Print Inspection: RL012991

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2019 with diagnoses including type II diabetes mellitus and a non-pressure chronic ulcer. The resident’s clinical record, dated 04/13/26 through 07/13/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: a. The resident’s service plan did not provide clear direction to staff in the following areas: * Assistance with laundry, showering, evacuation, and transfers; * Preferred name; * Lower extremity wounds; * Hoarding, including cleaning chemicals; * Use of urinals at bedside; and * Vision, including increased difficulty reading the menu. b. The resident’s service plan was not reflective of the resident’s current status related to his/her current weight. The need to ensure service plans were reflective of residents' status and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Associate ED) and Staff 3 (RN/Health and Wellness Director) on 07/15/26 at 2:00 pm. 2. Resident 4 was admitted to the facility in 04/2025 with diagnoses including type II diabetes mellitus and leukemia. The resident’s clinical record, dated 04/13/26 through 07/13/26, was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: a. The resident’s service plan did not provide clear direction to staff in the following areas: * Bowel incontinence, including use of briefs and preference for frequent checks versus calling for assistance; * Ambulation with four-wheeled walker in his/her apartment; * Activity preferences; * Providing assistance with showering; * Wheelchair cushion and cleaning; * Evacuation assistance; and * Incontinence pad placement. b. The resident’s service plan was not reflective of the resident’s current status in the following areas: * Current medications; and * Skin condition. The need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Associate ED) and Staff 3 (RN/Health and Wellness Director) on 07/15/26 at 2:00 pm. 3. Resident 3 was admitted to the facility in 01/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 04/20/26 through 07/13/26 clinical record was reviewed, and staff and the resident were interviewed. The 07/08/26 service plan was not reflective and did not provide clear direction to staff regarding delivery of services in the following areas: * Transfer assistance; and * Toileting assistance. In an interview with Staff 16 (CG/MT) on 07/15/26 at 11:58 am, she reported the resident frequently refused assistance, so staff were not assisting with every transfer. The need to ensure the service plan was reflective of the resident’s current status and care needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (RN, Health and Wellness Director) on 07/15/26 at 1:30 pm. They acknowledged the findings.

1. . The service plans and assessments for Residents #1, #3 and #4 were updated to reflect their current needs. For Resident #1 there were updates to: - Assistance with laundry, showering, evacuation, and transfers; - Preferred name; - Lower extremity wounds; - Hoarding, including cleaning chemicals; - Use of urinals at bedside; and - Vision, including increased difficulty reading the menu. For Resident #2, there were updates to: - Bowel incontinence, including use of briefs and preference for frequent checks versus calling for assistance; - Ambulation with four-wheeled walker in his/her apartment; - Activity preferences; - Providing assistance with showering; - Wheelchair cushion and cleaning; - Evacuation assistance; and - Incontinence pad placement. - Current medications; and - Skin condition. For #4, there were updates to: - Transfer assistance; and - Toileting assistance. 2. Clinical associates were re-educated by the Associate Executive Director on 8/1/, 2026 regarding the need to review each service area to identify the current resident needs and staff direction. Clinical associates will also be re-educated on the community's overall service assessment and service plan policies. 3. For the next thirty days, the Health and Wellness Director or designee will review two service plans and two service assessments each week to confirm that the plan and assessment are consistent with current care needs and provide clear directions to associates on the delivery of care and services. 4. Health and Wellness Director, Executive Director, and Associate Executive Director

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved for 2 of 3 sampled residents (#s 2 and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 09/2024 with a diagnosis of anemia. The resident’s clinical record, dated 04/14/26 through 07/13/26, was reviewed, and staff and resident’s spouse were interviewed. The following was identified: a. On 05/05/26, the resident was identified to have “redness to the lower back, above and on buttock, not open.” On 05/07/26, there was documentation the alert was closed for sore on buttock, and the alert was moved to the licensed nurse skin tracker to follow until resolved. However, there was no documented evidence of monitoring the skin condition at least weekly through resolution after 05/07/26. b. On 06/29/26, the resident was placed on “Alert for bed sores. Resident is starting 4 new bed sores to buttocks, monitor for any [complaint of] pain, or discomfort.” On 07/10/26, there was documentation the alert was closed for wounds to the bilateral buttocks and was moved to the skin program to be followed by the licensed nurse until resolved. During an interview on 07/14/26 at 10:07 am, Staff 3 (RN, Health and Wellness Director) confirmed she was unable to locate the licensed nurse skin tracker for either short-term change of condition for Resident 5. Additionally, Resident’s 5 skin was observed, and she confirmed the resident had no open areas to the low back or buttocks. The need to ensure monitoring of short-term changes of condition occurred at least weekly through resolution was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 on 07/15/26 at 1:40 pm. 2. Resident 4 was admitted to the facility in 04/2025 with diagnoses including type II diabetes mellitus and leukemia. The resident’s clinical record, dated 04/13/26 through 07/13/26, was reviewed, and staff and the resident were interviewed. The following was identified: a. On 05/07/26, the resident’s medications finasteride (for prostate health) and allopurinol (for kidney stones) were discontinued. There was no documented evidence of instructions or interventions determined and communicated to staff on all shifts or monitoring of the change through resolution. b. The resident returned to the facility from the hospital on 05/01/26 and was utilizing continuous oxygen at 3 liters per minute. On 05/12/26, the resident stated s/he no longer wished to use oxygen and wanted it to be removed from his/her room. The resident’s hospice RN and Staff 3 (RN, Health and Wellness Director) documented agreement with this plan. There was no documented evidence of instructions or interventions determined and communicated to staff on all shifts or monitoring of the change through resolution. c. On 05/12/26 the resident was identified to have a red rash in his/her “folds.” There was no documented evidence of monitoring the skin condition at least weekly through resolution. d. On 05/12/26, the resident was identified to have a small open wound on his/her peri-area. There was no documented evidence of monitoring the skin condition at least weekly through resolution. e. On 06/17/26, the resident was identified to have a “red area with cyst like lump” on his/her bottom, with a note on 06/19/26 stating the redness appeared to be worsening. There was no documented evidence of monitoring the skin condition at least weekly through resolution. The need to ensure there was documented evidence of instructions or interventions determined and communicated to staff on all shifts for short-term changes of condition and monitoring of the changes at least weekly through resolution was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 on 07/15/26 at 2:00 pm.

1. The community is unable to correct the rule violation for Residents #2 and #3 because the skin conditions have resolved. The Health and Wellness Director or designee will complete a skin assessment for Residents #2 and #3 during the week of August 10th to confirm that each resident's skin is currently intact. 2. Clinical associates will be re-educated by the District Director of Clinical Services on the community's policy regarding the tracking of open areas, temporary service plans, and changes in conditioned. All 3rd party notes will be reviewed to ensure all changes have been captured and TSP have been written and placed for staff to be alerted. Any missing TSPs will be written and distributed. 3. Third party provider notes and temporary service plans will be reviewed weekly by the Health and Wellness Director or designee. The Health and Wellness Director or designee will observe residents receiving wound care treatments weekly. 4. Executive Director and Health and Wellness Director.

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(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure management or a licensed nurse were notified of the services provided by the outside provider to ensure that staff were informed of new interventions, adjusted the service plan if necessary, and ensured reporting protocols were in place for 2 of 3 sampled residents (#s 4 and 5) who received outside services. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 09/2024 with a diagnosis of anemia. The resident’s clinical record, dated 04/14/26 through 07/13/26, was reviewed, and staff were interviewed. The following was identified: Between 04/14/26 and 07/13/26, the facility had documented evidence of four communication notes from hospice. There was no documented evidence of coordinating care with hospice care providers, including receiving potential recommendations and informing staff of new interventions, between 04/27/26 and 07/06/26. In an interview on 07/15/26 at 8:40 am, Staff 3 (RN, Health and Wellness Director) confirmed Resident 5 received hospice services approximately once weekly each from the nurse and bath aide. However, she was unable to find any documentation of communication or coordination of services between 04/27/26 and 07/06/26. The need to coordinate care with outside providers and ensure staff were informed of new interventions if necessary was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (RN, Health and Wellness Director) on 07/15/26 at 1:40 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 04/2025 with diagnoses including type II diabetes mellitus and leukemia. The resident’s clinical record, dated 04/13/26 through 07/13/26, was reviewed, and staff were interviewed. The following was identified: The resident returned to the facility from the hospital on 05/01/26 newly admitted to hospice services. Hospice was scheduled to have a nurse on-site with the resident a minimum of one time per week, and a bath aide twice per week, for a minimum of three visits per week. Between 06/19/26 and 07/13/26, the facility had documented evidence of only one communication with hospice. At 1:55 pm on 7/15/26 Staff 3 (RN/Health and Wellness Director) confirmed hospice had continued to visit and treat the resident during the identified time frame, but she was unable to find any documentation of communication or coordination of services. The need to coordinate on-site health services with outside service providers and ensure facility management or a licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 on 07/15/26 at 2:00 pm.

1. Third party providers for Resident #4 and #5 were contacted and the notes from this time period have been obtained and reviewed. Any changes were captured and care planned as needed. 2. Third party binder has been created to keep track of residents receiving services from an outside provider. The third party binder will be reviewed by the Health and Wellness Director weekly to identify any missing notes. Weekly nursing notes will be written to demonstrate coordination of care. 3. Weekly. 4 Execuitve Director and Helath and Welness Director.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 3 and 4) reviewed with medications the facility was responsible for administering. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including type II diabetes mellitus and leukemia. The resident’s clinical record, dated 04/13/26 through 07/13/26, was reviewed, and staff were interviewed. The following was identified: a. The facility did not have documented evidence of a signed physician’s order for the following medications which were listed on the resident’s MAR: * Docusate Sodium 100 mg, one capsule daily as needed (for constipation); * Guaifenesin 600 mg, one tablet every 12 hours as needed (for cough, congestion, and thick respiratory secretion); * Loperamide 2 mg as needed (for loose stools); and * Tylenol 500 mg, one tablet every 6 hours as needed (for pain). b. There were signed physician’s orders for the following medications, but they were not on the resident’s MAR and had not been made available to the resident: * Magnesium citrate solution, 296 ml daily as needed (for constipation); and * Ventolin inhaler 90mcg, two puffs every two hours as needed (for shortness of breath or mild respiratory distress). On 07/15/26 at 12:42 pm, Staff 3 (RN/Health and Wellness Director) confirmed the medications were not available in the medication cart. c. The resident had a signed order for benzonatate, 100 mg, one capsule every eight hours as needed (for cough). The facility instructed staff the medication could be administered every six hours. d. The resident had a signed order for ondansetron, 4 mg, one tablet every six hours as needed (for nausea). The facility instructed staff the medication could be administered every four hours. The need to ensure the facility had signed physician’s orders for all medications and treatments it was responsible for administering, and medication orders were carried out as prescribed, was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 on 07/15/26 at 2:00 pm. 2. Resident 3 was admitted to the facility in 01/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 06/01/26 through 07/13/26 MARs and physician orders were reviewed, and the following was identified: The resident had an order for ondansetron 4 mg every six hours as needed for nausea and vomiting. The order on the MAR indicated 4 mg every four hours as needed. The resident was administered the medication one time on 07/07/26. The need to ensure physician orders were carried out as written was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (RN, Health and Wellness Director) on 07/15/26 at 1:30 pm. They acknowledged the findings.

1. A review of the MAR and physician's orders for Residents #4 and #3 was conducted on 7/17/26. Physician orders were obtained as needed and the residents' MARs were updated. 2. A review of the MAR and Physician's Order will be conducted for existing residents by 8/26, 2026 to confirm there is a physician's order for each medication to be given. A physician's order will be obtained if one is not currently present. 3. New orders will be checked by the Health and Wellness Director or designee daily through triple-check process. Physician Orders will be reviewed and submitted for verification quarterly during scheduled evaluations. 4. Executive Director and Health and Wellness Director.

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 accurate and had resident-specific parameters and instructions for PRN medications for 3 of 3 sampled residents (#s 3, 4, and 5) whose medications were administered by the facility. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 09/2024 with a diagnosis of anemia. The resident's 06/01/26 through 07/13/26 MARs and physician's orders were reviewed. The following was identified: a. The resident had three PRN medications for pain which did not have specific parameters and instructions for administration: * Hydrocodone-acetaminophen 10-325 mg, 0.5 tablet every four hours; * Acetaminophen 500 mg, two tablets every four hours; and * Morphine sulfate 15 mg, 0.5 tablet every 1 hour as needed for pain and shortness of breath. b. The resident had two PRN medications for constipation which had conflicting parameters and instructions for administration: * GlycoLax oral powder 17 grams, one scoop by mouth every 24 hours as needed for constipation if no bowel movement in three days; and * Bisacodyl rectal suppository 10 mg, administer one suppository on day three of no bowel movement. During an interview on 07/14/26, Staff 4 (RCC) confirmed the electronic MAR system did not have parameters on which medication should be administered and in what order listed for staff for the pain medication, and staff would have to verify with the nurse which PRN constipation medication to use first prior to administration. The need to ensure the resident's MAR included resident-specific parameters and staff instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (RN, Health and Wellness Director) on 07/15/26 at 1:40 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 04/2025 with diagnoses including type II diabetes mellitus and leukemia. The resident’s clinical record, dated 04/13/26 through 07/13/26, was reviewed, and staff were interviewed. The following was identified: a. The resident had four PRN medications for pain which did not have specific parameters and instructions for administration: * Oxycodone 5 mg, one tablet every two hours; * Acetaminophen 325 mg, two tablets every four hours; * Acetaminophen 650 mg suppository every six hours; and * Tylenol Extra Strength 500 mg, one tablet every six hours. b. The resident had three PRN medications for a cough which did not have specific parameters and instructions for administration: * Benzonatate 100 mg, one capsule every six hours; * Guaifenesin 600 mg, one tablet every 12 hours; and * Guaifenesin 100 mg/5ml oral solution, 20 ml every six hours. c. The resident had two PRN medications for respiratory secretions which did not have specific parameters and instructions for administration: * Glycopyrrolate 1 mg, one tablet every 8 hours; and * Guaifenesin 600 mg, one tablet every 12 hours. d. The resident had two PRN medications for dyspnea which did not have specific parameters and instructions for administration: * Oxycodone 5 mg, one tablet every two hours; and * Lorazepam 0.5 mg, one tablet every two hours. e. The resident had four PRN medications for constipation which did not have specific parameters and instructions for administration: * Bisacodyl suppository, one every 24 hours; * Docusate sodium 100 mg, one capsule daily; * Polyethylene Glycol 3350 powder, one packet every 24 hours; and * Senna 8.6 mg, two tablets every 24 hours. f. The MAR lacked information related to dose and/or frequency for the following medications: * Bisacodyl suppository (for constipation); and * Fluticasone propionate 50 mcg/act (for allergic rhinitis). The need to ensure PRN medications included resident-specific parameters and instructions for administration and the MAR included the dosage was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (RN, Health and Wellness Director) on 07/15/26 at 2:00 pm. 3. Resident 3 was admitted to the facility in 01/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 07/01/26 through 07/13/26 MARs and physician orders were viewed. The resident had the following PRN medications for bowel care: * Bisacodyl rectal suppository once every 24 hours as needed for constipation; * Polyethylene Glycol once every 24 hours as needed for constipation; and * Senna once every 24 hours as needed for constipation. There were no instructions to staff regarding the sequential order of administration for these PRN bowel care medications. The need to have resident-specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (RN, Health and Wellness Director) on 07/15/26 at 1:30 pm. They acknowledged the findings.

1. The parameters for any PRN medication have been updated by the Health and Wellness Director or designee for Residents #3, #4 and #5. 2. These parameters for PRN medications will be obtained and verified at the time the order is entered and at daily triple-check process. Orders will also be reviewed for the appropriate parameters at quarterly Physician Order reviews. 3. For the next 90 days, the Health and Wellness Director will review new orders weekly to verify that the parameters for any PRN medications are present. 4. Executive Director and Health and Wellness Director.

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 411-054-0090 (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 according to Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records, dated 02/2026 through 06/2026, were reviewed, and the following was identified: a. Unannounced fire drills were not conducted and recorded every other month at different times of the day, evening, and night shifts. b. Written fire drill records lacked comments relating to residents who resisted or failed to participate in the drills. During an interview on 07/14/26 at 1:45 pm, Staff 7 (Maintenance Manager) confirmed there were fire blankets available on each stairwell on the second floor. However, she acknowledged the staff had not been trained on how to use the blankets to transfer residents who required assistance to navigate the stairs from the second floor to the first floor in the event of a fire. The need to ensure fire drills were conducted according to the Oregon Fire Code, with all required components documented, was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (RN, Health and Wellness Director) on 07/15/26 at 1:40 pm. They acknowledged the findings.

1.here were no residents impacted by the alleged violations. Fire drills were conducted on the three shifts. 2. Separate section of fire drill binder for AL and MC created as well as separate tasks in electronic maintenance queue. Fire drills will be executed on the three shifts quarterly. The Fire Drill Report will be updated to include, at a minimum, the following elements: Date and time of day; Location of simulated fire origin; The escape route used; Problems encountered and comments relating to residents who resisted or failed to participate in the drills; Evacuation time-period needed; Staff members on duty and participating; and Number of occupants evacuated. 3. The fire drill binder will be reviewed monthly by the ED to verify that fire drills have been completed in accordance with community policy and Oregon rules. 4. Maintenance Manager, Exectuive Director, Associate Executive Director.

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 411-054-0300 (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 exterior pathways were maintained in good repair, toxic materials were in locked storage, and all garbage was stored in covered refuse containers. Findings include, but are not limited to: The facility was toured on 07/15/26 at 1:00 pm, and the following was observed: * Multiple drop-offs of 2 to 4 inches were noted along the courtyard pathway; * Multiple areas of pathway near a courtyard fountain were slick with water and algae; * Three five-gallon propane tanks were placed near the courtyard pathway; * An uncovered oil drum was present at the rear of the building and filled with used cooking oil; and * Two large refuse containers in the courtyard were uncovered. The need to ensure exterior pathways were maintained in good repair, toxic materials had locked storage, and all garbage was stored in covered refuse containers was reviewed during a walk-through of the facility grounds with Staff 1 (ED) and Staff 7 (Maintenance Manager) on 07/14/26 at 2:15 pm. They acknowledged the findings.

1. The following immediate corrections were made on 7/16/26: - Sidealk drop-offs have been leveled with soil - Fountain was adjusted to not splash on sidewalk and algae was scrubbed off. - Propane tanks were moved to safe storage in Maintenance office - Lid was installed on grease barrel in dumpster enclosure. 2. The following preventative measures will be taken: - TELS task was created for monthly check for drop-off level. TELs task has been created to check sidewalk near fountain for algaem monthly. Propane tanks will be stored in locked cabinet. Lid check will be added to weekly dumpster area walk-through. 3. this will be evaluated monthly. 4. Executive Director and Maintenance Manager

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:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all materials and surfaces and all equipment necessary for the health, safety, and comfort of residents were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 07/13/26 at 1:00 pm, and the following was observed: a. First floor: *Black and gray carpet stains at the facility entrance, sitting room, and in front of the elevator; *Love seat and armchair near 119 had worn and stained upholstery; *Double doors and the single door leading from the dining room to the courtyard were not in working order; *Dining room kitchenette had significant debris, build-up, and/or staining near cereal dispensers, juice machine, inside/outside of the cabinets, and on glass storage surfaces; *Dining room chairs had significant debris build-up and scuffing; and *Room 114 had extensive build-up of dust and debris on the heating/cooling unit, large black and brown carpet stains, spider webs and black debris in/on the light above the bed, and large areas of mineral build-up on the toilet. b. Courtyard: *Black tablecloth with staining and debris; *Two large grills with debris build-up on cooking surfaces and exterior surfaces; and *Three picnic tables with uncleanable surfaces with exposed wood. c. Second floor: *Black and brown carpet stains on the stairs, in front of the elevator, and carpet along the staircase and top of the staircase in front of the elevator; *Staining inside cabinets in the laundry room; and *Room 220 had black carpet stains. The need to ensure all materials and surfaces and all equipment necessary for the health, safety, and comfort of residents were kept clean and in good repair was reviewed during a walkthrough of the facility grounds with Staff 1 (ED) and Staff 7 (Maintenance Manager) on 07/14/26 at 2:15 pm. They acknowledged the findings.

1. The following immediate corrections were made on 7/16/26: - Weekly carpet cleaning. - The stained furniture was removed. -Dining room kitchenette was cleaned - AL114 was deep cleaned. - Courtyard furniture with rough surfaces were covered. - Courtyard trash cans with missing lids were removed. - 2nd floor laundry room cabinets were cleaned. - AL220 carpet was shampooed. 2. The following preventative measures will be taken: - Furniture stain checks will be added to weekly walk throughs. - Carpet in lobby will be checked weekly and cleaned as needed. - Housekeepers have been re-educated on reporting housekeeping refusals to Maintenance Manager or ED - Courtyard furniture added to weekly walk throughs -Laundry room cabinets added to housekeeping schedule. - Housekeepers re-educated on reporting carpet stains to Maintenance Manager or ED. 3. Monthly for the next 90 days. 4. Executive Director and Maintenance Manager

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: