Print Inspection: RL013277

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#6) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The move-in evaluation was reviewed and lacked the following required elements: * Customary routines, including bathing; * Spiritual and cultural traditions; * Presence of thought disorders, behavioral or mood problems; * Personality, including how a person copes with change or challenging situations; * Ability to understand and be understood; * Pharmaceutical and non-pharmaceutical interventions for pain; and * Nutritional habits, including fluid preferences and weight if indicated. The need to ensure move-in evaluations addressed all required elements was reviewed with Staff 1 (Administrator) on 07/30/26 at 1:39 pm. She acknowledged the findings.

1. Level of care evaluation has been updated for resident 6 to address all required components in OAR with detailed and personalized information for the resident. 2. To prevent recurrence a training has been scheduled with all staff who complete initial evaluations to review the process for completing the evaluation using our tool which includes all required elements. Initial evaluations will be reviewed prior to a resident moving in to ensure that all elements have been addressed and are personalized for the resident. To further ensure compliance, a move in audit will be completed for all new residents within a week of admission to verify that all elements have been addressed. 3. This system will be reviewed at the time of move in with the initial evaluation, within a week of move in with the audit, at 30 days, and quarterly thereafter as evaluations are updated. 4. The Executive Director and Licensed Nurses will be responsible for maintaining this system.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move in evaluations addressed all required elements for 1 of 1 sampled resident (#6) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The move-in evaluation was reviewed and lacked the following required elements: * Customary routines including bathing; * Spiritual and cultural traditions; * Presence of thought disorders, behavioral or mood problems; * Personality including how a person copes with change or challenging situations; * Ability to understand and be understood; * Pharmaceutical and non-pharmaceutical interventions for pain; and * Nutritional habits, including fluid preferences and weight if indicated. The need to ensure move-in evaluations addressed all required elements was reviewed with Staff 1 (Administrator) on 07/30/26 at 1:39 pm. She acknowledged the findings.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 4 of 6 sampled residents (#s 1, 2, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the assisted living facility in 12/2025 with diagnoses including chronic obstructive pulmonary disease and type 2 diabetes. Observations of the resident, interviews with staff and review of the service plan, dated 07/22/26, and subsequent interim service plans (ISPs) were completed during the survey. Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Inaccuracy regarding the resident’s ability to ambulate with a walker; * Instructions regarding the resident’s use of an electric wheelchair, how staff should assist with keeping the device charged, and to whom malfunctions should be reported; * Instructions for staff on the resident’s chronic pain treatments and how s/he expressed pain; * Instructions on signs and symptoms of depression to report while on anti-depression therapy; * Instructions for staff on signs and symptoms of a specific skin condition, and to whom they should be reported; * Inaccurate information regarding the number of staff required to assist the resident with evacuation; * Instructions for staff as to how the side rails were to be used, monitored for safety, and to whom any malfunctions should be reported; and * Instructions to staff on how to assist the resident to and from his/her vehicle with his/her electric wheelchair when Resident 2 left the facility. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) on 07/30/26 at 1:05 pm. She acknowledged the findings. 2. Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The resident’s clinical record was reviewed, including the 06/18/26 service plan, observations were made, and interviews were conducted. During the survey, Resident 6 was observed to have an oxygen concentrator in his/her room and a CPAP machine next to his/her bed. The service plan was not reflective of the residents’ current care needs and/or was not implemented in the following areas: * Instruction regarding the resident’s hallucinations; * Instruction related to the resident’s oxygen use at night; * Instruction related to the resident’s continuous positive airway pressure machine; and * Instruction regarding evacuation assistance, including number of staff required. The need to ensure resident service plans were reflective of current care needs and were implemented was reviewed with Staff 1 (Administrator) on 07/30/26 at 1:39 pm. She acknowledged the findings. 3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy. Observations of the resident’s apartment, interviews with the resident and staff and review of the resident's most recent service plan dated 07/22/26, and interim service plans showed the service plan did not provide clear direction to staff and/or was not reflective of the resident's use of an alternating pressure mattress. The need to ensure service plans were reflective of the resident's current use of assistive devices and provided clear direction to staff was discussed with Staff 1 (ED) on 07/29/26 at 2:10 pm. She acknowledged the findings. 4. Resident 4 was admitted to the facility in 10/2023 with diagnoses including Parkinson’s disease. Observations of the resident, interviews with resident and staff, review of the resident's service plan, dated 07/13/26, and signed physician’s order dated 06/25/26 were completed. The resident's service plan was not reflective and did not provide clear instruction to staff regarding meal assistance and the need to cut the resident’s food into bite sized pieces. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) on 07/29/26 at 2:10 pm. She acknowledged the findings.

