care coordination, timely review of outside provider documentation, implementation of provider orders, and documentation of interventions provided by facility staff. Any identified concerns will be addressed promptly through additional education, corrective action, and follow-up monitoring as appropriate.

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

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document the resident’s request or approval of a supportive device with restraining qualities, evaluate less restrictive alternatives prior to the use of the device, instruct caregivers on the correct use of and precautions for the device, and include information regarding the use of the device in the resident’s service plan for 1 of 1 sampled resident (#1) who was observed with side rails. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2025 with diagnoses including developmental delay. The resident was identified in the acuity interview on 08/31/26 as having a side rail. On 08/31/26, Resident 1’s vacant room was observed with a half side rail on the bed in the lowered position. On 09/01/26, Resident 1 was observed in bed with the side rail in the raised position at 10:00 am and in the lowered position at 2:00 pm. On 08/31/26 at 2:50 pm, Staff 6 (CG) stated he always lowered the side rail after providing ADL assistance for the resident and leaving him/her in bed to rest, so the resident did not attempt to use it to self-transfer. On 09/01/26 at 10:23 am, Staff 7 (CG) stated the side rail was always left in the raised position when the resident was in bed. The resident’s service plan, dated 08/20/26, did not include any instructions for staff as to how the side rails were to be used and monitored for safety or to whom any malfunctions should be reported. A current assessment for the side rails was requested on 09/02/26, and a copy of the initial assessment, completed on 06/19/26, was provided. Review of the side rail assessment identified the following: * There was no documented evidence the resident specifically requested or approved of the device and the facility informed the individual of the risks and benefits associated with the device; * There was no documented evidence other less restrictive alternatives were evaluated prior to the use of the side rail or that caregivers were instructed on the correct use of and precautions for the device; and * There was no documented evidence the facility instructed caregivers on the correct use and precautions related to use of the device. The need to ensure the assessment for a supportive device with restraining qualities contained all required elements and instruction regarding the use of the device was included in the resident’s service plan was reviewed with Staff 1 (ED) on 09/02/26 at 11:30 am. He acknowledged the findings.

PLAN OF CORRECTION 1. Corrective Action for Residents Affected by the Deficient Practice The facility reviewed all residents utilizing supportive devices with restraining qualities on 9/21/2026 to identify and correct any deficiencies. The RN updated the bed rail assessments to accurately reflect each resident’s preferences, needs, and safety considerations. 2. Systemic Changes to Prevent Recurrence To prevent recurrence of this deficiency, all supportive devices with restraining qualities will have clear instructions documented under the assistive device of the resident’s care plan. The instructions will include: • Who to report to if the equipment is not being used appropriately; • Who to report to in the event of equipment failure or malfunction; • When the device is appropriate to apply and use; • When the device should not be applied or used; and • Any applicable safety concerns or precautions. The care plan will be reviewed and updated with each required care plan update and whenever there is a significant change in the resident’s condition, needs, preferences, or use of the supportive device. 3. Monitoring and Responsibility The Administrator or designee will be responsible for monitoring the implementation of this Plan of Correction and ensuring that the corrective actions are consistently followed and maintained.

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

OAR 411-054-0037 (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 following a significant change of condition for 1 of 1 sampled resident (#1) who experienced a significant change of condition. Findings include, but are not limited to: During the acuity interview at 9:58 am on 08/31/26, staff reported Resident 1 had recently experienced a significant change of condition and was admitted to hospice services. The resident’s service plan was reviewed and showed it was updated on 08/20/26 to reflect the significant change of condition. The resident’s ABST evaluation was reviewed and showed it was last updated 06/22/26. The need to ensure residents’ ABST evaluations were updated when a resident experienced a significant change of condition was reviewed with Staff 1 (ED) at 11:30 am on 09/02/26. He acknowledged the findings.

PLAN OF CORRECTION 1. Corrective Action for Residents Affected by the Deficient Practice The facility reviewed all resident 1 ABSTs on 09/23/2026 to ensure that ABST accurately reflects the residents’ current needs and that staffing is sufficient to meet both scheduled and unscheduled care needs. 2. Systemic Changes to Ensure the Deficiency Does Not Recur The facility will review and update all residents’ ABSTs when service plans are due and whenever there is a significant change in a resident’s condition or care needs. This process will help ensure that ABSTs remain current and accurately reflect residents’ needs and required staffing. 3. Responsible Party for Monitoring and Implementation The Facility Administrator or designee will be responsible for monitoring the implementation of this Plan of Correction and ensuring that the corrective actions are completed and maintained.

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: