Print Inspection: CHOW012216

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 observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect and have a homelike environment for 1 of 1 sampled resident (#1) with chair and bed alarms. Findings include, but are not limited to: Resident 1 was admitted into the facility in 03/2025 with diagnoses including Parkinson’s disease and neurocognitive disorder with Lewy bodies. The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident’s service plan, dated 06/02/26, noted the resident’s behaviors were affected by noise. The service plan stated the resident would pull apart bed alarms and tab alarms as s/he did not want to use them, and staff had installed a motion sensor to replace the other alarms. Throughout the survey, 06/29/26 through 07/02/26, the resident was observed to have bed alarm and chair alarms which alerted via a loud noise when the resident attempted to move him/herself independently. A motion sensor was also present in the room and audibly alerted to the kitchen area, which was located outside the resident’s room. In an interview on 07/02/26 at 9:45 am, Staff 1 (Executive Director) stated the resident often refuses and/or disassembles the alarms, as s/he prefers to be independent with ADLs, and noted the alarms can cause the resident to have increased behaviors. On 06/30/26 at 1:30 pm, Resident 1 stated s/he did not want the alarms and had repeatedly asked staff to remove the alarms. The need to ensure residents' right to be treated with dignity and respect and have a homelike environment was reviewed on 07/02/26 at 10:30 am with Staff 1, Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

Pacific Living Center of Grants Pass at Heidi will implement the following: 1. This is for resident 1, The bed and tab alarm were removed. All resident rights were reread and signed by all staff of Heidi house 6/25/26 to be followed for all alarms or corrections put in place per resident rights. 2. All alarms and resident preferences regarding alarms and sensors will be reviewed and updated in service plan. Instructions will be added to Care Plans on what staff should chart on and monitor for when a resident refuses to follow provider orders (bed/tag alarms) for residents who have provider orders. Residents will be asked if provider orders for alarms are tolerable for resident to be sure the resident agrees with the alarm, and resident rights will be followed. This will be evaluated prior to resident move in for new residents. 3. Prior to move in and during level of care assessments. 4. The Executive Director/ Assistant and Community nurse.

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:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted into the facility in 03/2025 with diagnoses including Parkinson’s disease and neurocognitive disorder with Lewy bodies. The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: a. The resident’s service plan, dated 06/02/26, was not reflective of the resident’s current status in the following areas: * Use of gait belt with transfers; * Status of skin, including indication of skin concerns as ongoing, despite those areas having resolved prior to service plan update; and * Fall interventions, including a note to remind the resident to call for assistance and a urinal placed next to the bed. b. The resident’s service plan did not provide clear direction to staff regarding the delivery of service in the following areas: * Wake patterns throughout the night and how to support the resident when s/he was awake; * Preference to stand when showering and use of grab bar to assist; * How to assist with dressing due to left shoulder dislocation and pain; * How to adjust the resident’s environment due to the effect of noise on his/her behaviors; * Volume of speech; * How the resident expressed pain and non-pharmacological interventions for pain; * When to don/doff sling; and * Modification to pull cord. The need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2024 with diagnoses including Alzheimer’s disease and epilepsy. The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident’s service plan, dated 05/28/25, was not reflective of the resident’s care needs and/or did not provide clear direction to staff in the following areas: * The effect of environmental factors such as noise, light, and temperature on his/her behaviors; * Assist required with transfers and mobility; * How the resident communicated pain and non-pharmacological interventions for pain; * Assist required when resident was having a “weaker day”; * Assist provided while eating; and * Frequency of weight monitoring. The need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

Pacific Living Center of Grants Pass at Heidi will implement the following: 1. The Executive Director/Community Nurse updated all sections in resident 1 and 2 forms/service plans to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services. Resident 2’s Care Plan was updated to reflect environmental noise/lighting and how resident 2 communicates pain (pharmaceutical/non-pharmaceutical). Care Plan was updated to on how caregivers are to assist resident 2 with “weaker days” and assistance with eating. Weekly weight monitoring put in place for resident 2. 1a) Resident 1 Care Plan updated to reflect resident’s preference on use of gait belt for transfers. Skin monitoring set in place for Community Nurse’s weekly checks. Note placed in resident 1’s room to alert staff via pull cord when needing assistance. Care Plan updated on resident preference and use of urinal next to bed. 1b) Service Plan updated with instructions for staff to support resident 1 during waking hours in the night and resident preference for sleep schedule. Service Plan updated resident 1 preference to stand when showering and using grab bar. ADLS updated in service plan for pain in shoulder of resident 1. Service plan updated to reflect resident preference to environmental noise due to behaviors and how caregivers are to respond to resident 1 volume of speech and expression of pain (pharmaceutical/non-pharmaceutical). Service Plan updated for monitoring and how to/when to use sling. Cord length was extended for resident 1 use. 2. All Residents forms/service plans will be reviewed and updated to ensure service plans are reflective of residents needs and provide clear direction to staff regarding the delivery of service. Assign all staff COC training classes to Oregon Care Partners 6/26/26 and report to RN and re-train 6/26/26. Community Nurse will do weekly COC monitoring and 1 month prog note review. Add daily hydration consumption in EMAR.. Add modified utensils to POC tasks for residents who need special plates/bowls/utensils. Two weeks before Care Plan quarterly is due, Executive Director will give staff a care plan form to fill out that states any changes in daily routine/activities/ADLS to implement in the Care Plan. Community Nurse will review before quarterly. All staff will receive additional training at the next in-service on how to read the care plans and to notify management if any of the residents care needs have changed. 2a) All residents will get an assessment for gait belt use and preference of use in Care Plan. 2b) Sleep schedule will be reviewed with all residents and preferences will be updated in order for care staff to support resident during night/wake hours. 3. Audit once a month for 3 months then quarterly and on every level of care assessment. 3a) Skin weekly, Gait belts 3b) Upon move in and Level of Care Assessments. 4. Executive Director, Community Nurse, Regional Director of Operations 4a) Executive Director, Community Nurse 4b) Executive Director

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, to communicate the determined action or intervention to staff on all shifts, and to document weekly progress until the condition resolved for 1 of 2 sampled residents (#1) whose changes of condition were reviewed. Findings include, but are not limited to: Resident 1 was admitted into the facility in 03/2025 with diagnoses including Parkinson’s disease and neurocognitive disorder with Lewy bodies. The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: a. On 04/17/26, the resident experienced a witnessed fall. Staff 9 (CG) documented in the incident report the resident had a bruise and abrasion to his/her right lower leg. There was no documented evidence the area was monitored at least weekly through resolution. b. On 05/05/26, the resident’s primary care physician placed instructions for modifications to the resident’s eating schedule due to a “massive hiatal hernia” which placed the resident at a significant risk of choking. The resident frequently refused to comply with instructions to reduce his/her risk of choking. There was no documented evidence of instructions to staff regarding what to do when the resident refused to comply and was at an increased risk of choking. c. On 05/17/26 the resident experienced an injury fall with an abrasion to his/her left eyebrow. There was no evidence of monitoring of the abrasion at least weekly through resolution. d. On 05/18/26 Staff 4 (RN) documented the resident’s left shoulder had become dislocated again following surgery on 05/11/26. There was no documented evidence of interventions determined and communicated to staff on all shifts related to caring for the resident and his/her shoulder, including modifications to dressing or use of his/her arm, based on this change of condition. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

Pacific Living Center of Grants Pass at Heidi will implement the following: 1. Resident 1 placed on alert charting for any changes in condition, medications or incidents. Community Nurse will coordinate care with outside providers. 1a) Resident 1, all skin issues and concerns have been evaluated/resolved by Community Nurse. 1b) Service Plan instructions put in place for all staff on what to chart/document if resident 1 is refusing provider meal/hydration orders. 1c) Resident 1, all skin issues and concerns have been evaluated/resolved by Community Nurse. 1d) Service Plan updated for care staff instructions on ADLS/all assistance with resident 1 dislocated shoulder. 2. All staff will be taking two classes in Oregon care partners relating to falls and recognizing a Change of Condition 6/26/26 and to be completed by 8/31/26. Executive Director and Assistant will audit alert charting for correct opening documentation on incidents, Tsp’s, change of conditions and monitoring. Monitoring will continue each shift and any concerns will be reported to Community Nurse until resolved and closed by the Executive Director or Nurse. Any COC needed and observed will be reported and put on the Nursing communication board in point click care and communicated with the nurse, along with a weekly nurse assessment documented until resolved for all residents. The Executive Director and Nurse will close alerts when resolved. 2a) All residents' skin issues and concerns will be evaluated/reviewed by Community Nurse with weekly notes until resolved. 2b) Instructions will be placed for all staff to follow for all residents with provider orders for meal/hydration plans. Resident preferences will be placed in instructions. 2c) All residents' skin issues and concerns will be evaluated/reviewed by Community Nurse with weekly notes until resolved. 2d) All residents will have updated service plan changes regarding any change in physical condition or change in condition for all ADLS. 3. Spot check 3 times a week that, Regional Director will audit incidents weekly for 2 months and then monthly after. 3a) With every skin/injury concern following with weekly notes until resolved. 3b) Monthly 3c) With every skin/injury concern following with weekly notes until resolved. 3d) Monthly 4.The Executive Director, Community nurse, Assistant Executive Director, Regional Director of Operations 4a) The Executive Director/Assistant and Community Nurse 4b) The Executive Director/Assistant 4c) The Executive Director/Assistant and Community Nurse 4d) The Executive Director/Assistant

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#1) who experienced a significant change of condition related to ADLs. Findings include, but are not limited to: Resident 1 was admitted into the facility in 03/2025 with diagnoses including Parkinson’s disease and neurocognitive disorder with Lewy bodies. The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: On 04/24/26, the resident’s service plan and level of assistance from staff with ADLs was updated, instructing staff to provide stand by assist and allow the resident to independently attempt ADLs, grooming, transferring, and dressing. On 05/11/26, the resident underwent left shoulder replacement surgery and returned to the facility the same day. As of his/her return to the facility on 05/11/26, the resident required two-person assistance with all ADLs and had a large surgical wound. There was no documented evidence of an RN assessment which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for all significant changes of condition was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4, Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

Pacific Living Center of Grants Pass at Heidi will implement the following: 1. A change of condition was completed on resident 1 to address post-surgery activities of daily living The Community Nurse completed Resident 1 assessment and addressed all post-surgery activities of daily living. 7/9/26 2. COC will be initiated by the Executive Director and a Nursing Assessment will be completed within 24 hours on any Change of conditions needed for all residents. All significant changes needed will be put on the dashboard of PCC for Nurse. 3. Spot check 3 times weekly and upon every Change of Condition. Audit monthly. 4. The Executive Director/Assistant, Community Nurse and Regional Director

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

OAR 411-054-0055 (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 orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted into the facility in 03/2025 with diagnoses including Parkinson’s disease and neurocognitive disorder with Lewy bodies. The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, and staff were interviewed. The following was identified: a. The resident did not receive his/her medication per signed physician order on the following dates: * Carbidopa/levodopa 50-200 mg, two tablets by mouth nightly (for Parkinson’s disease): 06/11/26 through 06/13/26; * Carbidopa/levodopa 25-100 mg, half of a tablet four times daily (for Parkinson’s disease): four doses missed on 06/05/26 through 06/07/26 and two doses missed on 06/08/26; and * Sertraline 50 mg, give ½ tablet by mouth every day (for depression): 06/08/26. 2. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Alzheimer’s disease and epilepsy (seizures). The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, and staff and the resident were interviewed. The following was identified: The resident had comprehensive signed physician orders faxed and dated 05/15/26. Staff 4 (RN) initialed the orders to note they had been reviewed on 05/18/26. a. On 05/15/26 the resident received a signed order stating the following medications should be discontinued. As of 06/29/26, the medications were still being administered: * Fluticasone propionate 50 microgram nasal spray, daily (for allergies); * Furosemide 20 mg, one table daily (for fluid retention); and * Potassium chloride 10 mEq, one tablet daily (for supplement). b. The resident had a signed order, dated 05/15/26, for diclofenac 1% gel, applied topically two times daily as needed (for pain). The medication was not on the resident’s MAR and had not been made available to the resident. c. The resident had a signed order dated 05/27/26 for atorvastatin 80 mg, one tablet daily (for cholesterol). The medication was not administered 06/20/26 through 06/22/26. d. The resident had a signed order dated 05/15/26 for levothyroxine 25 microgram, one tablet daily (for hypothyroidism). The medication was not administered 06/21/26 through 06/23/26. e. The resident had a signed order, dated 06/08/26, for loperamide 2 mg, two capsules to be administered as needed for “first loose stool,” and one capsule as needed “for each loose stool after initial.” On 06/09/26, the resident was incorrectly administered one capsule for his/her first loose stool. Approximately 18 hours later, the resident was incorrectly administered two capsules for the subsequent loose stool. The need to ensure medication orders were carried out as prescribed was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

PROVIDER'S PLAN OF CORRECTION Pacific Living Center of Grants Pass at Heidi will implement the following: 1. Resident 1 and 2 had Providers notified regarding missing doses of medication/discontinue order error 7/1/26. 1a) Resident 1’s Provider was notified of missed Carbidopa doses for 6/5/26, 6/7/26, 6/8/26, 6/11/26 and 6/13/26 and missed Sertraline doses for 6/8/26. Resident 2’s Provider was notified for continued use of Fluticasone spray, Furosemide, Potassium chloride after D/C was ordered. 1b) Resident 2’s diclofenac 1% gel clarification was asked to the provider for continued use or d/c as 5/15/26 discharge paperwork continued and 90 day orders 5/15/26 from provider d/c use. 1c) Resident 2’s Provider was notified for 6/20/26, 6/21/26 and 6/22/26 missing dose of atorvastatin 1d) Resident 2’s Provider was notified for levothyroxine missing dose of 6/21/26, 6/22/26 and 6/23/26. 1e) Community Nurse fixed systematic error for Resident 2’s Loperimide order as the wrong sequence of administration was triggered. Notified Provider of medication concern. 2. Executive Director will clarify all orders with Provider if 90 day orders and Discharge paperwork are ordered on the same day for all/any residents in order to avoid missing medications or continuing use of a D/C med. All residents will be placed on alert charting and monitored for any missed medication. All new orders will be approved by Executive Director/Community Nurse. 2a) Communication with provider will be done by the Executive Director/Assistant after a missing dose of medication for all residents and Community Nurse will be notified. Monitoring for symptoms will be implemented to med aids. 2b) Communication with Provider will be done by the Executive Director for medication clarification for all residents after discharge paperwork is ordered/uploaded. 2c) Communication with provider will be done by the Executive Director/Assistant after a missing dose of medication for all residents and Community Nurse will be notified. Monitoring for symptoms will be implemented to med aids. 2d) Communication with provider will be done by the Executive Director/Assistant after a missing dose of medication for all residents and Community Nurse will be notified. Monitoring for symptoms will be implemented to med aids. 2e) Community Nurse will audit emar orders for any systematic errors regarding all resident’s medications with sequence patterns. 3. Weekly and upon discharge paperwork uploaded to PCC. 3a) Weekly 3b) Upon discharge paperwork uploaded to PCC 3c) Weekly 3d) Weekly 3e) Upon discharge paperwork uploaded to PCC 4. Executive Director, Assistant and Community Nurse. 4a) Executive Director/Assistant, Community Nurse 4b) Executive Director/Assistant, Community Nurse 4c) Executive Director/Assistant, Community Nurse 4d) Executive Director/Assistant, Community Nurse 4e) Executive Director/Assistant, Community Nurse

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 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions were included for PRN medications to address behaviors for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Resident 1 was admitted into the facility in 03/2025 with diagnoses including Parkinson’s disease and neurocognitive disorder with Lewy bodies. The resident’s clinical chart, dated 03/29/26 through 06/29/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: a. The resident had two medications to be administered as needed for behavioral symptoms, including yelling: * Lorazepam 0.5 mg, one tablet every eight hours as needed for agitation or anxiety, demonstrated by yelling, trembling, or fear. * Quetiapine 25 mg, one tablet by mouth daily for behaviors demonstrated by yelling, aggression, and hitting. The medications lacked clear, resident-specific parameters and instructions on which medication to administer when behavioral symptoms were present. In medication administration notes between 06/01/26 and 06/25/26, staff documented administering lorazepam or quetiapine for behaviors including the resident attempting to throw him/herself out of bed, trying to pull out his/her catheter, attempting to elope, and restlessness. In an interview on 07/02/26 at 9:30 am, Staff 1 (Executive Director) acknowledged the MAR did not describe which medication to administer when the resident presented these behaviors, which required MTs to make the determination of which medication to administer. b. The resident had an order for naloxone 4 mg/0.1 ml nasal spray, one spray as needed for opioid overdose. The MAR did not include resident-specific parameters or description of signs and symptoms indicating overdose. The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was reviewed on 07/02/26 at 10:30 am with Staff 1, Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

Pacific Living Center of Grants Pass at Heidi will implement the following: 1. Community Nurse implemented specific parameter instructions on which medication to administer for which exact symptoms for resident 1. 1a) Lorazepam and Quetiapine had parameters updated and a clear sequence of behaviors/symptoms were established for PRN use of each med 7/1/26. 1b) Symptoms of opioid overdose and instructions for PRN naloxone spray were added to Emar 7/1/26. 2. The Executive Director and Community Nurse will audit each new PRN order that comes in for all residents. The Community Nurse will add clear instructions and symptoms for needing use of all PRNS. 2a) Clear behaviors and symptoms will be added for Behavior PRNS for all residents and a sequence of use by Community Nurse. 2b) For all/any residents that have a naloxone spray PRN for opioid overdose, The Community Nurse will add symptoms of overdose and clear instructions for how to use PRN in the Emar. 3. Upon PRN orders added and weekly audits. 3a) Weekly 3b) Upon PRN orders 4. Executive Director and Community Nurse 4a) Executive Director and Community Nurse 4b) Executive Director and Community Nurse

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:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated no less than quarterly at the same time of service plan update for 6 of 11 unsampled residents, failed to ensure the staffing plan accounted for the unscheduled needs of residents, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to: The facility was a licensed MCC. During the acuity interview on 06/29/26, Staff 1 (Executive Director) identified two residents who required the assist of two care staff for transfers and care. Staff 1 stated care staff were considered universal workers. All food preparation and cooking was completed by MTs, and food service was completed by MTs and CGs. The staffing plan and ABST were reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (Regional Director) on 07/01/26 at 1:55 pm, and the following was identified: 1. There was no documented evidence of the ABST being updated at least quarterly for six of the 11 unsampled residents. 2. The facility’s ABST showed the minimum staffing required to address scheduled needs was: * Day shift: 2.63 care staff; * Swing shift: 2.35 care staff; and * Night shift: 1.41 care staff. The facility’s posted staffing plan, last updated 04/01/26, was: * Day shift: 2.5 care staff; * Swing shift: 2.5 care staff; and * Night shift: 2 care staff. The posted staffing plan failed to account for universal worker duties, including meal preparation and cooking, and did not account for the unscheduled needs of residents. 3. The facility schedule, dated 06/21/26 through 06/29/26, was reviewed and revealed the facility failed to document staffing to meet or exceed the posted staffing plan on 59% of the shifts reviewed. The need to ensure residents’ ABST evaluations were updated no less than quarterly at the same time the service plan was updated, ensure the staffing plan accounted for the unscheduled needs of residents, and ensure consistent staffing to meet or exceed the posted staffing plan was reviewed with Staff 1, Staff 2, Staff 3, Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

Pacific Living Center of Grants Pass at Heidi will implement the following: 1. 6 out 11 unsampled resident’s ABST were updated 7/1/26. Staffing schedule was updated with extra staffing on the floor 7/1/26. 2. ABST updates will be done for all residents upon move in and with every level of care assessment or changes of condition. by The Executive Director and audited by The Regional Director. Staff will be scheduled according to ABST staffing needs/caregiving hours needed. 3. Weekly and upon every move in, level of care assessment, quarterly and change of condition. 4. The Executive Director and The Regional Director

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:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to: C200 and C363.

Refer to: C200 and C363.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C260, C270, C280, C303, and C310.

Refer to: C260, C270, C280, C303, and C310.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted into the facility in 03/2025 with diagnoses including Parkinson’s disease and neurocognitive disorder with Lewy bodies. The resident’s clinical chart, dated 03/29/26 through 06/29/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident’s service plan, dated 06/02/26, lacked an individualized plan related to his/her nutrition and hydration needs and preferences in the following areas: * Instructions from the resident’s physician related to the resident’s “massive” hiatal hernia, including the use of plates and bowls with walls, large rubber-handled utensils, no food or drink besides water for two hours prior to bed, use of wedge under pillow to keep him/her propped at all times in bed, staying upright for at least 30 minutes after eating, and encouraging smaller meals more frequently; * Use of a specific cup and wide straw; * Snack around 4:00 am with preference for multiple peanut butter and jelly sandwiches; * Milkshake flavor preference; * Nectar thick liquids only; and * Preferred meal location. The need to ensure individualized nutrition and hydration plans were developed and included in the service plan was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Alzheimer’s disease and epilepsy (seizures). The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, and staff and the resident were interviewed. The following was identified: The resident’s service plan, dated 05/28/26, lacked an individualized plan accurate to the resident’s current nutrition and hydration needs and preferences in the following areas: * Recent history of weight loss; * Preference for dining location; * Assist provided by staff while dining; and * Snack preferences. The need to ensure individualized nutrition and hydration plans were developed and included in the service plan was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

Pacific Living Center of Grants Pass at Heidi will implement the following: 1. Residents 1 nutrition and hydration plan was updated in the service plan to reflect preferences, wants and needs including location they prefer to eat as well as any special diet orders/utensil orders and assistance needed. Resident 2 nutrition and hydration plan was updated to reflect weight loss, preferences, wants and needs including location they prefer to eat as well as any special diet orders and assistance needed. 7/2/26. 2. All residents' Nutrition and hydration plans will be reviewed and updated to reflect current preferences, wants and needs. Hydration/Meal forms have been put in place for all residents for care staff to update for any/all resident’s preference or diet change. Diet cards have been put in place for care staff access in the kitchen. 3. Weekly and upon move in/quarterly/change of condition. 4. Executive Director

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted into the facility in 03/2025 with diagnoses including Parkinson’s disease and neurocognitive disorder with Lewy bodies. The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The current activity evaluation failed to address: * Past interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; and * Adaptations needed to participate. There was no evidence of an activity plan, developed based on the resident’s activity evaluation, which reflected the resident’s current preferences and needs. There was no documented evidence of daily structured and non-structured activities provided and included on the resident’s service plan. The need to ensure activity evaluations included all required components, an activity plan was developed based on the activity evaluation which reflected the resident’s current preferences and needs, and daily structured and non-structured activities were included on the resident’s service plan was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Alzheimer’s disease and epilepsy (seizures). The resident’s clinical record, dated 03/29/26 through 06/29/26, was reviewed, and staff and the resident were interviewed. The following was identified: The current activity evaluation failed to address: * Physical abilities and limitations; * Adaptations needed to participate; and * Activities for behavioral intervention. There was no documented evidence of an activity plan, developed based on the resident’s activity evaluation, which reflected the resident’s current preferences and needs. There was no documented evidence of daily structured and non-structured activities provided and included on the resident’s service plan. The need to ensure activity evaluations included all required components, an activity plan was developed based on the activity evaluation which reflected the resident’s current preferences and needs, and daily structured and non-structured activities were included on the resident’s service plan was reviewed on 07/02/26 at 10:30 am with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), Staff 3 (Regional Director), Staff 4 (RN), Staff 5 (Vice President of Operations), and Staff 6 (Regional Director of Operations). They acknowledged the findings.

Pacific Living Center of Grants Pass at Heidi will implement the following: 1. Resident 1 activity assessment was updated to reflect the past and current preferences and needs, and daily structured and non-structured activities, current abilities and skills, emotional/social needs and patterns, physical abilities and limitations/adaptations needed to Participate. 7/2/26. Resident 2 activity assessment was updated to reflect all activity preferences, physical abilities and limitations/ adaptations needed to participate and activities for behavioral intervention. 2. All applicable questions on form/services before move in will be personalized with as much information as we can obtain for all areas of activities and preferences and current interests for all residents current and new. Physical ability and adaptations will be implemented into all activity plan as well as location preference for activities. 3. Upon move in/30 day/quarterly and change of condition 4. Executive Director/Assistant Executive Director

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: