OAR 411-054-0025 (7) Facility Administration: Policy & Procedure Temporary rule language in effect until 02/05/2027 (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. (a) The facility must develop and implement the following policies and procedures: (A) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (B) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (C) Effective methods of responding to and resolving resident complaints. (D) A policy on smoking. The facility may designate itself as non-smoking. The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (E) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (F) A policy on facility employees not receiving gifts or money from residents. (G) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (b) The facility must develop and implement the policies and procedures for the following rules: (A) Food preparation including temperatures and distribution policy as outlined in the Food Sanitation Rules. (B) Service planning policy as outlined in OAR 411-054-0036. (C) Medication administration policy as outlined in OAR 411-054-0055. (D) Facility closure policy as outlined in OAR 411-054-0010. (E) Abuse reporting policy as outlined in OAR 411-054-0028. (F) Change of condition and monitoring policy as outlined in OAR 411-054-0040. (G) Resident health services policy as outlined in OAR 411-054-1195 0045. (H) Staffing training policy as outlined in OAR 411-054-0070. (I) Facility safety program as outlined in OAR 411-054-0090. (J) Emergency and disaster planning policy(s) as outlined in OAR 1199 411-054-0093. (K) Safe cooking appliances policy as outlined in OAR 411-054-0200. (L) ABST Policy for accurate and consistent implementation of the ABST as outlined in OAR 411-054-0037. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs, 24 hours of the day, 7 days a week. (M) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (N) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), and OAR 411-054-0085 (Refunds and Financial Management). (O) If licensed as an assisted living or residential care facility with an endorsed memory care, the facility must follow all OAR chapter 411, division 57 policy and procedure requirements. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: During the entrance conference and subsequent follow-up requests on 09/21/26, the survey team requested three months of resident council, food committee, and town hall meeting minutes. Notes reviewed from 06/16/26 through 09/15/26 noted the following resident concerns: * Quality of food; * Running out of food; * Stealing of resident belongings; * The administrator failed to show up for appointments with residents; * Residents being harassed (no clarification or follow-up related to whom); and * Communication (no clarification or follow-up regarding with whom). During individual and group interviews, unsampled residents reported the following: * No follow-up from the administrator on resident concerns; * The administrator was not approachable; and * The administrator’s response to resident concerns included “everything is fine.” and “if you don’t like it, you can move.” During an interview on 09/23/26 at 12:17 pm, Staff 1 (ED/Director of Operations) acknowledged challenges in the community concerning several residents. Staff 1 stated residents were encouraged to bring concerns to the resident council and/or come to administration directly. Residents had documented concerns related to dining room service, administrative approach to residents, and communication. There was no documented evidence there was an effective method of responding to and resolving resident complaints. The need to ensure the facility developed effective methods of responding to and resolving resident complaints was discussed with Staff 1 (ED/Director of Operations) on 09/23/26 at 12:43 pm. Staff 1 recognized the ongoing concerns and discontent with residents. Refer to C200.

1. Executive Director will meet monthly with president of the council to discuss residents concerns. They will also review resident meeting notes for follow up discussion on responding to resident conerns. At Town Hall, Executive Director will review concerns with feedback from the company stand point with resolutions. 2. Executive Director will attend Chef Chats, Activity Chats and Town Hall to ensure all conerns are being heard and addressed. Documentation of meetings will be kept in Executive Director for review. 3. Community will be attending meetings monthly and as needed with residents concerns. Executive Director has an open door policy at all times. 4. Executive Director will be responsible for oversight of residents concerns and resolving complaints. Date of compliance will be 11-22-2026.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were treated with dignity and respect and were able to voice grievances without concern or distress. Findings include, but are not limited to: Multiple interviews were conducted from 09/21/26 through 09/23/26 with unsampled individual residents, a resident group, an outside provider, and residents’ family members. Record review, including resident council minutes, “Chef Chat” notes, and town hall meeting minutes, was conducted. The following statements were made verbally or noted in documentation: * Staff 1 (ED/Director of Operations) “gave me a dressing down,” “made me feel like a child”; * No follow-up from Staff 1 related to resident concerns; * Staff 1 “talks over residents,” and “is not nice to women, treats women like they don’t know anything”; * ”I stay away” from Staff 1; * Staff 1 “is a bully”; * Staff 1 “rules in fear”; * Twenty-four residents signed a petition regarding the overall management of the facility; * Staff 1 was reported to have told residents, “If you have a problem with something going on at the facility, you don’t have to live here”; * A resident reported s/he felt like “I have a target on my back”; * Staff 1 “doesn’t see people as people but rather as problems”; * Staff 1 allegedly stated, when responding to a food complaint, “If you don’t like it, move”; * ”. . . inability to file a grievance or talk with Staff 1 anymore . . . If you don’t fit into the square hole you’re not allowed”; * Hope the corporation “gets rid of” Staff 1 based on how he treated dietary servers and women; * “Arrogant attitude”; and * “Always disrespectful,” The ongoing documented and reported resident concerns showed a lack of treating residents with respect and dignity. During an interview on 09/23/26 at 12:17 pm, Staff 1 stated the following: * “These residents come after you hard”; * One resident had been getting “a lot of residents on [his/her] bandwagon”; * The loss of a culinary director had a significant impact on the residents and generated a lot of “food-related issues”; * “They are targeting me”; * “It’s very hard to help these people”; and * “Trying to turn it around.” Staff 1 recognized the ongoing concerns and discontent with residents.

1. Lakeview Senior Living is in the process of hiring a new Executive Director to run the day to day operations. Management will continue to work with each resident on their specific concerns and find resolutions. 2. Executive Director will attend all meeting with residents, walk the dining room to check on tables during meal times and incourage residents that Executive Director has an open door policy. Executive Director will keep notes or meeting notes in a binder in the Executive Director office. 3. This will be ongoing daily, weekly and monthly. 4. Executive Director will be monitoring and talking with residents for satisfaction and resolutions of concerns and residents voices to be heard. Corrections will be completed by 11/22/2026.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility?s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 3 of 5 sampled residents (#s 1, 2, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2020 with diagnoses including glaucoma and gout. On 09/22/26 at 9:45 am, Resident 5 was observed ambulating in his/her apartment using a wheelchair. Alert and oriented with clear speech, the resident reported some days staff assisted with transfers from bed, lower body dressing, showers, provided medications, and assisted when going to and from the dining room for dinner. The resident reported no longer using the walker due to falls and was using the wheelchair for all mobility in and out of the apartment. The resident reported having home health physical therapy services every Thursday and presented copies of exercises s/he was told to complete one to two times daily. On 09/22/26 at 10:30 am, Staff 4 (MT) reported that due to the number of falls recently, staff assisted Resident 1 to go from a laying to sitting position at bedside, with transfers to wheelchair from bed, assisted with dressing when needed and with showers, and administered all ordered medications. Staff 4 reported the resident was independent in many areas but had declined recently, and some days was weaker, needed more assist, and had frequent safety checks done. Resident 5's service plan, dated 08/18/26, was not reflective of the resident's current needs and/or lacked clear instructions to staff in the following areas: * Refusal of cares; * Transfer assist; * Dressing assist; * Medication administration; * Outside provider, including instructions for daily exercises; * Safety checks; * Ambulation in unit; and * Evacuation assist. The need to ensure the service plan reflected resident’s current care needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED/Director of Operations) and Staff 3 (Health Services Director/RN) on 09/23/26 at 1:30 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2026 with diagnoses including right below knee amputation. During an observation on 09/21/26 at 1:55 pm, Resident 2’s bed had bilateral side rails in the up position. The side rails were loose and there was a gap between the mattress and the rail. The current service plan, dated 09/21/26, noted the resident had bed rails for bed mobility and transfers and rarely slept in the bed. The service plan did not identify precautions related to the use of the devices with restraining qualities. The lack of safety precautions on the service plan was discussed with Staff 1 (ED/Director of Operations) and Staff 3 (Health Services Director/RN) on 09/23/26 at 1:21 pm. No additional information was provided. 3. Resident 1 was admitted to the facility in 12/2025 with diagnoses including chronic obstructive pulmonary disorder and dementia. During an interview and observation on 09/23/26 at 11:00 am, Resident 1 had a hospital bed with bilateral half side rails in the up position and securely fastened to the bed. Resident 1 stated the side rails were used to assist with mobility, including getting in and out of bed and repositioning while in bed. The current service plan, dated 07/29/26, noted the resident had half bed rails for positioning. The service plan did not identify the precautions related to the use of the devices with restraining qualities. The lack of safety precautions on the service plan was discussed with Staff 1 (ED/Director of Operations) and Staff 3 (Health Services Director/RN) on 09/23/26 at 2:00 pm. They acknowledged the findings.

1. Upon move ins for a new resident, all service plan will be reviewed by Resident Service Director and residents/POA or family. Upon 30 days of admission, service plans will reviewed and updated as needed. August Health is our system we use at Lakeview to track service plans. Every 90 days service plans will be reviewed and updated. Lakeview will get resident/POA or family signature on the service plan. Change of conditions will happen with 48 hours by RN and updated service plans will be reviewed and signed by resident/POA or family. R#1 service plan has been reviewed and updated to reflect safety precuations for bed rails. Care Staff have be in serviced on safety precuations. R#2 service plan has been updated with safety measures for bed rails safety on care plan. Care Staff have been in services on R#2 safety pre cautions on bed rails and updated service plan. R#5 service plan has been udpated to reflect current care needs. Care staff have reviewed careplan with signature for knowledgement of new service plan needs. 2. Service plans will be tracked and monitored in August Health. 3. Evaluations will be reviewed daily for upcoming assessment that need to be completed. 3. This is ongoing and daily for review at our daily clincial meeting with RN, RSD, RSC and ED. 4. Executive Director and Clincial team will be responsible daily to review all service plan are due or about to be due. Plan of correction wil be 11/22/2026.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced significant changes of condition were evaluated and referred to the nurse and/or short-term changes of condition were monitored weekly through resolution for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) reviewed with changes of condition. Resident 2 experienced ongoing weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility with diagnoses including inadequate oral intake, anxiety, and depression. The resident’s 03/01/26 through 09/18/26 clinical record was reviewed, interviews with staff and the resident were conducted, and observations of the resident were made. a. Resident 2’s weight records identified the following: * 03/01/26 – 167.8 pounds; * 04/15/26 – 166.4 pounds; * 05/15/26 – 162.4 pounds; * 06/04/26 – 165.4 pounds; * 07/30/26 – 163.1 pounds; * 08/30/26 – 152 pounds; and * 09/18/26 – 144 pounds. Between 07/30/26 and 08/30/26 Resident 2 experienced an 11.1-pound weight loss, or 6.8% of his/her body weight, in approximately 30 days, which constituted a severe weight loss and significant change of condition. There was no documented evidence the facility evaluated the weight loss, referred the condition to the RN, or that the service plan was updated. Between 08/30/26 and 09/18/26 Resident 2 lost an additional eight pounds, or 5.2% of his/her body weight, resulting in another significant weight loss. Observations during the survey identified the resident ate meals in his/her apartment and was able to eat independently. Resident 2 ate 100% of his/her meals on 09/21/26, 09/22/26, and 09/23/26. The facility failed to evaluate the resident’s weight loss, refer to the RN, and determine interventions, and the resident continued to lose weight. During interviews with Staff 3 (Health Services Director/RN) on 09/23/26 and Resident 2 on 09/22/26, both confirmed the resident had experienced weight loss. b. There was no documented evidence the following short-term changes of condition were monitored at least weekly through resolution: * 07/09/26 – Missed doses of trazodone (for sleep); * 07/19/26 – Missed doses of amlodipine (for hypertension); and * 08/18/26 – Discontinuation from hospice. During an interview on 09/23/26 at 1:21 pm, Staff 3 acknowledged she had not been resolving short-term changes of condition. During an interview with Staff 1(ED/Director of Operations) and Staff 3 (Health Service Director/RN) on 09/23/26 at 1:21 pm, Resident 2’s severe and ongoing weight loss and changes of condition without documented evidence of weekly monitoring through resolution was reviewed. No additional information was provided. 2. Resident 1 was admitted to the facility in 12/2025 with diagnoses including chronic obstructive pulmonary disorder and dementia. The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, and the following was identified: There was no documented evidence short-term changes of condition were monitored with weekly progress noted until resolution for the following: * 06/29/26 – Non-injury fall, found on floor; * 07/04/26 – Discontinued medication (glipizide); * 07/05/26 – Non-injury fall; * 07/15/26 – Fall with injury, scratch on back; * 07/15/26 – Shower head hit jaw of resident; and * 07/20/26 – Fall with right leg pain. An interview with Staff 3 (Health Services Director/RN), on 09/22/26 at 10:03 am, confirmed she was the person responsible for resolving short-term changes of condition and had been “busy” and had not discontinued monitoring. The need to ensure that changes of condition were monitored, with weekly progress noted through resolution, was reviewed with Staff 1 (ED/Director of Operations) and Staff 3 on 09/23/26 at 2:00 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 07/2026 with diagnosis including bi-lateral lower extremities edema and poly-osteoarthritis. The resident’s 07/08/26 through 09/20/26 clinical record was reviewed, and the following was identified: There was no documented evidence the following short-term changes were monitored until resolution: * 07/08/06 - New move-in; * 07/12/26 - Fall with injury, ER visit; * 07/16/26 - Swelling to right lower leg, ER visit; * 07/18/26 - Cut to great left toe; * 07/24/26 - New medication started (clindamycin); * 08/06/26 - ER visit due to shortness of breath; * 09/04/26 - Return from ER visit, started new antibiotic; and * 09/12/26 - ER visit due to shortness of breath, swelling in legs. An interview with Staff 3 (Health Services Director/RN), on 09/22/26 at 10:03 am, confirmed she was the person responsible for resolving short-term changes of condition and had been “busy” and had not discontinued monitoring. The need to ensure that changes of condition were monitored, with weekly progress noted through resolution, was reviewed with Staff 1 (ED/Director of Operations) and Staff 3 on 09/23/26 at 2:30 pm. They acknowledged the findings. 4. Resident 4 moved into the facility in 12/2023 with diagnoses including chronic kidney disease with severe obesity. Weight records from 06/2026 to 09/2026 were reviewed, and the following weight changes were identified: * 07/21/26 - 291.9 pounds; * 07/28/26 - 239.4 pounds; * 08/13/26 - 244 pounds; and * 08/22/26 - 261.1 pounds. Between 07/21/26 and 07/28/26 Resident 4 experienced a 52.5-pound weight loss, or 17.99% of his/her body weight, in a one-week period, which constituted a severe weight loss and significant change of condition. Between 08/13/26 and 08/22/26 Resident 4 experienced a 17.1-pound weight gain, or 7% of his/her body weight, in a one-week period, which constituted a severe weight gain and a significant change of condition. Review of records revealed no follow-up documentation to evaluate the resident’s weight fluctuations and refer to the RN related to the significant changes. On 09/23/26 at 10:34 am, Staff 3 (Health Services Director/RN) stated staff had challenges with weighing Resident 4 due to his/her power wheelchair size relative to their scale size, but agreed records indicated Resident 4 had experienced significant weight changes and no follow-up action occurred. The need to ensure the facility identified and addressed Resident 4’s significant weight changes was reviewed with Staff 1 (ED/Director of Operations) and Staff 3 on 09/23/26 at 1:47 pm. They acknowledged the findings. 5. Resident 5 was admitted to the facility in 07/2020 with diagnoses including glaucoma and gout. The resident’s 06/21/26 through 09/21/26 clinical record was reviewed, and the following was identified: There was no documented evidence short-term changes of condition were monitored with weekly progress noted until resolution for the following: * 08/11/26 - Fall with closed head injury, laceration, right arm skin injury, and skin discolorations; * 08/11/26 - A second fall without injury; * 08/16/26 - Non-injury fall; * 08/18/26 - Significant change of condition related to increased falls, dizziness, and increased back pain; * 08/25/26 - Fall with right elbow skin tear; and * 09/03/26 - New medication, tramadol for pain. On 09/22/26 at 11:00 am, Staff 3 (Health Services Director/RN) verified there was no monitoring of progress for short-term changes of condition documented weekly to resolution. The need to ensure that changes of condition were monitored, with weekly progress noted through resolution, was reviewed with Staff 1 (ED/Director of Operations) and Staff 3 on 09/23/26 at 01:30 pm. They acknowledged the findings.

1. Lakeview is hiring Elderwise Consultants to come and train and in service RN/Clinical team on change of conditions and monitoring. Daily, care team will notify RN if any change of conditions need to be evaluated and RN will have 48 hours to document change of condition.R#1 service plan has been updated and reviewed with care staff. R#1 will have a TSP in place to indentify temporary change of condition until new service plan is generated. R#2 Weight loss for resident has been tracked weekly to get baseline. Updated Service plan identifies weight loss, RN has monitored and reviewed current service plan to ensure it is correct and accurate to residents needs. R#3 will have TSP in place to identily short term changes, review and updated service plan will be done to ensure all residents care needs are captured. R#4 will be weight weekly to get a base line for weight. TSP and service plan will identify weight loss for monitoring and resolution. RN change of condition service plan will outline progess notes in August Health and alert charting. R#5 will have a TSP and updated service plan with change of condition. This will identify for care staff of new services or monitoring for care staff to chart in progress notes. RN will document resolution and weekly progress notes in August Health. 2. RN will use August Health daily to review all incidents documentated by care staff. This will promt RN to follow up with staff and residents to do a change of condition. Carestaff will continue to document in progress notes and resident to be on alert charting. 3. This will be evaluated daily and ongoing. 4. RN will ensure daily that August Health is reviewed, care staff notify RN when a change of condition occurs. RN will have 48 hours to invesigate, review and update service plan and ABST of any changes to care needs. RN will be in compliance by 11-22-2026.

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 significant changes of condition, including documentation of findings, resident status, and interventions made as a result of the assessment, for 2 of 2 sampled residents (#s 2 and 4) who experienced weight fluctuations. Resident 2 experienced ongoing weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility with diagnoses including inadequate oral intake, anxiety, and depression. Between 07/30/26 and 08/30/26 Resident 2 experienced an 11.1-pound weight loss, or 6.8% of his/her body weight, in approximately 30 days, which constituted a severe weight loss and a significant change of condition. Between 08/30/26 and 09/18/26 Resident 2 continued to lose an additional eight pounds, or 5.2% of his/her body weight, resulting in another significant weight loss. There was no documented evidence the facility RN had documented a significant change of condition assessment which included findings, resident status, and interventions made as a result of the assessment. Refer to C270, example 1a. 2. Resident 4 moved into the facility in 12/2023 with diagnoses including chronic kidney disease with severe obesity. Between 07/21/26 and 07/28/26 Resident 4 experienced a 17.99% weight loss, which constituted a severe weight loss and a significant change of condition. Between 08/13/26 and 08/22/26 Resident 4 experienced a 7% weight gain, which constituted a severe weight gain and a significant change of condition. There was no documented evidence the facility RN had documented a significant change of condition assessment which included findings, resident status, and interventions made as a result of the assessment. Refer to C270, example 4.

1. Lakeview has hired Elderwise Consultants to train, in service RN and clincial team on significant change of condition. R#2 will have a TSP and updated Change of Condition Service Plan. Weights will be conducted weekly and on alert charting. RN will do progress notes weekly until resolution. R#4 will have a TSP and updated change of condition service plan. Weights will be conducted weekly and on alert charting. RN will do progress notes weekly until resolution. 2. RN will review August Health daily of all incident reports. Care team will update RN daily of andy significant change of conditions. RN will have 48 hours to investigate and update service with with ABST on changes noted. 3. This will be daily and on going by RN and care team. 4. RN will be responsible for all significant change of conditions within 48 hours with invesitgation and progress notes reviewed. All tracked in August Health system. Compliance date of 11/22/2026.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to possess written, signed physician or other legally recognized practitioner orders for all medications administered by the facility for 1 of 5 sampled residents (#4) whose prescriber orders were reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in 12/2023 with diagnoses including chronic kidney disease with severe obesity, generalized anxiety disorder, chronic pain, and depression. Resident 4’s signed practitioner orders for medications were requested on 09/21/26 and none were provided. On 09/23/26 at 1:51 pm, Staff 3 (Health Services Director/RN) stated the facility did not possess written, signed physician or other legally recognized practitioner orders for Resident 4’s medications. The need to possess written, signed physician or other legally recognized practitioner orders for Resident 4’s medications was reviewed with Staff 1 (ED/Director of Operations) and Staff 3 on 09/23/26 at 1:47 pm. They acknowledged the findings.

1. Lakeview will audit med room with help from Elderwise Consultants. Audit will include to ensure community has doctors orders that match medications given to residents. R#4 Medications will match the MARs will doctors orders in resident file or chart. Pharmacy verification will also be conducted by RSD/RN. RSD will be sign off on medications with med techs to ensure order was received and is accurate to order from physican. 2. MARs in August Health will be reviewed daily by med techs, RSC and RN to ensure current and or doctors orders of medication match the MARs. 3. This will be daily and ongoing. To include Audits from our pharmacy and Elderwise Consultants. August Health is our system we use to track medications and documentation from doctors. 4. RN, RSC and Med tech will be resposible to ensure MARs, medication match doctors orders and order is clear on instructions for care staff to follow. Compliance date will be met by 11-22-2026.

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 residents' MARs were accurate regarding a reason for use and/or any resident-specific parameters and instructions for PRN medications for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2025 with diagnoses including chronic obstructive pulmonary disorder and dementia. The resident’s 09/01/2026 through 09/21/2026 MAR and current physician orders were reviewed, and the following was identified: The following medication lacked a reason for use: * Acetaminophen 500 mg cap three times daily as needed. An interview with Staff 8 (MT), on 09/23/26 at 9:15 am, confirmed the electronic MAR also did not include the reason for use for acetaminophen. The need to ensure the MAR included a reason for use was discussed with Staff 1 (ED/Director of Operations) and Staff 3 (Health Services Director/RN) on 09/23/26 at 2:00 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2026 with diagnoses including anxiety and depression. The resident’s 09/01/2026 through 09/21/2026 MAR and current physician orders were reviewed, and the following was identified: a. The following PRN pain medications lacked parameters for administration: * Acetaminophen 500 mg PRN pain; and * Oxycodone 5 mg PRN pain. b. The following medication lacked a reason for use: * Metformin. The accuracy of the MAR, including reasons for use and parameters, was discussed with Staff 1 (ED/Director of Operations) and Staff 3 (Health Service Director/RN) on 09/23/26 at 1:21 pm. No additional information was provided. 3. Resident 3 was admitted to the facility in 07/2026 with diagnoses including bi-lateral lower extremities edema and poly-osteoarthritis. The resident’s 09/01/26 through 09/21/26 MAR and current physician orders were reviewed, and the following was identified: a. The following PRN pain medications lacked parameters for administration: * Hydrocodone/APAP 5-325 mg, give 0.5 tablet every eight hours as needed (pain); and * Hydrocodone/APAP 5-325 mg, give 1 tablet every eight hours as (pain). b. The following medications lacked reason for use: * Amlodipine 5 mg daily; * Eliquis 5 mg twice daily; * Escitalopram 5 mg daily; * Levothyroxine 88 mcg daily; * Lisinopril 20 mg daily; * Metamucil smooth fiber packets 3,400 mg powder daily; * Metoprolol succ ER 25 mg twice daily; * Omega 3-6-9 1200 mg daily; * Saccharomyces Boul 250 mg twice daily; and * Lovastatin 20 mg daily. On 09/22/26 at 10:03 am, Staff 3 (Health Services Director/RN) stated that if the physician’s order did not include a reason for use, a reason for use would not be on the MAR. The need to ensure MARs included parameters for PRN medications and reasons for use for each medication was reviewed with Staff 1 (ED/Director of Operations) and Staff 3 on 09/23/26 at 02:30 pm. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 12/2023 with diagnoses including chronic pain, type 2 diabetes, and diastolic heart failure (a blood flow restriction). The resident’s 09/01/26 through 09/21/26 MAR was reviewed and the following was identified: The following medications lacked reasons for use: * Propranolol – 60 mg twice daily; * Torsemide – 20 mg daily; * Mounjaro – 2.5 mg/.5 ml weekly; and * Gabapentin – 300 mg daily. The need to ensure reasons for use of each medication on the MAR was reviewed with Staff 1 (ED/Director of Operations) and Staff 3 (Health Services Director/RN) on 09/23/26 at 1:47 pm. They acknowledged the findings. 5. Resident 5 was admitted to the facility in 07/2020 with diagnoses including gout and glaucoma. The resident’s 09/01/26 through 09/21/26 MAR and current physician orders were reviewed, and the following was identified: a. The following PRN pain medications lacked parameters for administration: * Acetaminophen 650 mg every six hours as needed (pain); * Ibuprofen 600 mg every six hours as needed (pain); and * Tramadol 50 mg twice daily as needed for pain. b. The following medications lacked a reason for use: * Cetirizine 5 mg daily; * Furosemide 60 mg twice daily; * Ipratropium Br. Solution two sprays in each nostril twice daily; * Latanoprost Solution, one drop in eyes at bedtime; and * Acetaminophen 650 mg every six hours. On 09/23/26 at 10:40 am, Staff 3 (Health Services Director/RN) stated that if the physician’s order did not include a reason for use, it would not be listed on the MAR. The need to ensure MARs included parameters for PRN medications and reasons for use of each medication was reviewed with Staff 1 (ED/Director of Operations) and Staff 3 on 09/23/26 at 1:30 pm. They acknowledged the findings.

1. Lakeview has hired Elderwise to audit our medication program. RN, RSC and Med Techs will review MARs for all residents on medication program. We will ensure medications have reason for use and parameters for administration per doctors orders. R#1 medication review will have RSD/RN and Med Techs verify and confirm has reason for use is documentated on MARs per doctors order. RSD/RN will complete an audit and in service to verify medications have reason for use. R#2 -community will verify with physician/pharmacy that parameters for administration are on MARs. Med Techs will be in service for reason of use and ensure August Health MARs match orders from physician. R#3 medication will be reviewed and updated with physician reason for use. This will be on the MARs and staff in service for understanding. R#4 medication will be reviewed and updated with physician to ensure we have reason for use. August Health MARs will be updated and staff to be in serviced for reason of use with medications. R#5 medications will be reviewed and consulted with physican on parameters for administration. This documentation will be on the MARs and staff to be in serviced on parameters by physician. 2.Care team will be reviewing doctors orders to MARs, to ensure parameters and reason for use are indentified on the MARs. 3. This will be reviewed daily and ongoing. 4. RN, RSC and Med Tech will be responsible to ensure all MARs are updated with the proper documentated per doctors orders are correct and accurate for compliance. Compliance date will be 11-22-2026.

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 for each care element 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 that ABST care time accurately reflected resident care needs for 1 of 5 sampled residents (# 5) whose ADL care time and service plans were reviewed. Findings include, but are not limited to: During the survey, Resident 5 was observed using a wheelchair for mobility. Alert and oriented, the resident stated that although still doing many things independently, staff provided assistance with getting up from bed, showers, putting on socks and shoes, and wheelchair escorts to and from the dining room, and provided all of his/her medications. On 09/23/26 at 10:30 am, Staff 9 (MT) reported that assistance was often provided when the resident was going from a laying to sitting position in bed, with transfers from bed to wheelchair, for showers, and lower body dressing, and that frequent safety checks were done due to the number of recent falls. Review of Resident 5’s service plan, dated 08/18/26, and the facility ABST data showed inaccurate minutes recorded for care time in one or more of the following areas: * Time spent on safety checks, fall prevention; * Time spent with medication administration, passing out meds; * Time spent on ambulation, escorting to and from meals or activities; * Time spent transferring in or out of bed or chair; * Time spent with bathing; and * Time spent on dressing and undressing. The need to ensure care element minutes entered on the ABST were accurately reflective of the residents’ current care needs was discussed with Staff 1 (ED/Director of Operations) and Staff 3 (Health Services Director/RN) on 09/23/26 at 1:30 pm. The staff acknowledged the findings.

1. ABST will be reviewed before move in, within 30 days reviewed and updated. Also at 90 days evaluation. ABST will be reviewed upon change of condition and every 90 days for every resident for review and update. Lakeview uses the State ABST system to ensure proper staffing plan is met. R#5 service plan will be reviewed and updated to current care needs. ABST will reflect and match the time of assistance resident will receive from staff members. In service will be conducted with care staff on updated ABST needs for R#5. This will be verified by RSD/RN. 2. Everyday at clincial meeting, ABST is on the agenda to review and get a look back. When a change of condition happens, ABST will be reviewed and updated at the same time. 3. This is daily and ongoing based on residents needs. 4. RN, RSC and Clinical team will be responsible for updating ABST and reviewing it daily to ensure it is accurate. date of compliance will be 11-22-2026.