1. Service plans for residents 1, 2, 4, 6 have been updated to include all required components and to reflect resident's current care needs, including clear directions to staff regarding the delivery of services and have been printed for staff to review. 2. To prevent recurrence, all current resident service plans will be audited for accuracy. A form has been implemented for care staff to document any discrepancies between resident service plans and actual care needs and/or preferences. Form will be turned into RCC so that service plans can be updated. All staff will be reeducated on the importance of service plans including detailed instructions and resident preferences. 3. Service plans will be evaluated and reviewed upon admission, at 30 days, quarterly and with significant change of condition. 4. The Executive Director and Licensed Nurses will be responsible for maintaining this system.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 4 of 6 sampled residents (#s 1, 2, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the assisted living facility in 12/2025 with diagnoses including chronic obstructive pulmonary disease and type 2 diabetes. Observations of the resident, interviews with staff and review of the service plan, dated 07/22/26, and subsequent interim service plans (ISPs) were completed during the survey. Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Inaccuracy regarding the resident’s ability to ambulate with a walker; * Instructions regarding the resident’s use of an electric wheelchair, how staff should assist with keeping the device charged, and to whom malfunctions should be reported; * Instructions for staff on the resident’s chronic pain treatments and how s/he expressed pain; * Instructions on signs and symptoms of depression to report while on anti-depression therapy; * Instructions for staff on signs and symptoms of a specific skin condition, and to whom they should be reported; * Inaccurate information regarding the number of staff required to assist the resident with evacuation; * Instructions for staff as to how the side rails were to be used, monitored for safety, and to whom any malfunctions should be reported; and * Instructions to staff on how to assist the resident to and from his/her vehicle with his/her electric wheelchair when Resident 2 left the facility. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) on 07/30/26 at 1:05 pm. She acknowledged the findings. 2. Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The residents clinical record was reviewed, including the service plan, dated 06/18/26, observations were made, and interviews were conducted. During the survey, Resident 6 was observed to have an oxygen concentrator in his/her room and a CPAP machine next to his/her bed. The service plan was not reflective of the residents’ current care needs and/or was not implemented in the following areas: * Instruction regarding the resident’s hallucinations; * Instruction related to the resident’s oxygen use at night; * Instruction related to the resident’s continuous positive airway pressure machine; and * Instruction regarding evacuation assistance, including number of staff. On 07/28/26 at 10:58 am, Resident 6 reported s/he would hallucinate at times and was not sure what s/he could eat with his/her diet restrictions. The need to ensure resident service plans were reflective of current care needs and were implemented was reviewed with Staff 1 (Administrator) on 07/30/26 at 1:39 pm. She acknowledged the findings. 3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy. Observations of the resident’s apartment, interviews with the resident and staff and review of the resident's most recent service plan dated 07/22/26, and interim service plans showed the service plan did not provide clear direction to staff and/or was not reflective of the resident's use of an alternating pressure mattress. The need to ensure service plans were reflective of the resident's current use of assistive devices and provided clear direction to staff was discussed with Staff 1 (ED) on 07/29/26 at 2:10 pm. She acknowledged the findings. 4. Resident 4 was admitted to the facility in 10/2023 with diagnoses including Parkinson’s disease. Observations of the resident, interviews with resident and staff, review of the resident's service plan, dated 07/13/26, and signed physician’s order dated 06/25/26 were completed. The resident's service plan was not reflective and did not provide clear instruction to staff regarding meal assistance and the need to cut the resident’s food into bite sized pieces. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) on 07/29/26 at 2:10 pm. She acknowledged the findings.

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, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition and ensure weekly progress was noted until the condition was resolved and failed to refer significant changes of condition to the facility nurse for 2 of 6 sampled residents (#s 3 and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 02/2026 with diagnoses including dementia and type 2 diabetes. Resident 3’s clinical records from 04/27/26 through 07/26/26 and current service plan, dated 04/27/26, were reviewed. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan for the following change of condition: * A progress note dated 06/24/26 by a visiting nurse practitioner reported Resident 3 had an overall decline, with word finding difficulty, poor oral intake and an increase in ADL assistance. It was also reported this decline was likely to be a new baseline for Resident 3. In an interview on 07/28/26 at 9:55 am, Staff 1 (ED) stated the nurse practitioner’s report was missed and Resident 3’s change of condition was not referred to the facility RN. The need to determine, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition and ensure weekly progress was noted through resolution was discussed with Staff 1 on 07/29/26 at 2:05 pm. She acknowledged the findings. 2. Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The resident’s clinical record, including the 06/18/26 service plan, was reviewed. There was no documented evidence the facility documented the following changes of condition, determined actions or interventions, communicated actions or interventions to staff, and/or monitored the following changes through resolution: a. On 06/01/26, the resident experienced a skin tear to their left knee. There was no documented evidence the facility documented the skin tear, determined actions or interventions, communicated those actions or interventions to staff, or monitored the injury through resolution. On 07/30/26 at 1:30 pm, Staff 1 (Administrator) confirmed the resident had a skin tear and there was no additional documentation. b. On 06/17/26, the resident experienced a significant weight gain and there was not consistent documentation the resident's condition was monitored consistent with his/her evaluated needs. c. On 06/26/26, the facility received physician orders with changes to the resident’s diet, including daily protein intake, fluid restrictions, and sodium restrictions. There was no documented evidence the facility monitored these changes through resolution. On 07/29/26 at 9:32 am, Staff 1 (Administrator) confirmed the facility did not monitor the resident’s protein intake or restrict fluids or sodium. d. On 7/16/26, the resident returned to the facility from the hospital. There was no documented evidence the facility communicated the resident’s return with determined actions and interventions, or was monitored through resolution. On 07/30/26 at 1:30 pm, Staff 1 (Administrator) confirmed there was no additional documentation related to the resident’s return from the hospital. The need to ensure the facility determined, documented, and communicated to staff what actions or interventions were needed for the resident following a change of condition, and ensure weekly progress was noted through resolution, was reviewed with Staff 1 and Staff 3 (Director of Health Services/RN) on 07/30/26 at 1:45 pm. They acknowledged the findings.

1. Change of condition assessments for residents 3 and 6 were completed and updated by RN. Service plans have been updated and interventions have been reviewed for effectiveness. Service plan includes clear direction to direct care staff on current interventions. 2. To prevent recurrence, staff will be reeducated on our alert charting guidelines, when to notify the LN/RN and providing resident-specific interventions to staff when a change of condition has been identified. 24 hour summary will be reviewed five days a week as part of daily standup meeting, which includes a review of any documentation in the past 24 hours to identify any changes of condition. On Mondays the 72 hour summary will be reviewed to include all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will trigger a LN assessment. Resident specific interventions will be implemented as necessary. The change of condition will be monitored until resolved or new baseline is determined and interventions will be monitored for efficacy and updated as needed. 3. This system will be evaluated five days a week as part of stand up meeting and as needed when a change of condition occurs. 4. The Executive Director and Licensed Nurses will be responsible for maintaining this system.

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, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition and ensure weekly progress was noted until the condition was resolved and failed to refer significant changes of condition to the facility nurse for 2 of 6 sampled residents (#s 3 and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 02/2026 with diagnoses including dementia and type 2 diabetes. Resident 3’s clinical records from 04/27/26 through 07/26/26 and current service plan, dated 04/27/26, were reviewed. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan for the following change of condition: * A progress note dated 06/24/26 by a visiting nurse practitioner reported Resident 3 had an overall decline, with word finding difficulty, poor oral intake and an increase in ADL assistance. It was also reported this decline was likely to be a new baseline for Resident 3. In an interview on 07/28/26 at 9:55 am, Staff 1 (ED) stated the nurse practitioner’s report was missed and Resident 3’s change of condition was not referred to the facility RN. The need to determine, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition and ensure weekly progress was noted through resolution was discussed with Staff 1 on 07/29/26 at 2:05 pm. She acknowledged the findings. 2. Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The resident’s clinical record, including the current service plan dated 06/18/26, was reviewed. There was no documented evidence the facility documented the following changes of condition, determined actions or interventions, communicated to staff, and/or monitored the following changes through resolution: a. On 06/01/26, the resident experienced a skin tear to their left knee. There was no documented evidence the facility documented the skin tear, determined actions or interventions, communicated those actions or interventions to staff, or monitored the injury through resolution. On 07/30/26 at 1:30 pm, Staff 1 (Administrator) confirmed the resident had a skin tear and there was no additional documentation. b. On 06/17/26, the resident experienced a significant weight gain and there was not consistent documentation the resident's condition was monitored consistent with his/her evaluated needs. c. On 06/26/26, the facility received physician orders with changes to the resident’s diet, including daily protein intake, fluid restrictions, and sodium restrictions. There was no documented evidence the facility monitored these changes through resolution. On 07/29/26 at 9:32 am, Staff 1 (Administrator) confirmed the facility did not monitor the residents protein intake or restrict fluids or sodium. d. On 7/16/26, the resident returned to the facility from the hospital. There was no documented evidence the facility communicated the resident’s return with determined actions and interventions, or was monitored through resolution. On 07/30/26 at 1:30 pm, Staff 1 (Administrator) confirmed there was no additional documentation. The need to ensure the facility determined, documented, and communicated to staff what actions or interventions were needed for the resident following a change of condition, and ensure weekly progress was noted through resolution was reviewed with Staff 1 and Staff 3 (Director of Health Services/RN) on 07/30/26 at 1:45 pm.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed for 1 of 1 sampled resident (#6) who experienced a significant change of condition. Findings include, but are not limited to: Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The resident’s clinical record was reviewed and the following was identified: The resident’s weight was documented as follows: * 05/12/26 – 215.4 pounds; * 05/29/26 – 226.2 pounds; and * 06/17/26 – 226.3 pounds. Between 05/12/26 and 06/17/26, the resident gained 10.9 pounds, or 5.06% of the resident’s total body weight, in one month. This constituted a significant change of condition which required an RN assessment. An RN assessment was completed on 06/25/26, eight days after the significant change of condition was identified and noted “Weight trend indicates gradual gain over the past weeks. Assessment findings are concerning for possible fluid retention.” The need to ensure a timely RN assessment was completed after a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 3 (Director of Health Services/RN) on 07/30/26 at 1:45 pm. They acknowledged the findings.

1. Significant Change of condition assessment for resident 6 has been updated by RN to ensure that all interventions are in place. Service plan has been updated and interventions have been reviewed for effectiveness. Service plan has been updated to include clear direction to direct care staff on current interventions. 2. To prevent recurrence, Executive Director and Licensed Nurses have reviewed the regulations related to signicficant change of condition, including weight parameters and the timeliness for starting the RN assessment. The communities Licensed Nurses will complete the NurseLearn course "Significant change of condition: weight changes" to further understand the expectations. All weights entered in EMR will be reviewed 5 days a week during clinical standup to ensure timely identification of weight changes that trigger for the significant change parameters. Weekly the clinical team will review residents that are on significant change monitoring to ensure appropriate interventions have been implemented and are effective. The change of condition will be monitored weekly until resolution, or it is determined that the resident has established a new baseline. 3. This system will be evaluated five days a week as part of clinical stand up meetings. This system will further be evaluated monthly as part of the community CQI (Continuous Quality Improvement) process which includes a review of all weight exceptions as well as all residents requiring a significant change of condition RN assessment. 4. Executive Director and Licensed Nurses will be responsible for maintaining this system.

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (#6) who had orders for a diuretic medication. This resulted in an unnecessary visit to the emergency department for Resident 6. Findings include, but are not limited to: Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The resident’s clinical record was reviewed, including physician orders and 06/01/26 through 07/27/26 MARs, and interviews with staff and the resident were conducted. The following was identified: The resident moved into the facility with the following signed physician orders, dated 04/29/26: * Torsemide 10 mg, as needed, for weight gain of three pounds overnight or five pounds in a week; and * Daily weights. From 05/12/16 through 05/26/26, the resident’s weight was not documented on six occasions and on 05/26/26, the resident’s weight was 223.7 pounds. On 05/26/26, the resident’s order for torsemide was changed from 10 mg as needed to scheduled 20 mg, to be administered daily for five days and if “weight is greater than 213 pounds, get labs and continue torsemide 20 mg until weight is 213 [pounds]. If not losing weight, please call and I will increase dose.” From 05/26/26 to 06/01/26, five days after the facility received the order, the resident’s documented weight was 224.6 pounds. There was no documented evidence facility staff communicated with the prescriber as ordered. Additionally, the 06/2026 MAR revealed the medication was not administered from 06/01/26 through 06/09/26. On 06/09/26, the resident received a new order for torsemide 20 mg to be administered daily “until weight is down to 213 [pounds] or less.” The 06/2026 MAR indicated the medication was not administered on 06/09/26 or 06/10/26. On 06/25/26, Resident 6’s documented weight was 227.2 pounds. Facility staff notified the prescriber of the resident’s continued weight gain and reports of “feeling [shortness of breath] at times.” On 06/26/26, the facility received the following orders: * “Increase torsemide to 40 mg daily”; * “Fluid restrict to [less than] 2 [liters] total fluid [a] day”; and * “Sodium restrict to [less than] 1500 mg [a] day.” There was no documented evidence the facility followed the fluid restriction or sodium restriction orders. On 07/02/26, the facility received the following orders: * “Increase torsemide to 40 mg daily”; * “Continue daily weights. If weight not decreasing after [three] days, increase torsemide to 60 mg daily. If weight is still not going down, we will initiate IV diuresis at home”; * “Limit fluid to [two liters] daily”; and * “Heart healthy/low sodium diet.” The facility failed to document weights from 07/04/26 to 07/06/26. Per the prescriber order, if the resident’s weight had not decreased by 07/05/26, staff were to increase administration of the torsemide to 60 mg daily. On 07/07/26, facility staff started administering 60 mg a day, two days after the increase was ordered. The facility’s failure to follow physician orders placed the resident at risk for continued weight gain, and on 07/10/26 Resident 6 was admitted to the hospital for weight gain and chronic diastolic heart failure. On 07/15/26, the facility received the following discharge orders which indicated to start administering the new orders on 07/17/26: * Torsemide 80 mg, daily. If blood pressure was less than 100/60 and was not experiencing any swelling/difficulty breathing, staff were ordered to skip the torsemide for one day. From 07/17/26 through 07/27/26, the medication was not administered per physician order on four occasions: * 07/17/26 – the resident received 60 mg of torsemide; * 07/18/26 – 80 mg of torsemide was administered without a documented blood pressure; * 07/19/26 – 40 mg of torsemide was administered without a documented blood pressure and noted the resident refused 40 mg; and * 07/20/26 – 80 mg of torsemide was administered without a documented blood pressure. Additionally, the following orders were not administered as prescribed: * Dietary order for increase in daily protein to 60 grams; * Dietary order for fluid restrictions “[less than] 2L total fluid a day”; * Dietary order for sodium restriction to less than 1500 mg a day; and * Daily weights – weight increase of three pounds overnight or five pounds in one week. On 07/30/26 at 10:13 am, Staff 3 (Director of Health Services/RN) reported she was going to complete a full review of the resident’s orders and MAR to ensure accuracy and review the resident’s current orders with his/her provider. The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 1 and Staff 3 on 07/30/26 at 1:45 pm. They acknowledged the findings. ?

1. Obtained updated physicians orders for resident #6, verified all orders are in place and being followed as ordered by provider. 2. To prevent recurrence, Med Aide meeting will be scheduled to review the importance of following all physician orders, including parameters in place and the need to ask for clarification if orders or parameters are not clearly understood. To further prevent recurrence, the 24/72 hour report will be reviewed daily as part of clinical standup, which includes all eMAR notes written, as well as any weights and vitals documented. A weekly MAR audit will also be completed to identify any missed weights/vitals or medications. A weekly parameter audit will also be completed to ensure all parameters are being followed and that the provider is notified of any concerns. 3. This system will be evaluated weekly with audits and follow up training will be provided if indicated. 4. The Executive Director and Licensed Nurses will be responsible for maintaining this system.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate, including resident-specific parameters and instructions for medications, for 2 of 6 sampled residents (#s 2 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the assisted living facility in 12/2025 with diagnoses including chronic obstructive pulmonary disease and type 2 diabetes. The resident's 07/01/26 through 07/28/26 MAR, “Narcotics Disposition Log,” and physician's orders were reviewed. The following was identified: The resident had orders for PRN oxycodone HCl 5 mg, give one tablet every six hours for pain rated greater than five. The resident was administered the medication 83 times between 07/01/26 and 07/28/26. On eight occasions, the administration was documented in the “Narcotics Disposition Log,” but not on the resident’s MAR. The need to ensure resident MARs were accurate was reviewed with Staff 1 (ED) on 07/30/26 at 1:05 pm. She acknowledged the findings. 2. Resident 6 moved into the facility in 05/2026 with diagnoses including congestive heart failure, kidney failure, and type 2 diabetes. The resident’s clinical record was reviewed, including the 06/01/26 through 07/27/26 MARs and physician orders. The following was identified: a. The following orders were not transcribed accurately to the MAR: * Metoprolol Succinate ER 25 mg, was transcribed as Metoprolol Tartrate 25 mg, and was documented as administered on 46 occasions; * Torsemide 20 mg for five days and if “weight is greater than 213 pounds, get labs and continue torsemide 20 mg until weight is 213 [pounds]. If not losing weight, please call and I will increase dose.” The MAR indicated the medication had not been administered and documented administration of a previous order for Torsemide 20 mg; * An order dated 06/26/26 for Torsemide 40 mg, daily (for chronic diastolic congestive heart failure); and * Torsemide 80 mg, daily. If the resident’s blood pressure was less than 100/60 and s/he was not experiencing any swelling/difficulty breathing, staff were to skip the torsemide for one day. On 07/29/26 at 11:44 am, the above was reviewed with Staff 5 (RCC), and he confirmed several orders were not transcribed accurately or timely. b. The MAR lacked the following orders: * Oxygen as needed; * Continuous positive airway pressure machine (CPAP); * Ondansetron 4 mg, as needed, (for nausea or vomiting); * Increase protein intake to 60 mg, daily; * “Fluid restrict to [less than] 2 [liters] total fluid [a] day”; and * “Sodium restrict to [less than] 1500 mg [a] day.” On 07/27/26 at 12:29 pm, Staff 3 (Director of Health Services/RN) confirmed the above orders were not transcribed to the MAR. The need to ensure the MAR was accurate and included resident-specific parameters was reviewed with Staff 1 (ED) and Staff 3, on 07/30/26 at 1:45 pm. They acknowledged the findings.

1. Physician orders have been reconciled for resident #2 and resident #6 to ensure the MAR is accurate. A complete audit was done to verify that all narcotics given were documented both in the narcotic log book and in the eMAR. 2. To prevent recurrence, Med Aide meeting will be scheduled and will include reeducation on the importance of verifying that narcotics are documented both in the narcotic log book and in the eMAR system. The meeting will also include training on the importance of verifying that the medication name matches exactly what is ordered and what is being administered and that if there are discrepancies, the original order must be reviewed and the discrepancy must be fixed prior to administering the medication. Training will also include the importance of contacting the nurse if any discrepancies are found. To further prevent recurrance, a weekly audit of all narcotics will be completed to ensure they are documented in both places and ongoing education will be provided if indicated. 3. This system will be evaluated weekly with audits and as part of the LN triple check process which occurs Monday through Friday. 4. The Executive Director and Licensed Nurses will be responsible for maintaining this system.

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 at least every other month and fire and life safety instruction was provided to staff on alternate months from the fire drills per the Oregon Fire Code (OFC). Findings include, but are not limited to: Six months of fire and life safety records from 01/2025 through 06/2026 were reviewed on 07/28/26. The following was identified: * The facility lacked documented evidence unannounced fire drills were conducted and recorded every other month; and * The facility lacked documented evidence fire and life safety instruction was provided to staff at least every other month, on alternate months of the fire drills. 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 from fire drills per the OFC was discussed with Staff 1 (ED) on 07/29/26 at 2:10 pm. She acknowledged the findings.

1. Training provided to Maintenance Director on the regulations for fire drills including frequency, alternating shifts and locations, and all required components. Training also included a review of monthly staff inservice topics, including fire and life safety training on alternating months from fire drills. 2. To prevent recurrence, computer program used for scheduling maintenance tasks has been updated to populate fire drills on the necessary months with rotating shifts and locations. Staff inservice schedule will be followed to ensure fire and life safety training is provided on alternating shifts and a sign in sheet will be used to document attendance. 3. Fire drills and Inservice schedule will be reviewed monthly at CQI meetings to ensure schedule is being followed and all components are addressed. 4. Executive Director and Maintenance Director are responsible for maintaining this system.

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 (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 the interior of the facility was clean and maintained in good repair. Findings include, but are not limited to: The interior of the ALF was reviewed during the survey from 07/27/26 through 07/29/26. The following was identified: * Resident rooms 101, 210, 223, and 314 had heavily soiled and/or stained carpets. On 07/29/26 at 10:30 am, a facility walk-through was conducted with Staff 4 (Director of Environmental Services). He acknowledged the findings and stated the resident rooms would be placed on the list for the facility’s monthly carpet cleaning. The need to ensure the interior of the building was maintained in good repair was discussed with Staff 1 (ED) on 07/29/26 at 2:05 pm. She acknowledged the findings.

1. Carpets have been cleaned in resident rooms 101, 210, 223, and 314. 2. To prevent recurrence, a carpet cleaning schedule will be implemented to ensure resident carpets are being cleaned on a rotating basis. To further prevent recurrence, all housekeeping staff will be reeducated on the need to notify the maintenance director if carpets are found to be heavily soiled and/or stained during weekly housekeeping rounds. 3. This system will be evaluated using the environmental evaluation that is completed for every resident apartment on a semi-annual basis. 4. The Executive Director and Maintenance Director will be responsible for maintaining this system.

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: