Print Inspection: RL010287

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 2 of 2 sampled residents (#s 7 and 8) who were prescribed modified texture diets. The residents’ prescribed diets were not administered by the facility, placing them at risk of aspiration, choking, and/or death. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 10/2022 with diagnoses including dementia and dysphagia (difficulty swallowing). During the acuity interview on 06/16/26 at 9:30 am, Resident 7 was identified to be bedbound. Resident 7's 05/26/26 through 06/16/26 clinical record, including physician orders, service plan, and progress notes was reviewed, and the following was noted: * A physician order, dated 05/01/26, changed the resident’s diet texture to “soft bite size, extra gravy/sauces” modified diet texture and thin liquids. The service plan dated 05/16/26 indicated that staff were to bring food in and set it up on Resident 7’s bedside table, and s/he was on mechanical soft diet with thin liquids due to a history of aspiration. On 06/17/26 at 09:50 am, the surveyor entered Resident 7’s room. Resident 7 was observed lying in bed with the head of the bed at approximately 30 degrees. The resident was coughing with breakfast in front of him/her. The cough sounded wet and the resident was making remarks such as, “I’m choking.” The surveyor notified Staff 21 (MT), who was outside the door talking to a resident in the next room. She assisted the resident by elevating the head of bed with a remote and her hand and then called another staff member for assistance. Both Staff 20 (CG) and 21 assisted the resident by sliding him/her up on the bed then elevated the head of bed to 90 degrees and offered him/her a drink. At that time, Resident 7 stated he had been eating bacon when he started coughing. Staff 21 stated she had asked the kitchen to modify the diet but the cook currently working refused to modify the diet. Observation of the resident’s plate showed a regular texture egg, half eaten. Staff 20 and 21 confirmed the resident had received regular texture bacon and cinnamon roll, which the resident had eaten prior to surveyor arrival to the room. On 06/17/26 at 10:30 am, it was noted the resident had “extra mech soft/moist” diet texture requirements posted on the whiteboard in the kitchen. In an interview at the same time, Staff 25 (Chef) stated to meet the requirement of the diet texture, she cut regular texture food into pieces. When asked how she ensured the food was moist and soft, Staff 25 stated she had not received training on preparation of modified diets. Staff 25 stated she did not know what texture of breakfast Resident 7 received that morning. On 6/17/26 at 11:45 am, Staff 2 (RN) stated Resident 7 readmitted from the hospital in 04/2026 with a puree diet and honey thick liquids but was upgraded by hospice to the soft bite size, extra gravy/sauces modified diet texture with thin liquids on 05/01/26 per family request due to him/her refusing to eat the puree diet. Staff 2 also indicated that per hospital recommendation, the resident required positioning to 90 degrees during meals due to risk of aspiration and she had given the instructions for the kitchen staff and caregivers. She stated the system was for kitchen staff to notify caregivers when food was being delivered to the resident. She acknowledged the lack of communication between the kitchen staff and caregivers. In an interview on 06/17/26 at 12:20 pm, Staff 20 stated after the resident returned from hospitalization in 04/2026, staff were notified that s/he needed to be repositioned to sit up during meals. The kitchen staff were supposed to notify CGs when they delivered the food so the CGs could assist with repositioning, but the kitchen was not doing this. Staff 20 stated previously the resident received a modified texture diet, but for the past month the resident had been receiving a regular texture diet and sometimes she would cut it up for him/her. When asked if she notified the kitchen, she stated by the time she noticed the diet texture was regular, the resident had already eaten most of it. She further indicated the resident “coughed all the time” while eating. On 6/17/26 at 3:50 pm Staff 28 (Interim ED) was notified of the observation and staff interviews. The resident was served a regular diet texture despite an order for “soft and bite sized, extra gravy/sauces” diet texture due to dysphagia (difficulty swallowing). The lack of a room tray system including ensuring appropriate positioning prior to meal intake and staff training in preparing modified diets placed the resident at risk for choking and aspiration. An immediate plan of correction to address the reasonable precautions was requested from Staff 28 on 06/18/26 at 10:53 am. The plan of correction was received and accepted by the survey team on 06/18/26 at 1:17 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 28 and Staff 3 (LPN), on 06/18/26 at 2:20 pm. They acknowledged the findings. 2. Resident 8 was admitted to the facility in 01/2023 with diagnoses including traumatic subdural hemorrhage with loss of consciousness and cerebrovascular disease. Resident 8’s 05/12/26 through 06/14/26 clinical record, including physician orders, service plan, and progress notes, was reviewed, and the following was noted: * The resident returned to the facility following a hospital stay on 05/12/26; and * A physician order indicated a dysphagia (difficulty swallowing) diet with food texture of minced and moist and regular liquids. On 06/17/26, during the survey, it was noted the resident’s minced and moist diet requirement was posted on the whiteboard in the kitchen. On 06/17/26 at 12:35 pm, the resident was observed in the dining room consuming a regular diet that included a serving of sliced meat, two slices of wheat bread, gravy, pickle and a bowl of salad consisting of lettuce and carrots in the dining room. The resident was observed using a fork to cut the sliced meat and evidence of a chewed pickle spear was noted on the plate. On 06/17/26 at 12:50 pm, Staff 25 (Chef) reported the previous chef left last Saturday and she was covering the role. She stated she had not received training on preparation of modified diets, including the minced and moist diet required for this resident. She further explained that for any residents eating in the dining room, staff completed meal tickets based on the resident’s food selection and delivered the tickets to the kitchen for preparation. However, she stated the tickets did not include resident names or room numbers, therefore, kitchen staff were not aware of whether a resident required a special diet. The resident was served a regular diet despite an order for minced and moist diet due to dysphagia. The lack of a meal ticket communication system and staff training in preparing modified diets placed the resident at risk for choking and aspiration. On 6/18/26 at 9:54 am Staff 28 (Interim ED) was notified of the observation and staff interviews. An immediate plan of correction to address the reasonable precautions was requested from Staff 28 on 06/18/26 at 10:53 am. The plan of correction was received and accepted by the survey team on 06/18/26 at 1:17 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. During the exit interview on 06/18/26, the need to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 28. He acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? C160 - Reasonable Precautions Resident 8 is being served a diet of minced and moist foods. Resident 7 is now served a diet of soft bite-sized foods with extra gravy/sauces. All staff were in-serviced on diet orders, the importance of following them, and what each diet texture should look like. Dietary team, including cooks and dining staff, were trained on modified texture preparation. The community has a Meal Manager to ensure that diets coming out of the kitchen are correct. New Dietary Manager started 7/7/2026. All diets that come out of the kitchen are brought to the Dining Room Director and ED for review. Dietary Manager and ED or designee are responsible for ensuring diets are coming out per physician orders. Any discrepancies will be reviewed and brought to the following Quality Assurance meeting. 08.10.26

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 observation, interview and record review, it was determined the facility failed to report injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, for 2 of 2 sampled residents (#s 5 and 6) who had injuries of unknown cause. Findings include, but are not limited to: 1. Resident 5 moved into the assisted living facility in 03/2022 with diagnoses including moderate vascular dementia, atrial fibrillation, anticoagulation therapy, and restless leg syndrome. The resident’s clinical record was reviewed, including progress notes dated 01/01/26 through 03/23/26, interviews with the resident and staff were conducted, and observations of the resident were made. The following was identified: On 02/14/26 a MT documented “skin tear on right arm…wound care and bandage done” and on 03/14/26 a MT documented “replaced a [bandage] on lower right arm…look[s] like a[n] old skin tear opened…did wound care and new [bandage]”. There was no additional documentation of the skin injuries. On 03/24/26 at 10:24 am, Resident 5 reported having multiple skin injuries and was observed to have three 4X4 cm bandages on his/her right arm between the wrist and elbow, one 4X4 cm bandage on his/her lower right leg, two 4X4 cm bandages on his/her lower left leg with a tightly wrapped gauze cloth around his/her upper left calf with a large raised area, approximately the size of a tennis ball, under tightly wrapped gauze cloth. The resident was unable to state what happened regarding any of the injuries. On 03/25/26 at 10:26 am, Resident 5’s skin was assessed by Staff 2 (RN). Staff 13 (MT) and the RN Surveyor were present during the observation. Staff 2’s assessment noted the following: * Left lower leg had an 8X7 cm under the skin hematoma/blood blister; * Two covered wounds on lower left leg with 4X4 cm bandages (not visualized); * 4X4 cm bandage on the back of the lower right leg (not visualized); * 4X4 cm bandage on the back of the upper right leg (not visualized); and * Three 4X4 cm bandages on the lower right arm, between the wrist and elbow. The above injuries of unknown cause were required to be reported to the local SPD office unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse. There was no documented evidence the facility immediately investigated the resident’s injuries of unknown cause to rule out suspected abuse or neglect, and there was no documented evidence the facility reported the incidents to the local SPD office. On 03/25/26 at 12:43 pm, the above injuries of unknown cause were reviewed with Staff 1 (ED). She confirmed there were no documented investigations completed for the injuries. On 03/25/26 the above injuries of unknown cause were requested to be reported to the local SPD, and confirmation was provided on 03/26/26 at 10:19 am. The need to ensure all injuries of unknown cause were immediately investigated to rule out suspected abuse or reported to the local SPD office if abuse could not be ruled out was reviewed with Staff 1 (ED) at 1:41 pm on 03/26/26. She acknowledged the findings. 2. Resident 6 moved into the assisted living in 10/2024 with diagnoses including Alzheimer's disease, history of cerebral infarction (stroke) affecting the right dominant side, history of falling and congestive heart failure. Review of the resident’s hospice provider notes from 12/31/25 through 03/23/26, and progress notes from 12/23/25 through 03/23/26 identified the following: * 01/21/26: A skin tear to the left calf; and * 01/26/26: Skin tears on the right elbow, right knee, and left shin. During an interview on 03/25/26 at 2:45 pm, Staff 2 (RN) and Staff 3 (LPN) were unaware of how and when the injuries occurred. During an interview with the resident on 03/25/26 at 10:45 am, the injuries had resolved and the resident was unable to recall the injuries. These incidents represented injuries of unknown cause. There was no documentation the facility immediately investigated and documented the injuries were not the result of suspected abuse, and the facility did not report the injuries to the local office as suspected abuse. The need to ensure injuries of unknown cause were investigated promptly to rule out suspected abuse or reported if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 03/25/26 at 3:45 pm. The surveyor requested the facility to self-report the injuries. Verification of reporting was received on 03/26/26.

During Survey it was identified that ruling out abuse in a timely manner was not completed for residents #5 and #6. Resident 5 had mulitple skin tears (injury of unknow cause) and Resident 6 sustained 2 skin tears (injury of unknown cause). Facility reported both cases to APS on 3.26.2026. Family, Hospice and Health services met on 3.27.2026 to discuss care needs, implement safety interventons (geri sleeves, calf protectors) and discussed higher level of care needs, all parties involved and in agreement. Incident reports have been modified for med techs to determine abuse and neglect when completing report. All med techs and nurses training on incident reports, what constitutes an incident report and how to ensure complete investigations, and timeliness of investigation. Med tech meeting scheduled for April 28, 2026 training topic includes ruling out abuse in a timely manner. Incident reports will be audited daily by Administrator or designee to ensure that abuse and intervention are completed. Executive Director, Administrator, RN or designee is responsible to see that corrections are completed/monitored.

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 resident injuries were promptly investigated to rule out abuse and/or neglect and reported to the local Department office if abuse could not reasonably be ruled out for 1 of 2 sampled residents (# 8) who experienced injuries of unknown cause. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the assisted living facility in 01/2023 with diagnoses including traumatic subdural hemorrhage with loss of consciousness status unknown, cerebrovascular disease and right foot drop. The resident’s clinical record was reviewed, including progress notes, dated 05/25/26 through 06/14/26, and the following was identified: On 06/08/26, staff documented the resident sustained a skin tear to the right elbow. On 06/16/26 at 1:22 pm, Staff 27 (MT) was observed changing the bandage on the resident’s right elbow. Upon observation, the wound was noted to be an open area with surrounding bruising. 06/16/26 at approximately 1:30 pm, when asked about the skin tear on the right elbow, the resident stated s/he was unsure how the wound occurred. The resident was unable to state what happened regarding the skin tear on the right elbow. An incident report was requested during the survey. The facility provided the report, completed on 06/17/26 (during the survey), which stated “it was about 1.0 x 0.7 cm reddish pink wound bed…No surrounding redness around wound.” The incident report did not address how the resident sustained the skin tear on the right elbow. There was no documented evidence the facility immediately investigated the resident’s injury of unknown cause to rule out suspected abuse or neglect, and there was no documented evidence the facility reported the incident to the local Department office. On 06/17/26 at 2:30 pm, the above injury of unknown cause was reviewed with Staff 28 (Interim ED). He confirmed there was no documented evidence the incident report addressed the cause of the skin tear on the right elbow. On 06/18/26 at 9:30 am, the injury of unknown cause was reported to the local Department office, and confirmation was received. The need to ensure the injury of unknown cause was immediately investigated to rule out suspected abuse or reported to the local Department office if abuse could not be ruled out was reviewed with Staff 28 on 06/18/26 at 9:54 am. He acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? C231 - Investigations and Reporting. Resident 8 - Skin tears were reported. 08.10.26 Accepted Yes No Staff will be in-serviced on adding skin issues to the incident reporting process, and any injury of unknown cause or suspected abuse will be sent to the local SPD office. 2. How will the system be corrected so this violation will not happen again? Accepted Yes No All incidents will be reviewed in stand-up five days a week and double-checked against reported skin notes with the IDT team. A weekly audit will be completed to ensure accuracy. 3. How often will the area needing correction be evaluated? Accepted Yes No Licensed nurses, Executive Director, or designee will review resident incident reports for tracking and trending of incident types at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate the internal system to maintain compliance.

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 the quarterly evaluation accurately described the resident's current status and condition and evaluations were used as the basis to develop the resident’s quarterly service plan for 2 of 4 sampled residents (#s 3 and 6) whose quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into assisted living in 06/2022 with diagnoses including congestive heart failure and history of urinary tract infection. During an interview on 03/26/26 at 10:28 am, Staff 18 (CG) reported the resident required escorts to and from the dining room and all activities. A review of Resident 3’s quarterly evaluation dated 03/10/26 failed to accurately describe the resident's current status and condition in the following areas: * Frequency of assistance with bowel and bladder management; * Nailcare (independent versus assistance needed); and * Mobility (independent versus assistance needed). The need to ensure the quarterly evaluation accurately described the resident's current status and condition and was used as the basis for the quarterly service plan was discussed with Staff 1 (ED) and Staff 17 (Regional RN) on 03/26/26 at 12:25 pm. They acknowledged the findings. 2. Resident 6 moved into assisted living in 06/2022 with diagnoses including Alzheimer's disease, history of cerebral infarction (stroke) affecting the right dominant side, history of falling and congestive heart failure. A review of Resident 6’s 01/16/26 quarterly evaluation failed to accurately describe the resident's current status and condition in the following areas: * Frequency and level of assistance needed for toileting; * Use of siderails; * Behavior management (independent versus assistance); * Evacuation status (independent versus assistance; and * Weight monitoring. The need to ensure the quarterly evaluation accurately described the resident's current status and condition and was used as the basis for the quarterly service plan was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 03/25/26 at 2:45 pm. They acknowledged the findings.

Powell Valley Assisted Living will ensure move-in, 30-day, quarterly and as needed evaluations address all required elements. Moving forward, all admissions will have a completed Resident Evaluation to address all required elements. Resident #4's evaluation will be updated to address all required elements. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and HSD will be responsible.

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 residents' needs, provided clear direction to staff regarding care and services, and were implemented for 3 of 6 sampled residents (#’s 3, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the assisted living in 06/2022 with diagnoses including congestive heart failure. A review of temporary service plans (TSP’s) following the 03/10/26 service plan update identified the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Risks and precautions related to the use of bilateral siderails; * Intervention to float heels; and * Use of home health wound care and instructions for MT’s “to replace dressing after cleansing with wound cleanser, using foam bandages.” During an observation and interview on 03/26/26 at 10:40 am, Staff 19 (MT) confirmed the resident only had topical treatments for chronic skin breakdown. Staff 19 showed the surveyor the treatments available in the medication cart. Staff 19 stated “we don’t do any dressing changes for [the resident] ...no bandages and home health...” During the same observation with Staff 19, a half-length siderail was observed on the left side of the resident’s bed, in the raised position, and against the resident’s patio door. There was also a second quarter-length rail on the right side of the bed. In an interview on 03/26/26 at 10:28 am, Staff 18 (CG) reported care staff were to float the resident’s heels while in bed and ensure the footrests were on the wheelchair when escorting the resident to the dining room. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 17 (Regional RN) on 03/26/26 at 12:45 pm. They acknowledged the findings. 2. Resident 6 moved into assisted living in 10/2024 with diagnoses including Alzheimer's disease, history of cerebral infarction (stroke) affecting the right dominant side, history of falling and congestive heart failure. A review of progress notes and incident investigations from 12/23/25 through 03/23/26 showed Resident 6 had 13 falls during this period. A review of temporary service plans following the 01/16/26 service plan update identified the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Fall interventions; * Assistive devices needed during evacuation (walker versus wheelchair and use of the stair chair); * Pain status; * Cognitive status; * Ability to use call pendant; * Dressing status; * Mobility and assistive devices used; * Transfers (independent versus two-person assistance); * Communication status (independent versus assistance needed); * Use of oxygen, as needed; and * Risks and precautions related to the use of siderails. During an observation and interview with the resident in his/her apartment on 03/25/26 at 10:40 am, the following was identified: * The resident was slow to develop a response to questions, preferred yes or no questions, and had difficulty initiating in conversation; * No longer able to use the electric scooter or walker for ambulation and required escorts from care staff at all times; * The resident used a quarter-length bed rail positioned at the head of the bed; and * An oxygen concentrator was turned on with the tubing on the floor. In an interview on 03/24/26 at 9:00 am, Staff 15 (CG) reported the resident no longer used the call pendant, had frequent falls due to attempting to self-transfer, required a two person transfer, escorts to and from the dining room and any leisure activities, and required one person care for dressing and undressing at night time. The need to ensure resident service plans were reflective of current care needs and provided clear directions to staff was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 03/25/26 at 2:45 pm. They acknowledged the findings. 3. Resident 5 moved into the assisted living facility in 03/2022 with diagnoses including moderate vascular dementia, atrial fibrillation, anticoagulation therapy, and restless leg syndrome. The resident was observed to use a power wheelchair throughout the survey and had bilateral side rails on the bed in the upright position. The resident’s clinical record, including the 02/07/26 service plan, was reviewed, interviews with staff and the resident were conducted, and observations were made. The service plan was not reflective of the resident’s current care needs, lacked clear direction regarding the delivery of services, or was not implemented in the following areas: * Monthly weights for “fluid monitoring”; * Instructions related to lower leg edema, including use of compression stockings and when to report to the RN; * Instructions related to pulmonary edema, including interventions and when to report to the RN; * Resident 5 used his/her pendant to alert staff when s/he needed assistance; * Transfer assistance and the need for two staff and instruction related to safe transfers; * Dress and undressing and the need for the assistance of two staff; * Independent with ambulation with use of power wheelchair; * Bed changes and the need for two staff; * Use of bilevel positive airway pressure (BiPAP) machine, including instruction for use, cleaning, and maintenance; * Power wheelchair use, including assistance with charging at night, maintenance, and safety precautions; * Repositioning instruction related to use of pillows under lower legs while in bed; * Current skin conditions and instructions related to wound care, frequency, and what and when to report changes in these conditions to the nurse; * Instructions and safety precautions related to the use of siderails; * Use of an offloading pressure mattress; and * Emergency evacuation assistance, including number of staff needed. On 03/24/26 at 10:24 am, Resident 5 was observed to have a BiPAP machine bedside and reported staff would fill it with water for him/her to use independently. However, the resident was not sure the last time the equipment was cleaned and if s/he had any replacement pieces. On 03/25/26 at 2:12 pm, Staff 12 (MT) reported the resident required the assistance of two staff with transfers in and out of his/her bed and power wheelchair, bed changes, and at times dressing and undressing. The need to ensure service plans were reflective of residents’ needs and preferences, provided clear direction regarding the delivery of services, and were implemented was reviewed with Staff 1 (ED) at 1:41 pm on 03/26/26. She acknowledged the findings.

Powell Valley Living will ensure all residents' service plans are reflective of residents' current care need and preferences and provides clear direction regarding the delivery of services. All resident service plans will be updated and updated as needed to include resident changes. These updates will be written to provide clear direction to team members regarding the delivery of services. Service plan for Resident #3, #5 and #6 will be updated to reflect residents' current care needs and preferences and will provide clear direction regarding the delivery of services. A "Service Plan Update" form will be used to update a service plan as needed. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. All Staff Meeting will be held April 24, 2026 with topic to include service plans. ED, HSD and RN will be responsible.

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 care and services for 2 of 3 sampled residents (#s 7 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 10/2022 with diagnoses including dementia and dysphagia (difficulty swallowing) The resident’s 05/25/26 to 06/16/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The 05/16/26 service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Risks and precautions related to the use of bilateral side rails; * Instructions for staff on use of heel boots; * Diet texture of soft bite size, extra gravy/sauces, thin liquids; and * Instructions for staff on assisting the resident to sit up at 90 degrees for meals related to aspirations precautions. On 06/16/26 at 12:55 pm, Resident 7 was observed in bed with bilateral half-length side rail in the raised position. The right side rail was loose. The resident was observed to use the side rails during ADL care. Staff 26 (CG) who was assisting the resident at the same time acknowledged the side rail being loose and stated she would notify the front desk. During an observation on 6/17/26 at 9:50 am, Resident 7 was in bed eating breakfast and coughing and was positioned at approximately a 30-degree angle. In an interview on 6/17/26 at 11:45 am, Staff 2 (RN) confirmed the resident required a 90-degree positioning during meals due to aspiration precautions. The need to ensure service plans were reflective of residents’ needs and provided clear directions to staff was reviewed with Staff 28 (Interim ED) and Staff 3 (LPN) on 06/18/26 at 2:20 pm. They acknowledged the findings. 2. Resident 9 was admitted to the assisted living in 05/2025 with diagnoses including congestive heart failure. The resident’s 05/28/26 to 06/16/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The service plan, dated 04/29/26, lacked clear instructions to staff in the following areas: * Instructions on when to wear heel protector booties; * Use of bilateral half rails and their associated precautions; and * Instructions for staff assistance with supplemental oxygen. On 06/16/26 at 12:55 pm, Resident 9 was observed in bed with bilateral half rails in the raised position. An oxygen concentrator was positioned near the foot of the bed. The resident stated s/he needed the rails to help with repositioning, and care staff had to apply the nasal cannula and turn on the concentrator when s/he felt short of breath. Two heel booties were observed on the bed. The resident stated s/he didn’t know what they were for and staff “never put them on.” The need to ensure service plans were reflective of residents’ needs and provided clear direction to staff was reviewed with Staff 28 (Interim ED) and Staff 3 (LPN) on 06/18/26 at 1:50 pm. They acknowledged the findings.

C260 - Service Plan Resident 7 had bilateral side rails, heel boot instructions, diet texture, and resident body positioning for meals added to the service plan. Resident 9's service plan added verbiage to provide clear direction to staff in the areas of heel boot instructions, bilateral half rails, and instructions for supplemental O2. Administrative staff were in-serviced on updating a service plan so that it is reflective and provides clear directions to staff. All binders will be reviewed to ensure that all residents' service plans are in the charts and are updated to reflect resident-specific needs with clear directions. Executive Director, Wellness Director, Registered Nurse, RCC, or designee is responsible to see that corrections are completed and monitored. Any service plan audits will be reviewed at the following Quality Assurance meeting.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure short term changes of condition were evaluated, actions or interventions were determined and communicated to staff, and were monitored weekly through resolution, and significant changes of condition were evaluated, referred to the facility nurse, documented, and the resident’s service plan updated as needed for 3 of 6 sampled residents (#s 3, 5, and 6) who had documented short term and/or significant changes of condition. Findings include, but are not limited to: 1. Resident 5 moved into the assisted living facility in 03/2022 with diagnoses including moderate vascular dementia, atrial fibrillation, and restless leg syndrome. The resident’s 01/01/26 through 03/23/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations of the resident were made. a. Resident 5 experienced the following changes of condition that lacked documented evidence of determined actions or interventions, the intervention communicated to staff on each shift, and/or monitoring at least weekly through resolution: * 01/06/26: Lower leg edema; * 01/16/26: Wound on right lower leg; * 01/23/26: Two lower left leg wounds; * 01/27/26: Return from hospital with respiratory syncytial virus; * 01/29/26: Diagnosis of pulmonary edema; * 02/05/26: Admit to hospice; * 02/05/26: Wound developing on coccyx; * 02/14/26: Wound on lower right arm; and * 03/14/26: Two wounds on right forearm above the previous one identified. On 03/26/26 at 10:35 am, the above changes of condition were reviewed with Staff 3 (LPN), and no additional documentation was provided. b. On 03/24/26 at 10:24 am, Resident 5’s left lower leg was observed to have a large dark colored area, approximately the size of a tennis ball, with a tightly wrapped dressing located above the dark colored area. On 03/24/26 at 10:56 am, Staff 13 (MT) entered the resident’s room, saw the resident’s leg and stated the blood blister/hematoma did not look like that two days ago, and alerted Staff 3 (LPN). Staff 3 observed the wound and reported it was the first time she had seen the wound. An outside provider note, dated 03/17/26, documented the resident had “bruising/hematoma” with Staff 3’s initials dated 03/18/26, which indicated she reviewed the outside provider note. However, there was no facility documentation indicating the “bruising/hematoma” was evaluated, referred to the facility nurse, documented, or the resident’s service plan was updated as needed. On 03/25/26 at 9:52 am, Staff 2 (RN) reported she was not informed the resident had bruising or a hematoma and completed a skin assessment at 10:26 am. The assessment documented “A NEW wound noted on L [left] lower outer calf appears to be a large blood blister collected under frail skin: 8.0 x 7.0 cm. Has a central area that had bled on old bandage – measuring 4 x 1.0 cm that is darker in which seems to have a thin top layer of skin peeled off…” The need to ensure short term changes of condition were evaluated, actions or interventions were determined and communicated to staff, and were monitored weekly through resolution, and significant changes of condition were evaluated, referred to the facility nurse, documented, and the resident’s service plan updated as needed, was reviewed with Staff 1 (ED) at 1:41 pm on 03/26/26. She acknowledged the findings. 2. Resident 3 moved into the assisted living in 06/2022 with diagnoses including congestive heart failure. The residents home health provider notes, progress notes, temporary service plans from 12/23/25 through 03/23/26, and service plan update on 03/10/26 were reviewed during the survey. Resident 3 had the following changes of condition that lacked determined actions or interventions communicated to staff on each shift and monitoring at least weekly through resolution: * On 12/17/25: Macerated and excoriation on the bottom from potential shearing and pressure. On 12/31/25, the facility RN documented she assessed the resident’s skin with the HH RN. There were no further weekly monitoring notes from the facility RN or the HH RN, until the skin injury was resolved on 01/21/26. * On 01/19/26: A home health note identified left leg and knee pain. The facility failed to communicate the change to staff and to monitor the resident’s leg pain at least weekly through resolution. * On 03/12/26: Full body rash and new medication, prednisone 20 mg tablets instructing staff to administer for four days. The 03/2026 MAR documented two doses were given on 03/12/26 and 03/14/26. On 03/18/26, staff documented “last dose given 03/18/26.” There was no documented evidence the facility monitored the efficacy of the treatment and the resident’s skin condition at least weekly through resolution. The need to ensure the facility determined actions or interventions for changes of condition, the interventions were communicated to staff on all shifts, monitored for effectiveness and monitored at least weekly through resolution was discussed with Staff 1 (ED) and Staff 17 (Regional RN) on 03/26/26 at 12:45 pm. They acknowledged the findings. 3. Resident 6 moved into assisted living in 10/2024 with diagnoses including Alzheimer's disease, history of cerebral infarction (stroke) affecting the right dominant side, congestive heart failure, and had a history of falls. The resident’s hospice provider notes, progress notes, temporary service plans from 12/23/25 through 03/23/26 and service plan update on 01/16/26 were reviewed during the survey. a. Resident 6 had the following changes of condition that lacked determined actions or interventions, the interventions communicated to staff on each shift, and/or monitoring at least weekly through resolution: * 12/24/25: Increased swelling in hands and feet due to falls; * 01/08/26: Facial bruising from a fall on 12/27/25; * 01/21/26: Bruising on the right eye and a skin tear on the left calf; * 01/22/26: Bruise on the right upper back from a fall; * 01/26/26: A skin tear to the right elbow, right knee and left shin; * 01/29/26: Increased back pain that week; and * 03/04/26: Hematoma on the back of the head from a fall. b. Resident 6 had the following significant change of condition that was not referred to the facility RN for further assessment: * On 02/01/26: Hospice visit to assess the resident for facial drooping and symptoms of potential stroke; and * On 02/04/26: Hospice RN visit for assessment noted the resident had a significant change in status. The outside service provider notes were reviewed by Staff 3 (LPN). During an interview on 03/25/26 at 2:45 pm, Staff 3 confirmed she was aware and recalled the incidents and Staff 2 (RN) stated she was not aware hospice was out to assess Resident 6 for possible stroke symptoms. The need to ensure the facility determined action or intervention, the intervention was communicated to staff on each shift and/or monitored at least weekly through resolution for short term changes of condition, and significant changes of condition were referred to the facility RN for assessment was discussed with Staff 1 (ED), Staff 2 and Staff 3 on 03/25/26 at 3:45 pm. They acknowledged the findings.

Powell Valley Living will ensure that residents' short term and long term change of conditions are monitored appropriately. Community will determine actions/interventions needed, communicate actions or interventions to team members on all shifts, and monitor changes through resolution with weekly documentation. Resident #3, #5 and #6 significant change of condition assessment by RN was completed on March 26th 2026. RN assessments will be completed when applicable. Routine clinical meetings will be held at minimum 5 days/week with ED, HSD and RN. These meetings are a double check to review and identify resident short term and long term change of conditions. Weekly high risk resident meetings will take place to assure compliance. All staff in-service will be held on April 24, 2026. Training topics to include residents' short term and long term change of conditions. ED and HSD will be responsible

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 observation, interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed following significant changes of condition including findings, resident status, and interventions made as a result of the assessment, for 2 of 2 sampled residents (#s 5 and 6) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 6 moved into assisted living in 10/2024 with diagnoses including Alzheimer's disease, history of cerebral infarction (stroke) affecting the right dominant side, history of falling and congestive heart failure. The resident's hospice provider notes, progress notes, temporary service plans (TSP’s) from 12/23/25 through 03/23/26 and service plan update on 01/16/26 were reviewed during the survey. The following was identified: * On 02/01/26: Hospice visit to assess the resident for facial drooping and symptoms of potential stroke; and * On 02/04/26: Hospice RN visit for assessment noted the resident had a significant change in status. This constituted a significant change of condition requiring an RN assessment. There was no documented evidence an RN assessment including findings, resident status, and interventions made as a result of the assessment was completed. The outside service provider notes were reviewed by Staff 3 (LPN). During an interview on 03/25/26 at 2:45 pm, Staff 3 confirmed she was aware of the incident. During the same interview, Staff 2 (RN) stated she was not aware hospice had assessed Resident 6 for possible stroke symptoms and had not completed an RN assessment. The need to ensure the RN completed a significant change of condition assessment was discussed with Staff 1 (ED), Staff 2 and Staff 3 on 03/25/26 at 3:45 pm. They acknowledged the findings. 2. Resident 5 moved into the assisted living facility in 03/2022 with diagnoses including moderate vascular dementia, atrial fibrillation, anticoagulation therapy, and restless leg syndrome. The resident’s clinical record was reviewed, including outside provider documentation, observations of the resident were made, and interviews with staff were conducted. The following was identified: On 03/24/26 at 10:24 am, Resident 5’s left lower leg was observed to have a large, dark colored, raised area, approximately the size of a tennis ball, with a tightly wrapped dressing noted directly above the wound. At 10:56 am, Staff 13 (MT) entered the resident’s room, saw the resident’s leg and stated the wound did not look like that two days ago and alerted Staff 3 (LPN). Staff 3 observed the wound and reported this was the first time she’d seen the wound and “assumed” there was documentation in an outside provider’s note. An outside provider note, dated 03/17/26, documented the resident had “bruising/hematoma” with Staff 3’s initials dated 03/18/26, indicating she reviewed the outside provider note. However, there was no additional documentation related to the new wound. On 03/25/26 at 9:52 am, Staff 2 (RN) reported she was not informed of the new wound. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for residents who experienced a significant change of condition was reviewed with Staff 1 (ED) at 1:41 pm on 03/26/26. She acknowledged the findings.

During survey it was identified that an RN assessment was not completed for 2 of 6 sampled residents. Resident 5 had mulitple skin tears (injury of unknow cause) and Resident 6 sustained 2 skin tears (injury of unknown cause). Facility reported both cases to APS on 3.26.2026. Family, Hospice and Health services met on 3.27.2026 to discuss care needs, implement safety interventons (geri sleeves, calf protectors) and discussed higher level of care needs, all parties involved and in agreement. Med tech training scheduled for April 28, 2026 training will include teaching and counseling of group education activities as required by individual service plans and facility policies. RN will complete short term and significant change of condition weekly and as needed. Executive Director, HSD, RN or designee is responsible to see that corrections are completed and monitored.

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)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 2 of 2 sampled residents (#s 1 and 4) whose MARs and controlled substance disposition logs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 05/2023 with diagnoses including stroke and neuropathy. During the acuity interview on 03/23/26, staff reported the resident had chronic pain and was administered pain medications as needed. The resident’s 03/01/26 through 03/26/26 MAR and current physician orders were reviewed, and the following was identified: The resident had an order for morphine sulfate 20 mg every two hours as needed for chronic pain. The MAR showed the resident was administered the PRN narcotic on 39 occasions between 03/01/26 through 03/26/26. The controlled substance log contained 52 entries for 03/2026. Thirteen of the entries on the controlled substance log were not reflected on the MAR. The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 (ED) and Staff 17 (Regional RN) on 03/26/26 at 11:05 am. They acknowledged the findings. 2. Resident 4 moved into the facility in 01/2026 and had diagnoses which included pain. Resident 4 had a new order started on 03/12/26 for oxycodone (narcotic analgesic) 5 mg, 1/2 tablet every six hours PRN for moderate to severe pain. Resident 4's controlled substance disposition logs and MARs, reviewed from 03/12/26 through 03/23/26, revealed the resident received the PRN oxycodone on four occasions. However, the MAR lacked documentation that the resident received the medication on one of the four occasions. Inconsistencies between the MARs and controlled substance disposition logs were reviewed with Staff 1 (ED) on 03/26/26 at 8:50 am. She reviewed the documentation and acknowledged the discrepancies.

During survey it was identified that there were inconsistencies between MAR and controlled substance disposition logs for resident 1 and resident 4. HSD, RN and ED completed inservice with med tech staff on 3.27.2026 to inform staff of finding and provide support for medication administration. Med tech training Powell Valley Assisted Living will ensure tracking of controlled substance match EMAR click off times. Med tech training scheduled for April 28, 2026 training topics will include matching controlled substance to EMAR and ensuring time stamp on controlled substance book reflects EMAR time administration. ED, HSD, and RN is responsible to ensure all corrections are completed and monitored weekly.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. 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 observation, interview and record review, it was determined the facility failed to ensure diet orders were carried out as prescribed for 2 of 2 sampled residents (#s 7 and 8) who had modified diet orders. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 01/2023 with diagnoses including traumatic subdural hemorrhage with loss of consciousness status unknown and cerebrovascular disease. The clinical record dated 05/12/26 through 06/16/26 was reviewed and noted the following: * A physician order indicated a dysphagia diet with food texture of minced and moist. During the survey on 06/17/26 at 12:35 pm, the resident was observed consuming a regular diet consisting of a sliced meat, two slices of wheat bread, gravy, a pickle, and a bowl of salad consisting of lettuce and carrots, not a minced texture as prescribed. The need to ensure orders were carried out as prescribed was reviewed with Staff 28 (Interim ED) on 06/18/26 at 9:54 am. He acknowledged the findings. 2. Resident 7 was admitted to the facility in 10/2022 with diagnoses including dementia and dysphagia (difficulty swallowing). The resident's 06/01/26 through 06/16/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Resident 7 had a diet order dated 05/01/2026 for “soft bite size, extra gravy/sauces” diet texture and thin liquids. During the survey on 6/17/26, a board in the kitchen indicated “extra mech soft/moist” diet texture for Resident 7. On 06/17/26 at 09:50 am, an observation of Resident 7’s breakfast plate showed a regular texture egg, half eaten. In an interview at the same time Staff 20 (CG) and Staff 21(MT) confirmed the resident had received a regular texture bacon and cinnamon roll as well as the egg, and not the prescribed diet texture. The need to ensure physician orders were carried out as prescribed was discussed with Staff 28 (Interim ED) and Staff 3 (LPN) on 06/18/26 at 2:20 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? C303 - Systems Treatment Orders. Resident 8 is being served a diet of minced and moist foods. Resident 7 is now served a diet of soft bite-sized foods with extra gravy/sauces. The nursing team and dietary team were in-serviced on diet orders. The facility obtained all signed diet orders for all residents. These will be reviewed by the Wellness Team prior to approving the order to be placed into the TAR for administration. TAR and progress notes will be audited monthly for two months for accuracy as diet orders change, to ensure correct documentation is in place. Executive Director, HWD, Registered Nurse, RCC, or designee is responsible to see that dietary updates are completed and monitored. Any discrepancies will be brought to the following Quality Assurance meeting. 08.10.26

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 6) who had repeated medication and/or treatment refusals. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living community in 05/2023 with diagnoses including stroke and neuropathy. The resident's 03/01/26 through 03/23/26 MARs and current physician orders were reviewed. The following was identified: Staff documented the resident refused right posterior iliac wound care on four occasions, prescribed every three days to monitor a chronic surgical wound. There was no documented evidence the facility notified the resident’s prescriber of the repeated treatment refusals as required. On 3/25/26 at 11:54 am, Staff 11 (MT) confirmed she had spoken to the hospice prescriber and the prescriber stated, “she will send original orders to notify of every refusal of medications and treatments.” The need to notify the physician or other practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED) and Staff 17 (Regional RN) at 11:05 am on 03/26/26. They acknowledged the findings and no additional documentation was provided. 2. Resident 6 moved into assisted living in 10/2024 with diagnoses including Alzheimer's disease, history of cerebral infarction (stroke) affecting the right dominant side, history of falling and congestive heart failure. The resident's 03/01/26 through 03/23/26 MARs and current physician orders were reviewed. Staff documented the resident refused the following medications: * Ammonium lactate lotion (for skin integrity) on seven occasions; * Latanoprost eye drops on six occasions; * Senna (for constipation) on two occasions; * Clonazepam (for anxiety) on two occasions; and * Cannabis tincture (for anxiety) on two occasions. There was no documented evidence the facility notified the resident’s prescriber of the refusals. The need to notify the physician or other practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED) on 03/24/26 at 2:15 pm. She acknowledged the findings.

During survey it was identified that there was no documented evidence Powell Valley notified residents prescriber of medication refusals. Resident 1 and Resident 5 prescribers were notified of medication/tx refusals on 3.24.2026. Powell Valley Assisted Living will ensure resident medication and/or treatment refusals are communicated to Physician or Practitioner as requested by prescriber. Daily audits will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Med tech training to be held April 28, 2026. Training topics to include medication and treatment refusals. ED, HSD, charge nurse and/or Designee will be responsible to see that corrections are completed/monitored.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

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 an accurate MAR was maintained for all facility administered medications for 3 of 6 sampled residents (#s 3, 4 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted in 01/2026 with diagnoses including COPD (chronic obstructive pulmonary disease). The resident's 03/01/26 through 03/25/26 physician orders and MARs were reviewed. The following was identified: Resident 4 had an order for Trelegy inhaler one puff daily for COPD. According to the MAR, staff documented on several occasions between 03/14/26 and 03/25/26 that the inhaler was not available. However, there were also multiple occasions that staff initialed that the inhaler was administered during the same time frame. During an interview on 03/25/26, Staff 11 (MT) said the resident’s supply of Trelegy was out and she had reordered it on 03/21/26. She added that “it’s been out for a several days and should be coming in tonight.” She was unsure why staff had signed that the medication was given when it was out of supply. She further acknowledged that on 03/24/26, she inaccurately initialed that she administered the medication when she had not. The need to ensure MARs were accurate was discussed with Staff 1 (ED) on 03/26/26 at 8:50 am. She acknowledged the findings. 2. Resident 3 moved into the assisted living in 06/2022 with diagnoses including congestive heart failure. The residents 03/01/26 through 3/23/26 MAR and current physician orders were reviewed. The following was identified: The resident was prescribed and facility staff were administering Remedy Protect paste twice per day, Triad paste three times per day and every three hours, Calmoseptine ointment twice per day (all three topical treatments to prevent skin breakdown), and applying compression socks (for edema) in the morning and removing them each evening. Interviews on 03/26/26 at 10:28 am with Staff 18 (CG) and with Staff 19 (MT) at 10:40 am confirmed the caregivers were administering the topical treatments and applying the compression socks during ADL care. However, for each administration, facility MTs were initialing the MAR that they had administered the treatments. This represented an inaccurate MAR. The need to ensure an accurate MAR was kept was discussed with Staff 1 (ED) and Staff 17 (Regional RN) on 03/26/26 at 12:45 pm. They acknowledged the findings. 3. Resident 6 moved into assisted living in 10/2024 with diagnoses including Alzheimer's disease, history of cerebral infarction (stroke) affecting the right dominant side, history of falling and congestive heart failure. The resident’s 03/01/26 through 03/23/26 MAR and current physician orders were reviewed and identified the following pain medications lacked parameters, including the sequence of use: * Tylenol 500 mg tablet; * Diclofenac Gel; and * Oxycodone. On four occasions, MTs administered the PRN oxycodone to Resident 6. During an interview on 03/25/26 at 1:30 pm, Staff 13 (MT) acknowledged the PRN oxycodone was administered and could not state which one should be administered first. Staff 13 looked in the resident’s electronic health record and was unable to find additional instructions for the above PRN pain medications. The need to ensure PRN medications had clear instructions and parameters for use was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (LPN) on 03/25/26 at 3:45 pm. They acknowledged the findings.

During survey it was identified that the need to ensure prn medications had clear instructions and parameters for use. All 6 residents orders were reviewed and updated to reflect OAR on 3.25.2026. Powell Valley Assisted Living will ensure Medication Administration Records (MARs) will be accurate. Daily audits will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. Med tech training to be held on April 28, 2026. Training topics to include accuracy of MARs. ED, HSD, charge nurse and/or Designee will be responsible.

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 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and were administered only after documented, non-pharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#6) who was administered PRN psychotropic medications. Findings include, but are not limited to: Resident 6 moved into the assisted living in 10/2024 with diagnoses including Alzheimer's disease, history of cerebral infarction (stroke) affecting the right dominant side, history of falling and congestive heart failure. The 03/01/26 through 03/23/26 MAR and current physician orders were reviewed and identified the following: * The resident was prescribed PRN cannabis tincture and PRN clonazepam, both to treat anxiety; * MTs administered the clonazepam on 03/05/26, 03/13/26, and 03/14/26 and the PRN cannabis tincture on 03/19/26; * There was no documented evidence interventions were attempted with ineffective results prior to administering either of the medications; and * The MAR lacked resident-specific parameters for the PRN medications. The need to ensure PRN psychotropic medications had written, resident-specific parameters and were administered only after documented, non-pharmacological interventions were tried with ineffective results was discussed with Staff 1 (ED) and Staff 17 (Regional RN) on 03/26/26 at 12:45pm. They acknowledged the findings.

During survey it was identified that the need to ensure prn psychotropic medications had written, resident-specific parameters and were administered only after documented, non-pharmacological interventions. All 6 resident records were reviewed and updated to reflect OAR on 3.26.2026. Powell Valley Assisted Living will ensure non-pharmacological interventions are documented prior to administration of Psychotropic medications. Daily audits of administered PRNs will be completed by HSD, or Designee to be in compliance. Audits will be reviewed in monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff in-service to be held on April 24, 2026. Med tech meeting scheduled for 4/28/2026. Training topics to include non-pharmacological interventions prior to administration of PRN Psychotropic medications. ED, HSD, charge nurse and/or Designee will be responsible.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the acuity interview on 06/16/26, the following was identified * The facility was home to 88 residents at the time of survey; * The facility consisted of a three-story building; * The first floor had four residents who required two staff members to assist with transfers and other ADLs; * The second floor had five residents who required two staff members to assist with transfers and other ADLs; and * The third floor had five residents who required two staff members to assist with transfers and other ADLs. 1. On 06/16/26, the posted facility staffing requirement indicated the following: Day shift: Two and a half direct CGs and three MTs; Evening shift: Three direct CGs and two MTs; and Night shift: Two direct CGs and one MT. Review of staffing records, including the facility posted staffing plan, staff schedule and timecards, dated 06/01/26 through 06/14/26, showed the facility failed to staff according to its posted staffing plan on 11 of 42 shifts reviewed. In an interview on 6/16/26 at 1:12 pm, Staff 26 (CG) reported that when a staff member called out for a shift, the shift was not covered. On 6/26/26 at approximately 11:45 am Staff 8 (RCC) stated MCC staff or the RCC had covered some of the shifts where the ALF had been short staffed. During the follow-up survey on 06/26/26, the facility was staffed according to the posted staffing plan. The need to ensure the facility had a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 28 (Interim ED) on 06/18/26 at 9:54 am, and on 06/26/26 during the follow-up survey exit. He acknowledged the findings. 2. Resident 8 was admitted to the facility in 01/2023 with diagnoses including traumatic subdural hemorrhage with loss of consciousness and cerebrovascular disease. During the survey on 06/16/26 at approximately 1:30 pm, Resident 8 shared when s/he activated the call pendant, staff did not answer or respond in a timely manner. The resident further stated at times s/he had to wait more than one hour for assistance, particularly during shift changes or around 6:15 am or at night. The resident’s call light records were reviewed for the period of 05/25/26 through 06/16/26 and showed in 29 out of 69 call activations, staff responded more than 20 minutes after the call light was activated. In addition, on five occasions, staff response time exceed one hour after call light activation. On 06/17/26 at 12:15 pm, Staff 13 (MT) stated the facility had recently reduced MT hours. She stated a MT who typically worked from 6:00 am to 2:00 pm was now scheduled to work only from 6:00 am to 10:00 am and with another MT to cover the remaining of the shift. During the follow-up survey on 06/26/26, the survey team observed three CGs, three MTs and one trainee on duty. The survey team monitored the call system screen on the second floor in the medication room, and there were no outstanding or prolonged call lights observed. On multiple occasions on 06/26/26 during day shift, the call system display indicated all call lights had been addressed and there were no pending or unacknowledged call alerts. On 06/26/26 the facility was staffed according to the posted staffing plan; therefore, no immediate issues were identified during the follow-up survey related to adequate staffing. The need to ensure the facility had a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 28 (Interim ED) on 06/18/26 at 9:54 am and on 06/26/26 during the follow up survey exit. He acknowledged the findings. 3. Resident 9 was admitted to the assisted living in 05/2025 with diagnoses including congestive heart failure. The resident was identified in the acuity interview as requiring the assistance of two care staff for transfers and ADL cares. Resident 9 had also experienced several falls recently and was receiving hospice services. On 06/16/26 at 12:55 pm, the resident stated s/he had sometimes spent an entire eight-hour period in a soiled brief because care staff did not respond to his/her call light all shift. Other times, s/he could wait for hours before someone would come to help them be repositioned or retrieve a remote that had fallen on the floor, for example. S/he denied waiting longer during certain parts of the day, stating, “There’s never enough people working.” During a follow up survey, on 06/26/26 the facility was staffed according to the posted staffing plan, and survey was unable to determine if the call light wait times for Resident 9 were due to staffing issues or inadequate call system. The need to ensure the facility had a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 28 (Interim ED) on 06/18/26 at 9:54 am and on 06/26/26 during the follow up survey exit. He acknowledged the findings.

360 Staffing Requirements and staff Training Staffing posted changed to reflect actual staffing including scheduled and unscheduled needs. IDT Team in serviced on scheduled and unscheduled needs of the residents within the property including acuity per floor of the property. ED or designee are responsible for ensuring that ABST, Staff posting and scheduled and unscheduled needs are being met for the residents and all match. Any discrepancies to be review daily and brought to the following Quality Assurance meetings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured care time and care areas that staff were providing to each resident for 3 of 6 sampled residents (#s 3, 5 and 6) whose ABSTs were reviewed. Findings include, but are not limited to: The ABSTs, current service plans for Residents 3, 5 and 6 were reviewed, interviews with residents and staff were conducted, and observations of residents were made. The residents’ ABSTs did not accurately reflect care areas and time staff provided care to the residents. The need to ensure the ABST accurately captured care time and care areas that staff provided to residents was discussed with Staff 1 (ED) on 03/26/26 at 8:50 am. She acknowledged the findings.

During survey it was identified that the need to ensure the ABST accurately captured care time and and care areas that staff provided to residents. Records 3, 5 and 6 were updated to reflect ABST during interview with ED. Powell Valley Assisted Living will accurately capture care time and care elements team members provide to residents. Residents' corresponding ABST evaluations will be updated and updated as needed. Weekly audits will be completed by ED and HSD to assure compliance. Audits will be reviewed at monthly Quality Assurance/Quality Measurement meetings to ensure compliance and evaluate internal system to keep in compliance. Internal tracker developed to assure compliance. ED and HSD will be responsible.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

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 ABST was updated at least quarterly and following changes of condition to determine appropriate staffing levels to address activities of daily living and other tasks related to care, for 4 of 6 sampled residents (#s 1, 3, 5 and 6) and several unsampled residents. Findings include, but are not limited to: Review of clinical records, including service plans for Residents 1, 3, 5 and 6, revealed the facility's ABST tool was not updated quarterly and/or when there was a significant change of condition to reflect the residents' care needs, in order to ensure the ABST accurately determined the needed staffing level. The ABST evaluation date for several unsampled residents, reviewed during the survey, revealed the ABST evaluations had not been reviewed and updated in the last 90 days (quarterly). On 03/26/26 at 8:50 am, the need to ensure the ABST was updated at least quarterly and following changes in condition was discussed with Staff 1(ED). She acknowledged the findings.

During Survey, it was determined the acuity-based staffing tool was not updated for resident #3, #5, #6. as service plan updates occur, ABST will be updated. ABST for residents #3, #5 and #6 were updated during the preliminary findings meeting. RCC and LPN will complete service plan update quarterly, RN will complete Change of condition care plan. Receptionist will schedule care plan meeting with resident, family or designee. Executive Director will complete service plan meeting and ensure ABST is updated.Service plans and ABST will be reviewed at move in, quarterly updates and if a short term/significant change of condition arises.RCC, Administrator or designee is responsible to see that the corrections are completed and monitored.

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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC) with all required elements. Findings include, but are not limited to: On 03/25/26 at 11:38 am, fire drill records from 09/2025 through 02/2026 were reviewed with Staff 4 (Plant Operations Supervisor) and revealed a lack of documentation of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * Staff members on duty and participating; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. The need to ensure the facility conducted fire drills according to the Oregon Fire Code (OFC) with all required elements, was reviewed with Staff 1 (ED) at 1:41 pm on 03/26/26. She acknowledged the findings.

During Survey, it was determined that fire drills were not conducted according to the Oregon Fire Code (OFC) and fire and life safety instruction was not provided to staff on alternate months of fire drills. Fire drill was completed on 3/30/26. Fire drills will be completed every other month and fire life and safety will be discussed every month there is not a drill. Administrator and Maintenance Director will conduct an audit monthly to ensure proper documentation is completed for all fire drills and safety.Executive Director, Administrator and Maintenance will be responsible to see that the corrections are completed and monitored

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to: C231 and C260.

C455 - Inspection and Investigation: Inspection Intervals. See C231, C260.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure a call system that connected resident units to the care staff center or staff pagers. Findings include, but are not limited to: 1. Resident 9 was admitted to the assisted living in 05/2025 with diagnoses including congestive heart failure and was identified in the acuity interview as needing the assistance of two care staff for transfers and ADL care. Resident 9’s call light records from 05/26/26 to 06/16/26 were reviewed. For 140 of the 438 calls made by the resident, staff took longer than 20 minutes to respond; 58 of those response times exceeded one hour, with the longest response taking 7 hours, 42 minutes, and 11 seconds. At 1:45 pm, on 06/16/26, Staff 24 (CG) reported CGs used iPods to respond to resident pendant or pull cord activations. Additionally, CGs and MTs carried radios to communicate specific needs to one another. The CG also stated there were not enough pendants available to reset resident call lights, even if a call was answered, residents would not be able to call for assistance if the light had not been cleared. She confirmed she had not had access to an iPod for the last hour because the battery had run out. She reported frequently not having access to a device, either because they were not adequately charged at the start of the shift, or there weren’t enough of them. On this shift, there were no other devices to use while the iPod was charging, leaving her unable to receive alerts to resident calls for assistance. In an interview on 06/17/26 at 9:57 am, Staff 23 (CG) stated she was unable to clear a call made by an unsampled resident because her pendant was not pairing with the resident’s pendant to clear the call. She stated this happened frequently, and the resident was unable to use his/her pendant to communicate with care staff until the call was cleared. During the follow-up survey on 06/26/26, the survey team verified the availability of the call system devices and observed all three CGs on day shift had the necessary equipment, including walkie-talkie, iPods, and pendants used to reset the call system. The survey team also observed all three MTs on day shift each carried the necessary equipment, including a phone and walkie-talkie for communication. Based on these observations, there was no evidence of a shortage of call system devices or malfunction of the call system during the follow-up survey. There were no immediate issues identified during the follow-up survey on 06/26/26 related to the call system. The need to ensure the call system that connected resident units to the care staff center or staff pagers was in good repair and functional was reviewed with Staff 28 (Interim ED) and Staff 3 (LPN) on 06/18/26 at 1:50 pm and on 06/26/26 during the follow up survey exit. They acknowledged the findings. 2. Resident 7 was admitted to the facility in 10/2022. Resident 7’s service plan indicated s/he required the assistance of two staff for incontinence care and repositioning. On 06/16/26 at 12:55 pm an observation of ADL care was made. Staff 26 (CG) attempted to call for assistance using the radio but there was no response, so she proceeded to provide care alone. While the surveyor was interviewing Staff 26 later that day, Staff 23 (CG) approached. Staff 26 informed Staff 23 that she had been calling for assistance; Staff 23 stated she did not respond because she did not have a radio. Staff 26 gave her the pendant, iPod, and radio so she could answer call lights while the interview continued. Both Staff 23 and Staff 26 stated they did not have enough devices and had to share them. Staff 26 also reported that when a staff member called out for a shift, the shift was not covered. During the follow-up survey on 06/26/26, the survey team verified the availability of the call system devices and observed all three caregivers on day shift had the necessary equipment, including walkie-talkies, iPods, and pendants used to reset the call system. The survey team also observed all three MTs on day shift each carried the necessary equipment, including a phone and walkie-talkie for communication. Based on these observations, there was no evidence of a shortage of call system devices or malfunction of the call system during the follow-up survey. There were no immediate issues identified during the follow-up survey on 06/26/26 related to the call system. The need to ensure the call system that connected resident units to the care staff center or staff pagers was in good repair and functional was reviewed with Staff 28 and Staff 3 on 06/18/26 at 1:50 pm and on 06/26/26 during the follow up survey exit. They acknowledged the findings.

C655 - Nurse Call System. All staff will be in-serviced on carrying a walkie/iPhone each shift and the importance of answering call lights timely. The call light system was checked by the manufacturer and found to have a Windows error that overloaded the system and made it hard to identify call lights. This has since been corrected. ED was educated on staff posting to match ABST requirements. Town halls will be held monthly to review call light response times, and call logs will be pulled daily to ensure good responses from staff five times a week for three months. The call light system was added to other staff computers to observe call lights in real time and help staff address them timely. ED or designee will review findings each day call lights are pulled and address them with staff/sections as needed. Logs should be brought to the following Quality Assurance meeting for review.