Print Inspection: CHOW009341

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an injury of unknown cause was reported to the local Department office unless an immediate investigation reasonably concluded and documented the injury was not the result of abuse, for 1 of 1 sampled resident (#2) with an injury of unknown cause. Findings include, but are not limited to: Resident 2 moved into the assisted living in 06/2024 with diagnoses including frontal lobe dementia (Pick’s disease). The resident’s 12/02/25 through 03/02/26 clinical record was reviewed, and the following was identified: The 02/11/25 service plan indicated Resident 2 experienced expressive aphasia (impaired ability to speak) that severely limited his/her ability to communicate verbally with staff. The service plan noted the resident was “not always oriented to person, place, and/or time. Cognitive impairment.” Review of the resident's records showed the following: * Staff documented on 02/21/26 at 12:15 pm Resident 2 was found with his/her finger bleeding and was trying to state what happened but was unable. Staff documented a supervisor and the nurse were contacted regarding the injury. On 2/23/26 at 3:30 pm the facility RN documented the wound as “laceration is ‘L’ shaped .5 cm by .5 cm with flap intact.” Resident 2 was unable to say how the wound occurred. The laceration represented an injury of unknown cause which was required to be reported to the local Department office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. During an interview on 03/04/26 at 1:45 pm, Staff 1 (ED) and Staff 3 (RN) reported there was no documented investigation completed for the above incident, and they reported the injury of unknown cause had not been reported to the local Department office. The need to ensure all incidents and injuries of unknown cause were immediately investigated to rule out suspected abuse or reported to the local Department office if abuse could not be ruled out, was discussed with Staff 1 Staff 3, and Staff 4 (RCC) on 03/05/26 at 11:00 am. They acknowledged the findings. Survey requested the facility report the above incidents to the local SPD office. Confirmation that the incidents were reported was received before exit.

Corrective Action: Resident #2’s injury of unknown cause was reported to the local SPD office as requested by survey prior to survey exit, and documentation of the report was confirmed. The resident’s injury was assessed by the Director of Wellness and/or designee, wound care was initiated, and the resident was monitored for signs and symptoms of infection or further injury. The facility conducted a post-incident review and investigation regarding the injury to determine possible causes and to ensure resident safety. The resident’s service plan was reviewed and updated as needed to reinforce safety monitoring and staff awareness of the resident’s communication limitations related to expressive aphasia and cognitive impairment. Identification of Other Residents: The Executive Director, Director of Wellness, and RCCs conducted a review of incident reports and progress notes for the previous 30 days to identify any additional injuries of unknown cause that may not have been reported to the local SPD office or lacked documented investigation. Any identified incidents were reviewed to ensure appropriate documentation, investigation, and reporting requirements were met in accordance with Oregon ALF regulations. Systemic Changes: The facility has implemented the following system changes: • Re-education of all leadership staff (ED, Director of Wellness, RCCs, and shift supervisors) on Oregon ALF requirements for: o Injury of unknown cause o Mandatory abuse reporting o Immediate investigation requirements o Reporting to the local SPD office when abuse cannot be ruled out • Implementation of an Incident Investigation and Reporting Checklist to be completed whenever a resident injury occurs. • All injuries will require: o Immediate resident assessment o Incident report completion o RN or supervisor investigation o Determination if injury is known vs unknown cause o SPD reporting when abuse cannot be ruled out • The facility implemented a standardized investigation template to ensure documentation includes: o Resident interview (when possible) o Staff interviews o environmental review o timeline reconstruction o determination of abuse vs non-abuse • Education was provided to all direct care staff regarding: o recognizing injuries of unknown cause o immediate reporting requirements o escalation to leadership. Monitoring of Corrective Actions: The facility will implement the following monitoring process: • The Executive Director and/or Designee will review all incident reports weekly for 60 days to ensure: o injuries of unknown cause are identified o investigations are completed o SPD reporting occurs when required. • The Director of Wellness and/or designee will randomly audit resident progress notes and incident reports to confirm documentation and follow-up. • Findings will be reviewed during Quality Assurance / Risk Management meetings to identify trends or additional staff education needs. • Any issues with compliance will continue to be reviewed through QA processes.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident evaluations were completed quarterly after the resident moved into the facility for 4 of 6 sampled residents (#s 2, 3, 4, and 5) whose evaluations were reviewed. Findings include, but are not limited to: During the survey dated 03/02/26 through 03/05/26, quarterly evaluations were requested for residents 2, 3, 4, and 5. No documentation was provided. In an interview on 03/04/26 at 9:54 am, Staff 1 (ED) and Staff 3 (RN) confirmed evaluations had not been completed quarterly. The need to ensure quarterly resident evaluations were completed was discussed with Staff 1, Staff 3, and Staff 4 (RCC) on 03/05/26 at 11:26 am. They acknowledged the findings.

Corrective Action: Quarterly resident evaluations for Residents #2, #3, #4, and #5 were completed by the Director of Wellness and/or designee immediately following identification of the deficiency. The evaluations included a review of the residents’: • Current health status • Cognitive status • Functional abilities • ADL assistance needs • Safety risks • Service plan accuracy Service plans were reviewed and updated as needed to ensure they accurately reflected the residents’ current needs. The completed evaluations were placed in the residents’ clinical records. Identification of Other Residents: The Executive Director, Director of Wellness, and Resident Care Coordinators (RCC) will conduct a housewide audit of current residents to determine whether quarterly evaluations were completed as required after move-in. Any resident identified as missing a quarterly evaluation will have the evaluation completed immediately and documentation placed in the clinical record. Systemic Changes: The facility implemented the following system changes: Quarterly Evaluation Tracking System • A Quarterly Resident Evaluation Tracking Log has been implemented to track: o Resident move-in dates o Due dates for quarterly evaluations o Completion dates o Responsible staff member Calendar Alerts • The Director of Wellness and/or RCCs will utilize calendar reminders and electronic tracking to ensure evaluations are completed prior to the due date. Policy and Process Reinforcement • Leadership staff (ED, Director of Wellness, RCCs) received re-education on the regulatory requirement that resident evaluations must be completed: o Within 30 days of move-in o Quarterly thereafter o After a significant change in condition Staff Education • Education was provided to leadership staff responsible for care planning regarding: o Oregon ALF evaluation requirements o Documentation expectations o Service plan review timelines Monitoring of Corrective Actions: The facility will implement the following monitoring process: • The Director of Wellness and/or designee will review the Quarterly Evaluation Tracking Log weekly x 4 weeks then monthly x 3 months to ensure all upcoming evaluations are scheduled and completed timely. • The Executive Director and/or designee will conduct a monthly audit of random resident records for x 3 months to confirm quarterly evaluations are completed and documented appropriately. • Results of the audits will be reviewed during Quality Assurance / Quality Improvement (QA/QAPI) meetings. • Any identified issues will result in immediate corrective action and staff re-education. Any issues with compliance will continue to be reviewed through QA processes.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to ensure service plans were reflective of the resident’s care needs, provided clear direction regarding the delivery of services, and were updated no less than quarterly, for 3 of 6 sampled residents (#’s 2, 3, and 4), whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living in 03/2020 with diagnoses including chronic obstructive pulmonary disease. The resident’s 05/13/25 service plan and 12/02/25 through 03/02/26 temporary service plans were reviewed, interviews with the resident and staff were conducted, and observations of the resident were made. The following was identified: a. The service plan was not reflective of the resident’s care needs and lacked clear direction to staff in the following areas: * Use of oxygen while showering; * Assistance with personal hygiene and grooming verses independent with the tasks; and * Assistance with toileting verses independent with the task. b. The service plan was not updated quarterly, as required. During an interview on 03/03/26 at 1:50 pm, Staff 15 (CG) confirmed Resident 4 was independent with personal hygiene, grooming, toileting, and the resident did not use oxygen while showering. The need to ensure service plans were reflective of the resident’s care needs, provided clear direction regarding the delivery of services and were updated no less than quarterly was discussed with Staff 1 (ED), Staff 2 (Regional Director of Clinical Operations), Staff 3 (RN) and Staff 4 (RCC) on 03/04/26 at 1:00 pm. They acknowledged the findings. 2. Resident 2 moved into the assisted living in 06/2024 with diagnoses including frontal lobe dementia (Picks Disease). The resident’s 02/11/25 service plan and 12/02/25 through 03/02/26 temporary service plans were reviewed, interviews with the resident and staff were conducted, and observations of the resident were made. The following was identified: a. The service plan was not reflective of the resident’s care needs and lacked clear direction to staff in the following areas: * Aphasia and limited verbal communication; * Personal caregiver not listed on service plan; * Fall interventions no longer current since 08/01/2025; * Interventions for depression and anxiety; and * No specific interventions for staff to provide cueing and “general direction.” b. The service plan had not been updated quarterly, as required. During an interview on 03/03/26 at 1:50 pm, Staff 8 (MT) confirmed Resident 2’s verbal communication was impaired by aphasia, s/he had a personal caregiver, and there were not clear instructions for fall, depression, or disorientation interventions on the service plan. The need to ensure service plans were reflective of resident current needs and preferences, provided clear direction to staff, and were updated no less than quarterly was discussed with Staff 1 (Executive Director), Staff 3 (RN), and Staff 4 (RCC) on 03/05/26 at 11:00 am. They acknowledged the findings. 3. Resident 3 moved into the facility in 12/2015 with diagnoses including unspecified psychosis, and spinal stenosis – cervical region. The resident’s service plan was obtained on 03/02/26 from the service plan binder that the facility made available to all staff. The document was not dated. In an interview on 03/05/26 at 10:34 am, Resident 3 stated s/he had not met with the facility staff to review his/her service plan in “two years.” In an interview on 03/05/26 at 2:05 pm, Staff 1 (ED) acknowledged the facility was “behind in reviewing service plans.” When asked, she stated Resident 3’s service plan had last been reviewed on 04/17/24. The facility failed to review the service plan following quarterly evaluations. The need to ensure the service plan was reviewed at least quarterly was discussed with Staff 1, Staff 3 (RN) and Staff 4 (RCC) on 03/05/26 at 2:05 pm. They acknowledged Resident 3’s service plan had not been reviewed quarterly.

Corrective Action: Service plans for Residents #2, #3, and #4 were reviewed and updated by the Director of Wellness and/or designee to ensure they accurately reflect the residents’ current needs, preferences, and required staff interventions. The updated service plans now include: Resident #4 • Clarification that the resident does not require oxygen during showering • Updated direction for personal hygiene and grooming • Clarification of independence with toileting • Clear staff guidance regarding assistance levels Resident #2 • Documentation of expressive aphasia and impaired verbal communication • Inclusion of the resident’s personal caregiver • Updated fall interventions • Interventions addressing depression and anxiety • Clear direction for cueing, redirection, and staff guidance Resident #3 • Service plan was reviewed, dated, and updated • Resident participated in the service plan review to ensure preferences and care needs were accurately reflected • The plan now provides clear direction for staff regarding care delivery All revised service plans were placed in the residents’ clinical records and in the staff service plan binder used for care delivery. Identification of Other residents: The Executive Director and/or designee will conduct a house wide audit of current resident service plans to determine whether: • Service plans will be reviewed within the required quarterly timeframe • Care instructions will accurately reflect current resident needs • Plans will provide clear direction to staff Any service plan identified as outdated or lacking sufficient care direction was immediately reviewed and updated. Systemic Changes: A Service Plan Review Tracking Log will be implemented to track: • Resident move-in date • Date of last service plan review • Quarterly due dates • Completion of updates The Executive Director, Director of Wellness, and RCCs received education on Oregon ALF regulatory requirements related to: • Quarterly service plan review • Ensuring plans reflect current resident needs and preferences • Providing clear direction for staff care delivery Monitoring of Corrective Actions: The facility will implement the following monitoring process: • The Director of Wellness and/or designee will review the Service Plan Tracking Log weekly for 60 days to ensure service plans are reviewed and updated timely. • The Executive Director and/or designee will complete random monthly audits of resident service plans for x 3 months to verify: o Service plans are current o Care instructions are clear and accurate o Plans reflect resident needs and preferences • Results of the audits will be reviewed during Quality Assurance / Quality Improvement (QA/QAPI) meetings. • Any identified issues will result in immediate corrective action and staff re-education. Any issues with compliance will continue to be reviewed through QA processes.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer, for 1 of 6 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 10/2025 with diagnoses including chronic viral hepatitis, cirrhosis of liver, neuromuscular dysfunction of bladder and cellulitis of lower limbs. The most recent signed physician order list, dated 01/20/26, and any subsequent orders were reviewed and compared to the 02/2026 MAR/TAR. The following was identified: a. The following medications were not on the MAR and administered as prescribed between 02/01/26 and 02/28/26: * Trazodone (antidepressant) 150 mg tablet, 1 tablet daily; and * Nystatin topical powder, 1 application BID to skin fold rash of pannus. b. Changes to Resident 1’s Miralax (for constipation) orders were not followed or Miralax was administered without written, signed physician orders as follows: * The facility administered Miralax 17 gram packet, 4 doses every day shift from 02/01/26 through 02/09/26, which was consistent with the order on the 01/20/26 physician order list. However, the order was changed on 02/05/26 to administer 1 dose 4 times per day and the facility continued to administer Miralax per the previous order. * From 02/09/26 through 02/11/26, the facility administered Miralax 4 doses 4 times per day. The facility could not provide a signed written order for this administration. * On 02/12/26, the Miralax order was changed to 2 doses daily. This order was not implemented. Instead, from 02/12/26 through 02/28/26, the facility administered Miralax 1 dose 3 times per day. The facility could not provide a signed written order for this administration. On 03/04/26 at 10:20 am, the surveyor reviewed the inconsistencies with the MAR and the Miralax orders with Staff 3 (RN). She acknowledged the multiple order changes and stated she would provide the orders that were missing. During the remainder of the survey, Staff 3 did not provide additional documents that clarified the inconsistencies. The facility requested and received a current signed orders list dated 03/05/26 from the physician. The current order specified the resident should be administered Miralax 17 gram/dose, 2 doses daily. On 03/05/26 at 1:10 pm, the surveyor and Staff 14 (MT) reviewed the 03/2026 MAR. The facility was still administering Miralax 1 dose 3 times per day. The need to ensure medication and treatment orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer was reviewed with Staff 1 (ED), Staff 3 and Staff 4 (RCC) on 03/05/26 at 2:05 pm. No additional documentation was provided.

Corrective Action: Resident #1’s medication and treatment orders were immediately reviewed by the Director of Wellness and/or Designee. The following corrective actions were taken: • A current signed physician order list dated 03/05/26 was obtained from the resident’s provider. • The Medication Administration Record (MAR) and Treatment Administration Record (TAR) were updated to accurately reflect the current physician orders. • The order for Miralax 17 g – 2 doses daily was implemented as prescribed. • Orders for Trazodone 150 mg daily and Nystatin topical powder BID were verified with the physician and added to the MAR/TAR as appropriate. • Medication administration staff were instructed to administer medications only as ordered on the signed physician order list. • The resident was monitored for any adverse effects related to the previous inconsistencies in medication administration. All corrected orders and MAR updates were placed in the resident’s clinical record. Identification of Other Residents: The Director of Wellness and/or Designee will conduct a house wide audit of all resident medication and treatment orders by comparing: • The most current signed physician orders • The MAR/TAR • The medication cart contents • The medication cart contents The audit will verifiy that: • All medications and treatments listed on the physician order sheet were present on the MAR/TAR • Medication administration instructions matched the physician orders • All medications administered had signed physician orders documented in the resident record Any discrepancies identified were immediately corrected. Systemic Changes: The facility will implement the following system changes: 1) Medication Order Reconciliation Process A standardized Medication Order Reconciliation Process will be implemented to ensure: • All new medication or treatment orders are transcribed accurately onto the MAR/TAR • Orders are verified by Director of Wellness and/ or designee • Signed physician orders are obtained and placed in the resident’s record 2) Medication Change Verification When medication orders change: • The Director of Wellness and/or Designee will verify the order • The MAR/TAR will be updated immediately • Medication staff will be notified of the change prior to administration 3) Monthly Physician Order Review The Director of Wellness and/or designee will complete a monthly physician order reconciliation to ensure: • MAR/TAR entries match the most recent signed physician orders • All medications administered have written physician authorization 3) Staff Education Medication staff and leadership (ED, Director of Wellness, RCCs, and medication technicians) will receive education regarding: • Accurate transcription of physician orders • MAR/TAR reconciliation • Administration of medications only as ordered • Documentation requirements for medication and treatment orders. Monitoring of Corrective Actions: The facility will implement the following monitoring process: • The Director of Wellness and/or Designee will perform random weekly MAR/TAR audits for 60 days to ensure medication administration matches signed physician orders. • The Executive Director and/or Designee will conduct random monthly medication record audits x 3 months to verify: o Physician orders match MAR/TAR entries o All medications administered have signed orders o Medication changes are implemented correctly • Results of the audits will be reviewed during Quality Assurance / Quality Improvement (QA/QAPI) meetings. • Any identified issues will result in immediate corrective action and staff re-education. Any issues with compliance will continue to be reviewed through QA processes.

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 411-054-0037 (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 an acuity-based staffing tool (ABST) was completed, updated and reviewed for each resident, prior to a resident moving in and no less than quarterly at the same time the resident’s service plan was updated, for 5 of 7 sampled resident’s (#’s 1, 2, 3, 4, and 5) and multiple unsampled residents, whose ABST evaluations were reviewed. Findings include, but are not limited to: During the acuity interview on 03/02/26 at 10:38 am, Staff 3 (RN) confirmed the census was 72 residents. On 03/02/26 at 1:26 pm, the facility ABST was reviewed and the following was identified: * The facility ABST consisted of three units: Terrace One, Terrace Two, and Terrace Three, totaling 52 residents; * Multiple unsampled residents were not entered into the ABST; * Resident 1’s ABST was not completed prior to moving into the facility; * Resident 4 was not entered into the ABST; and * Resident 2, 3, and 5's ABSTs were not updated quarterly, at the same time the resident’s service plan was updated. During an interview on 03/03/26 at 12:30 pm, Staff 1 (ED) reported 20 residents were not in the ABST because “the facility merged with another license [within the same building] and we haven’t moved those residents into the ABST” [for the current license]. The need to ensure an acuity-based staffing tool (ABST) was completed or updated and reviewed for each resident, and the ABST was updated prior to a resident moving in and no less than quarterly, at the same time the resident’s service plan was updated was discussed with Staff 1 on 03/03/26 at 12:30 pm. She acknowledged the findings.

Corrective Action: The Director of Wellness/ and or Designee completed a full review of the Acuity-Based Staffing Tool (ABST). Corrective actions included: • Residents #1, #2, #3, #4, and #5 were entered or updated in the ABST to reflect their current acuity levels. • ABST evaluations were completed for residents who were missing from the tool, including those affected by the facility license consolidation. • The ABST was updated to include all residents currently residing in the facility. • Resident #1’s ABST was completed to reflect the resident’s current care needs. • Residents #2, #3, and #5 had their ABSTs updated to reflect current acuity levels consistent with their most recent service plan reviews. • The facility confirmed the ABST now accurately reflects the current census and resident care needs. Identification of Other Residents: The Director of Wellness and/or designee will conduct a house wide audit of current residents to verify: • Each resident will be entered into the ABST • ABST assessments will reflect current care needs • ABST reviews will correspond with service plan review timelines Any resident not previously entered into the ABST will immediately added and assessed. Systemic Changes: The facility will implement the following system changes: 1) ABST Tracking Process An ABST tracking log will be implemented to ensure the following are completed: • ABST evaluation prior to resident move-in • ABST review no less than quarterly • ABST review at the same time as service plan updates 2) Move-In Checklist Update The facility move-in process will include a required step to complete the ABST prior to resident admission. 3) Quarterly Care Review Alignment ABST updates will now be completed simultaneously with quarterly service plan reviews to ensure resident acuity is accurately reflected. 4) Leadership Education Education will be provided to the Executive Director, Wellness Director, and RCCs regarding: • Oregon ALF ABST regulatory requirements • Ensuring all residents are entered into the tool • Maintaining accurate census and acuity tracking • Updating ABST with service plan reviews Monitoring of Corrective Actions: The facility will implement the following monitoring process: • The Director of Wellness and/or designee will review the ABST weekly for 60 days to ensure: o All residents are entered in the tool o ABSTs are updated with service plan reviews o New admissions are entered prior to move-in • The Executive Director will complete monthly audits of the ABST x 3 months to confirm: o Census matches the ABST o Resident acuity levels are current o Quarterly updates are completed • Findings will be reviewed during Quality Assurance / Risk Management meetings. • After the monitoring period, ABST compliance will continue to be reviewed quarterly as part of QA oversight.

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: