Print Inspection: RL011544

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 readily available to staff, were reflective of residents' current status, provided clear instructions to staff, and were updated at least quarterly for 6 of 7 sampled residents (#s 1, 2, 3, 5, 6, and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 04/2026 with diagnoses including chronic obstructive pulmonary disease. Observations made on 04/28/26 showed there was no service plan readily available to staff in the service plan binder kept on the unit. On 04/28/26 at 2:35 pm, Staff 1 (Administrator) provided a current service plan dated 04/16/26. The 04/16/26 service plan was not readily available to staff. The need to ensure service plans were readily available to staff was discussed with Staff 1, Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 2:10 pm. They acknowledged the findings. 2. Resident 6 moved into the facility in 10/2024 with diagnoses including congestive heart failure. The service plan readily available to staff in the service plan binder kept on the unit was dated 11/26/25. On 04/29/26 at 2:00 pm, Staff 1 (Administrator) provided a current service plan dated 03/17/26. The 03/17/26 service plan was not readily available to staff. The need to ensure service plans were readily available to staff was discussed with Staff 1, Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 2:10 pm. They acknowledged the findings. 3. Resident 1 moved into the facility in 04/2019 and was noted to have an unsteady gait. Interviews with the resident and facility staff were conducted during the survey. On 04/28/26 observations showed the resident’s service plan located in the service plan binder available to staff was dated 11/05/25. Resident 1's quarterly service plan, last updated on 02/18/26, was not made available to staff, was not reflective of the resident's current needs, and lacked clear instructions to staff regarding the resident’s use of an ankle-foot orthosis. The need to ensure the service plan was readily available to staff, reflected residents' current care needs, and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 1:35 pm. They acknowledged the findings. 4. Resident 2 moved into the facility in 04/2021 with diagnoses including chronic left side body weakness. Interviews with the resident and facility staff were conducted during the survey. On 04/28/26 observations showed the resident’s service plan located in the service plan binder available to staff was dated 11/05/26. Resident 2's quarterly service plan, last updated on 02/18/26, was not made available to staff, was not reflective of the resident's current needs and preferences, and lacked clear instructions to staff in the following areas: * The need for assistance from one to two staff with transfers; * The need for assistance with grooming; and * Information regarding the resident’s roles within the facility resident council. The need to ensure the service plan reflected residents' current needs and preferences and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 1:35 pm. They acknowledged the findings. 5. Resident 3 moved into the facility in 07/2018 with a diagnosis of degeneration of the brain. a. The service plan readily available to staff, located in the service plan binder, was last updated 12/10/25. The updated service plan, dated 03/04/26, was received on 04/28/26. The service plan showed Resident 3 had a significant change of condition, including a hospice admit, and this information was not available to staff. b. Resident 3's service plan was not reflective or did not provide clear direction to staff in the following areas: * Use of a space heater; and * Effective non-pharmacological interventions for behaviors. The need to ensure service plans reflected the resident's needs as identified in the evaluation and included clear direction for staff was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 12:35 pm. The findings were acknowledged. 6. Resident 7 moved into the facility in 11/2018 with diagnoses including mild cognitive impairment. The resident’s service plan, dated 11/12/25, was reviewed. Resident 7 and staff were interviewed. a. The resident’s service plan was not reflective or did not provide clear instruction to staff in the following areas: * The presence of a cat; and * Smoking, including how s/he obtained the cigarettes and where they were stored. b. Resident 7’s service plan was not updated at least quarterly. On 04/30/26 at 2:27 pm, Staff 6 (Resident Services Director) confirmed that the resident’s service plan had not been updated since 11/12/25. The need to ensure service plans were reflective, provided clear instruction to staff, and were updated at least quarterly was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 11:18 am. They acknowledged the findings.

1) Service plan binder updated with move in service plan for Resident 5 dated 04/16/2026. 2) Service plan binder updated with quarterly service plan for Resident 6 dated 03/16/2026. 3) Service plan binder updated with quarterly service plan for Resident 1 dated 02/18/2026. Service plan updated to reflect use of ankle-foot orthosis on left leg/foot in Ambulation/Mobility and in Dressing/Undressing twice a day. Service plan updated for staff to assist resident to put it on in the morning before breakfast and remove it at night when he is in bed. 4) Service plan binder updated with quarterly service plan for Resident 2 dated 02/18/2026. Service plan updated to reflect 2 person transfer assists on/off toilet, on/off recliner, in/out of bed, in/out of wheelchair. Service plan updated to reflect 1 person assist with grooming tasks twice a day in the morning and before bed. Service plan updated that resident no longer chooses to no longer pariticpate in resident council in a Secretary role and insead now chooses to join resident council meetings as she chooses. 5) Service plan binder updated with Change of Condition - Admission to Hospice service plan dated 03/04/2026. Space heater not required in apartment and removed from apartment with resident consent. Service plan updated with non pharmacological interventions for caregivers if he refuses services and care along with pharmacological interventions for Medication Techs to follow MAR for behaviors. 6) Service plan binder updated with quarterly service plan for Resident 7 dated 02/25/2026. Service plan updated with verbiage on where cigarettes are stored and how resident is able to obtain cigarettes from staff upon request. Service plan updated that resident no longer has a cat but does have cat toys still in resident apartment and resident shows no signs of distress from no longer having a pet. Facility Administrator will review all updated service plans from weekly service plan meetings to ensure that all resident needs are met in the service plan with Resident Service Director and Director of Nursing every Friday. This is to ensure accuracy of service plan to resident current needs/assistance. Any corrections to service plan will occur at that time. ABST will be updated, if needed, during that time with TSPs being put into place for direct care staff and Medication Techs.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, communicated to staff on each shift, were monitored at least weekly until the condition resolved, and were monitored consistent with the residents’ evaluated needs and service plan for 4 of 7 sampled residents (#s 1, 2, 4, and 7), who were reviewed for changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 06/2025 with diagnoses including bipolar disorder and anxiety. The resident’s clinical record, dated 01/15/26 through 04/28/26, was reviewed. Staff and Resident 4 were interviewed. The following changes of condition were identified: a. A progress note dated 01/15/26 identified a potential resident-to-resident altercation. There was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the action or intervention to staff on each shift, or documented weekly progress until the condition resolved. b. A progress note dated 03/21/26 identified a staff-to-resident altercation. There was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the action or intervention to staff on each shift, or documented weekly progress until the condition resolved. c. A progress note and corresponding temporary service plan, both dated 04/06/26, identified Resident 4 reported experienced diarrhea "for about a week." There was no documented evidence the condition was monitored through resolution. The need to ensure resident-specific actions or interventions were determined, documented, communicated to staff on each shift, and were monitored at least weekly until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 11:18 am. They acknowledged the findings. 2. Resident 7 moved into the facility in 11/2018 with diagnoses including mild cognitive impairment and was identified as being at risk for falls. The resident’s clinical record, dated 01/15/26 through 04/28/26, was reviewed. Staff and Resident 7 were interviewed. The following changes of condition were identified: * A progress note dated 01/15/26 identified a potential resident-to-resident altercation; * On 01/28/26, staff documented that Resident 7 had a verbal altercation with an unsampled resident's family member; and * On 03/10/26, staff documented the resident had a fall in his/her apartment. Resident 7 reported to have hit his/her head but refused to go to the hospital. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the actions or interventions to staff on each shift, or documented weekly progress until the conditions resolved. The need to ensure resident-specific actions or interventions were determined, documented, communicated to staff on each shift, and were monitored at least weekly until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 11:18 am. They acknowledged the findings. 3. Resident 1 moved into the facility in 02/2019 with diagnoses including anemia. The resident was identified to be at risk for falls in the 04/28/26 acuity interview. The resident’s 01/23/26 through 04/28/26 clinical record was reviewed, and the 02/18/26 service plan included instructions for multiple fall interventions. Resident 1 experienced the following changes of condition between 01/23/26 and 04/22/26: a. In a 01/23/26 progress note, staff documented the resident received new medication orders to begin ferrous gluconate 324 mg (for anemia) daily and levothyroxine sodium 25 micrograms (for low thyroid levels) daily. There was no documented evidence the resident was monitored, with progress noted at least weekly through resolution, for the medication changes. b. In a 02/01/26 progress note, staff documented the resident experienced two falls on 02/01/26. The resident was transferred to the hospital where s/he was diagnosed with a contusion (bruise) to the right thigh. There was no documented evidence the facility evaluated previous fall interventions for effectiveness, determined if new interventions needed to be developed for the resident, or monitored the resident’s injury, with progress noted at least weekly through resolution. c. In a 04/07/26 progress note, staff documented the resident had a non-injury fall. There was no documented evidence the facility evaluated the previous fall interventions for effectiveness or determined if new interventions needed to be developed for the resident. d. In a 04/08/26 progress note, staff documented redness to the resident’s perineal area. In an 04/30/26 interview, Staff 11 (CG) stated the resident’s skin condition was still present, and staff were treating the condition with barrier cream. There was no documented evidence the condition was monitored, with progress noted at least weekly through resolution. In an interview on 04/30/26 at 10:47 am, Staff 4 (LPN) confirmed the lack of documented monitoring through resolution for Resident 1’s medication changes and skin conditions and the lack of documented evaluation of fall interventions after the resident’s most recent falls. The need to ensure changes of condition were monitored at least weekly until resolution and to monitor each resident consistent with his or her evaluated needs and service plan was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 1:35 pm. They acknowledged the findings. 4. Resident 2 moved into the facility in 02/2021 with diagnoses including depression. The resident was identified to be at risk for falls in the 04/28/26 acuity interview. The resident’s 02/25 /26 through 04/28/26 clinical record was reviewed, and the 02/18/26 service plan included instructions for multiple fall interventions. Resident 1 experienced the following changes of condition between 02/23/26 and 04/28/26: a. In a 03/24/26 progress note, staff documented the resident received new medication orders to begin duloxetine 20 mg (for depression) daily. There was no documented evidence the resident was monitored, with progress noted at least weekly through resolution, for the medication change. b. In a 04/20/26 progress note, staff documented the resident experienced a non-injury fall. There was no documented evidence the facility evaluated previous fall interventions for effectiveness or determined if new interventions needed to be developed for the resident. In an interview on 04/29/26 at 12:50 am, Staff 4 (LPN) confirmed the lack of documented monitoring through resolution for Resident 2’s medication change and the lack of documented evaluation of fall interventions after the resident’s most recent fall. The need to ensure changes of condition were monitored at least weekly until resolution and to monitor each resident consistent with his or her evaluated needs and service plan was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 1:35 pm. They acknowledged the findings.

1) Service plan updated to reflect incidents between other resident and staff member with non pharmacological interventions. Staff member responsible for placing resident on alert charting for diarrhea was educated by RN on proper alert charting documentation and notification to RN or PCP.RN assessed resident that there were no lasting effects from episodes of diarrhea. 2) Service plan updated to relfect incidents between other resident and a visiting family member with non pharmacological interventions. Staff member responsible for placing resident on alert charting for fall was educated by RN on proper alert charting documentation and notification to RN or PCP. RN assessed resident that there were no lasting effects from fall. 3) Service plan updated to reflect review of current fall interventions and effectiveness. Service plan updated for recurring redness to perineal area and interventions. Clinical Tracker created for nursing oversight for skin issue to perineal area with at least weekly documentation until resolution. 4) LPN documented on resident showing no adverse reactions due to increase in medication. Staff member responsible for placing resident on alert charting for change in medication was educated by RN on proper alert charting documentation. Update to Incident Tracking system completed by IT Director to ensure notification of incident reports being created are sent in real time via email to the Administrator, RN, LPN. Facility Administrator will conduct a weekly Clinical Tracker meeting with RN, LPNs, Resident Services Director, and Deputy Director to review any recent fall(s) with effectiveness of current fall interventions, skin issues/wounds, short term changes of conditions, Significant Change of Conditions. Administrator and RN will review charting notes daily for any required follow ups during the work week and for the 3 day period on Mondays for the weekend. Administrator will communicate any concerns or issues from charting notes with RN. RN will delegate follow ups to LPNs , unless concern requires a change of condition. RN will follow up with Administrator once concern has been addressed and plan is in place for monitoring.

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 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6, and 7) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 07/2018 with a diagnosis of degeneration of the brain. The resident's 04/01/26 to 04/28/26 MAR and current physician orders were reviewed, and the following was identified: a. Staff documented the following medications were not administered as prescribed because the resident was sleeping: * Haloperidol lactate (for agitation) on five occasions; and * Omeprazole (for reflux) on 26 occasions. b. Ascorbic acid (vitamin C) was discontinued on 03/13/26; however, it was transcribed on the current MAR. The medication was administered seven times, marked as “waiting on med delivery” four times, and as refused for three times. In an interview with Staff 4 (LPN) on 04/29/26 at 9:35 am, she acknowledged the ascorbic acid should have been discontinued, and she would update the MAR to include a later time administration for the haloperidol and omeprazole. On 04/30/26 at 12:35 pm, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN). They acknowledged the findings. 2. Resident 1 moved into the facility in 02/2019 with diagnoses including hypothyroidism. Review of Resident 1’s 04/01/26 through 04/28/26 MAR, and current physician's orders, dated 03/10/26, identified the following: Staff documented the following medication and treatment orders were not administered as prescribed because the resident was sleeping: * Levothyroxine sodium 25 micrograms (for low thyroid levels) on 28 occasions; and * Monitor oxygen level saturations (for acute respiratory failure) on 19 occasions. On 04/30/26 at 1:35 pm, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN). They acknowledged the findings. 3. Resident 2 moved into the facility in 04/2021 with diagnoses including gastroesophageal reflux disease. Review of Resident 2’s 04/01/26 through 04/28/26 MAR and current physician's orders, dated 03/24/26, identified the following: Staff documented an order for omeprazole 20 mg (for ulcer prevention) was not administered on 23 occasions because the resident was sleeping. On 04/30/26 at 1:35 pm, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN). They acknowledged the findings. 4. Resident 4 moved into the facility in 06/2025 with diagnoses including hyperlipidemia, prostatic hyperplasia, and acid reflux. The resident’s MAR, dated 04/01/26 through 04/28/26, and physician’s orders were reviewed, and the following was identified: a. The following medications were not administered as the facility was "waiting on delivery" from the pharmacy: * Atorvastatin (for hyperlipidemia) on 04/22/26; and * Tamsulosin (for benign prostatic hyperplasia) on 04/21/26 and 04/22/26. b. Omeprazole (to treat acid reflux) was not administered 15 out of 28 times. Staff documented the resident was sleeping. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 11:18 am. They acknowledged the findings. 5. Resident 7 moved into the facility in 11/2018 with diagnoses including hypertension. The resident’s MAR, dated 04/01/26 through 04/28/26, and physician’s orders were reviewed and the following was identified: Resident 7 had a physician's order for staff to obtain the resident’s blood pressure weekly, directing staff to fax the physician if the blood pressure reading was greater than 140/90 or was less than 100/60. On 04/08/26, Resident 7's blood pressure was documented as less than 100/60. Staff documented they had not notified the physician. On 04/15/26 and 04/22/26, the resident's blood pressure was documented as greater than 140/90. Staff documented they had not notified the physician. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 11:18 am. They acknowledged the findings. 6. Resident 5 moved into the facility in 04/2026 with diagnoses including chronic obstructive pulmonary disease. Review of the resident's 04/01/26 to 04/28/26 MAR and current physician orders showed the following: * A physician order dated 04/16/26 directed staff to apply a nicotine patch transdermally in the morning and to ensure to remove the old patch and place a new patch each morning. According to the MAR, staff initialed three times the old patch was not removed after a new patch was placed. On 04/30/26 at 2:10 pm, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN). They acknowledged the findings. 7. Resident 6 moved into the facility in 10/2024 with diagnoses including congestive heart failure. Review of the resident's 04/01/26 to 04/28/26 MAR and current physician orders showed the following: Staff documented the following orders were not administered as prescribed because the resident was sleeping: * Metoprolol (for atrial fibrillation) on five occasions; * Warfarin (for atrial fibrillation) on five occasions; and * Full set of vitals to be taken three times daily, one occasion at 4:00 pm and 18 occasions at 11:00 pm. On 04/30/26 at 2:10 pm, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN). They acknowledged the findings.

1) Omeprazole order moved from 0530 to 1030 per resident preference and history of refusal at 0530 due to sleeping. Omeprazole order was discontinued on 5/12/26 by Caring Hearts Hospice Nurse. Haloperidol order moved from 2000 to 18000 per resident preference and history of refusal at 2000 as resident sleeps earlier at night. Ascorbic Acid order was discontinued 4/28/26 per Caring Hearts Hospice orders. 2) Levothyroxine order moved from 0530 to 0730 per resident preference. O2 SAT monitoring added a window of time during from when caregivers provide ADL care to obtain O2 SAT readings. 3) Omeprazole order moved from 0530 to 0730 per resident preference. 4) Atorvastatin order was delivered the next day on 4/22/26. Tamsulosin order was delivered on 4/23/26. Medication Techs educated on documentation of reordering medications with call to pharmacy and documentation in MAR on conversation with pharmacy for follow up by Nurse. Omeprazole order moved from 0530 to 0730 per resident preference. 5) RN called PCP office to verbally notify of elevated BP readings on 5/1/2026. Order recordings for BP reading clarified as "Is SBP over 140 or under 100? Yes/No", "Is DBP over 90 or under 60? Yes/No", "If Yes to either, PCP notified? Yes/No", "RN notified? Yes/No" for clear instructions to Medication Techs. 6) Clarification for Nicotine patch added as follows for recording of application of new patch and removal of previous patch: "Old patch still on? Yes/No", "If No, patch missing? Yes/No" , "If Yes, removed old patch? Yes/No" , "Initaled and Dated? Yes/No". Education provided by RN and LPNs to document appropriately if resident moved patch on own in a chart note. 7) Medication Techs instructed by RN on ensuring phsyician orders are being administered as prescribed and if resident refuses due to sleeping, notificaiton to PCP of refusal of medication every time and notification to RN. Administartor, RN, and LPNs to review exceptions once daily in the morning Tuesday - Friday to review any refusal of medications or medications unable to be given due to resident sleeping with appropriate notification to PCP with monitoring and TSP in place until resolution by RN and/or LPNs; with review on Mondays for previous 3 days due to the weekend.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were kept accurate and included resident-specific parameters for PRN medications for 5 of 7 sampled residents (# 2, 3, 4, 5, and 6) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 06/2025 with diagnoses including prostatic hyperplasia, asthma, and erectile disfunction. The resident’s clinical record, dated 01/15/26 through 04/28/26, was reviewed, and the following inaccuracies were identified: a. There were two circled initials on the MAR, dated 04/21/26 and 04/22/26, prazosin (benign prostatic hyperplasia) with no documentation as to why the dates were circled. b. An entry on the MAR for albuterol (for asthma) instructed staff to have the resident "inhale [one to two] puffs by mouth every [four to six] hours if needed for shortness of breath." The parameters for unlicensed staff to follow were not resident-specific. c. Resident 4 had a physician’s order for sidenfil (for erectile disfunction). Staff noted in a progress note, dated 03/12/26, that the resident was not willing to pay the $803.37 co-pay. Due to non-payment, the pharmacy was not delivering the medication to the facility. Resident 4's 04/01/26 through 04/28/26 MAR was reviewed. There were five times when staff documented the medication had been administered even though the facility did not have the medication to administer. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 11:18 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 02/2021 with diagnoses including chronic numbness on the left side. Review of Resident 2’s 04/01/26 through 04/28/26 MAR and current physician's orders, dated 03/24/26, identified the following: * The resident had an order for arthritis pain relief 0.075% topical cream to be applied three times daily to the left hand and foot. The 2:00 pm entry for 04/15/26 was blank. * The resident had PRN orders for nystatin ointment and nystatin powder (both for rash). The MAR did not include the specific treatment information for staff to differentiate one order from the other. During an interview on 04/29/26 at 12:50 pm, Staff 4 (LPN) confirmed the blank on the MAR and was unable to verify if the treatment was administered to the resident. The need to ensure MARs were accurate and included the type of treatment to be administered was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 on 04/30/26 at 1:35 pm. They acknowledged the findings. 3. Resident 3 moved into the facility in 07/2018 with a diagnosis of degeneration of the brain. The resident's 04/01/26 to 04/28/26 MAR and current prescriber orders were reviewed, and the following was identified: a. The following PRN medications lacked resident-specific parameters or instructions to direct unlicensed staff on which medication should be administered and in what order: * Bisacodyl and stimulant laxative for constipation; and * Acetaminophen tablets, acetaminophen suppository, and morphine for pain. b. The following medications were duplicated on the MAR: * Senexon and stimulant laxative for constipation; and * Maalox and Mylanta for upset stomach/heartburn. During an interview on 04/29/26 at 9:23 am, Staff 4 (LPN) confirmed the electronic MAR system lacked parameters on which medication should be administered and in what order listed for staff. She confirmed the reasons for use for the duplicative medications. The need to ensure residents' MARs were accurate and included resident-specific parameters and instructions for administration of PRN medications was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 12:35 pm. They acknowledged the findings. 4. Resident 5 moved into the facility in 04/2026 with diagnoses including chronic obstructive pulmonary disease. The resident's 04/01/26 to 04/28/26 MAR and current physician orders were reviewed, and the following inaccuracies were identified: * An entry on the MAR instructed staff to give senna plus, two tablets by mouth twice a day for constipation. Five of the 17 entries were blank. During an interview on 04/29/26 at 11:55 am, Staff 4 (LPN) confirmed the blanks on the MAR and was unable to verify if the medication had been administered. The need to ensure MARs were accurate and included initials of staff administering medications was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 2:15 pm. They acknowledged the findings. 5. Resident 6 moved into the facility in 10/2024 with diagnoses including congestive heart failure. The resident's 04/01/26 to 04/28/26 MAR and current physician orders were reviewed, and the following inaccuracies were identified: * An entry on the MAR instructed staff to check weights daily using the same scale. One of the 23 entries was blank; * An entry on the MAR instructed staff to give warfarin sodium one tablet by mouth daily. One of the 26 entries was blank; and * An entry on the MAR instructed staff to take a full set of vitals three times a day. Four of the 4:00 pm entries were blank. During an interview on 04/29/26 at 2:25 pm, Staff 3 (RN) confirmed the blanks on the MAR and was unable to verify if the daily weight and full vitals were taken and if the medication was administered. The need to ensure MARs were accurate and included initials of staff administrating medications was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 on 04/30/26 at 2:15 pm. They acknowledged the findings.

1) Prazosin order administration for 4/21/26-4/22/26 was investigated to find that resident was in the middle of changing PCPs and had no refills from the Omnicare Pharmacy. Medication was received on 4/23/26 and administered appropriately. New PCP was notified of missing the 2 doses due to changing PCPs. New PCP faxed for clarification on current PRN Albuterol order due to range of number of puffs from 1-2 and range in time of 4-6 hours. Order suspended pending clarification with RN phone call follow up. Staff members involved in clicking off Sildenafil order (that was not available) as administered provided instruction by RN on proper documentation and further follow up in 7 days by RN or LPNs on ensuring proper documentation for those staff members. 2) Administrator reviewed resident record and clarified order with RN. Nystatin cream to be applied at 0400 and 1600, Nystatin powder to be applied 0700 and 2000. Specified instruction note on orders to clean affected areas well with wet warm wash cloth and soap and pat dry to remove previous order application(s) prior to applying new application. 3) Clarification note completed by LPN to administer PRN Senexon first and then PRN Bisacodyl 2nd for PRN bowel care needs. Order received to discontinue PRN Stimulant Laxative. Clarification note completed by Administrator and RN to adminsiter PRN Acetaminophen oral tablets first then PRN Morphine second if needed for PRN pain management. PRN Acetaminophen suppository clarified to utilize to administer if unable to administer oral Acetaminophen. Hospice clarification received that order for PRN Mylanta is not active and order for PRN Maalox Plus is current and active. QMAR updated with signed orders received. 4) Senna Plus order reviewed by Administrator and RN. Review found order was entered appropriately upon move in on 4/16/26 and upon receiving medication from pharmacy order was approved, however, start date of when medication was received was not corrected appropriately. Staff member that approved order was instructed by RN on proper approval procedure of medication. 5) Order for Daily Weights and missing of one entry reviewed by Administrator and RN. Review found that staff members responsible for obtaining weight and warfarin administration had received refusal from resident 3x and had forgotten to enter refusals appropriately. Staff member instructed by RN on appropriate documentation and consequences of not documenting appropriately. Administrator conducted instructional Medication Tech meeting with all Medication Techs on ensuring proper documentation for all orders on shift(s) to ensure no missing documentation is found. Administartor, RN, and LPNs to review Missed Med Report once daily in the morning Tuesday - Friday to review any Missed Medication(s) and follow up with Staff Member responsible for the Missed Medication for correction(s) to be completed with 24 hours by RN and/or LPNs; with review on Mondays for previous 3 days due to the weekend.

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 were administered only after documented, nonpharmacological interventions were tried with ineffective results and that medications administered to treat a resident’s behavior had written, resident-specific parameters for 1 of 1 sampled resident (#3) who had an order for PRN psychotropic medications. Findings include, but are not limited to: Resident 3 moved into the facility in 07/2018 with a diagnosis of degeneration of the brain. The resident's 04/01/246 to 04/23/26 MAR and clinical record were reviewed. The following was identified: a. The resident had an order for lorazepam, administer one tablet daily as needed for anxiety. The MAR indicated staff administered the PRN medication on two occasions. There was no documented evidence staff attempted non-pharmacological interventions with ineffective results prior to administration of the medication. b. There were no written, resident-specific parameters on the MAR to indicate behaviors for when the medication would be administered or non-pharmacological interventions to try prior to administration. * Lorazepam for anxiety; and * Haloperidol for agitation. In an interview on 04/29/26 at 9:25 am, Staff 4 (LPN) confirmed there were no non-pharmacological interventions to attempt prior to administration of a PRN psychotropic medication or resident-specific parameters on the electronic version of the MAR. The need to have resident-specific parameters and to document non-pharmacological interventions attempted with ineffective results prior to administering a PRN psychotropic medication was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 12:35 pm. They acknowledged the findings.

1) PRN Haloperidol and PRN Lorazepam orders reviewed by Administrator and RN. During review, PRN Haloperidol order clarified by RN with Hospice to administer first for anxiety/agitation and then PRN Lorazepam order second for anxiety/agitation. Order note updated of effective non-pharmacological interventions for PRN Haloperidol and PRN Lorazepam orders. RN to review all PRN Psychotropic orders and provide instruction of non pharmacological resident-centered interventions for all residents.

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 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 8, 9, 13, and 14) completed orientation training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Administrator) at 12:46 pm on 04/30/26. The following was identified: There was no documented evidence Staff 8 (CG), hired 02/27/26, Staff 9 (CG), hired 02/23/26, Staff 13 (MT), hired 02/02/26, and Staff 14 (Cook), hired 01/15/26, completed preservice orientation training in one or more of the following areas: * Residents' rights and values of community-based care, * Abuse and reporting requirements; and * Fire safety and emergency procedures; * Infectious disease prevention; * Approved HCBS course; * Approved LGBTQIA2S+ course; and/or * Preservice dementia training. The need to ensure newly hired staff completed orientation training prior to beginning their job responsibilities was discussed with Staff 1, Staff 2 (Deputy Administrator), and Staff 3 (RN) at 12:46 pm on 04/30/26. They acknowledged the findings.

Staff member(s) were assigned classes on Oregon Care Partners on 05/01/2026 for completion of preservice training classes for: Residents' rights and values of community-based care, Abuse and reporting requirements, Fire Safety and Emergency Procedures, Infectious disease prevention, Approved HCBS course, Approved LBGTQIA2S+ course, and Preservice dementia training with required completion by 05/29/2026. Administrator will be meeting with each new hire and going over required classes and assign the required classes on Oregon Care Partners on day of new hire paperwork with HR Assistant. Fire Safety and Emergency Procedure to be completed the same day of new hire paperwork with walkthru conducted by a team from Maintenance, Administrator, or Deputy Administrator.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 9 and 13) demonstrated knowledge and performance in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Administrator) at 12:46 pm on 04/30/26. The following was identified: There was no documented evidence Staff 9 (CG), hired 02/23/26, and Staff 13 (MT), hired 02/02/26, demonstrated knowledge and performance within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and/or * First aid and abdominal thrust training. The need to ensure newly hired direct care staff demonstrated knowledge and performance in all assigned job duties within 30 days of hire was discussed with Staff 1, Staff 2 (Deputy Administrator), and Staff 3 (RN) at 12:46 pm on 04/30/26. They acknowledged the findings.

Staff member(s) 30 day Competency from Survey were completed by 05/18/2026. Administrator to enter all new hires with anticipated 30 day competency testing on Employee Tracker to ensure it is completed by Resident Services Director for caregivers and the RN/LPNs for Medication Techs. All 30 day competency evaluations to be submitted to Administrator upon completion. Additional classes on Oregon Care Partners will be added to 30 day Competency Evaluation for : role of service plans, Assistance with Activities of daily living, changes assosicated with normal aging, Identifying changes of condition, General food safety, First Aid/CPR, Communication, and Medication Management for Medication Techs.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. 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 ensure fire drills were conducted at least every other month in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: Six months of facility fire drill and fire and life safety records from 10/2025 through 03/2026 were reviewed on 04/28/26 and revealed the facility lacked documented evidence fire drills were conducted at least every other month and fire and life safety instruction was provided to staff on alternate months of fire drills. On 04/28/26 at 4:15 pm, Staff 1 (Administrator) confirmed the facility had not conducted fire drills or provided fire and life safety instruction to staff as required. The need to ensure fire drills were conducted and recorded at least every other month and fire and life safety instruction was provided to staff on alternate months of fire drills, per OFC was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 1:35 pm. They acknowledged the findings

Oregon Care Partners class Fire, Safety, and Emergency Preparedness assigned to all staff, direct and non direct carestaff for completion with review by Administrator by 5/31/2026. Fire Drill plan for the rest of the year reviewed with Director of Plant Operations and Administrator. Topics of instruction plan for the rest of the year reviewed with Director of Plan Operations and Administrator. Fire Drill Plan: May 28,2026 (Day Shift), July 22, 2026 (Day Shift), September 23,2026 (NOC shift), November 18,2026 (Swing shift). Fire Life Safety Discussions: June 24,2026 (Power Outage), August 26,2026 (Water/Sewer), October 21,2026 (Gas), December 16,2026 (Active Shooter).

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 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. Findings include, but are not limited to: Documentation of the facility’s emergency preparedness plan including evidence that a drill of the plan was conducted at least twice a year was requested on 04/29/26 at 1:50 pm. There was no documented evidence the facility conducted a drill of the plan at least twice a year. Staff 1 (Administrator) confirmed at the same time the facility was not conducting a drill of the plan at least twice a year. The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required was discussed with Staff 1 (Administrator), Staff 2 (Deputy Administrator), and Staff 3 (RN) on 04/30/26 at 1:35 pm. They acknowledged the findings.

Tabletop excercise conducted by Administrator and Plant Operations Director, Director of Resident Services, Deputy Administrator, Maintenance team on 05/15/2026 to review facility emergency preparedness plan. Evaucation Drill scheduled for 6/3/2026 for all staff response training. Evacuation Drill will be conducted by Plan of Operations Director and Administrator to review staff response and proper staff evacuation protocol of residents. Review of Evacuation Drill with staff will be conducted June 24,2026.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the exterior pathways and access to the ALF's common use areas were maintained in good repair. Findings include, but are not limited to: The facility courtyards and sidewalks were observed on 04/28/26 at 9:30 am and the following was identified: Drop-offs of approximately two to three-and-a-half inches in height along sidewalks that were not edged with grass around the community, including both circular courtyards. The need to ensure the exterior pathways and accesses to the facility common use areas was discussed with Staff 1 (Administrator) and Staff 2 (Deputy Administrator) on 04/29/26. The findings were acknowledged.

Facility courtyard and walkways reviewed by Plant Operations Director and Administrator on 05/04/2026. Discussions to fill with dirt and bark dust along the areas of the walkways and courtyard not lined with grass. Area(s) of concern to be filled in by 05/29/2026 by Maintenance team. Administrator and Plant Operastions Director and Administrator will walk the courtyards and walkways of the facility once a month to assess any further need of areas to be filled in.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: