Print Inspection: RL013720

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and were readily available to staff for 2 of 6 sampled residents (#s 4 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 01/2021 with diagnoses including dementia, major depressive disorder including suicidal attempts and ideation and borderline personality disorder. The resident’s clinical record was reviewed, including the service plan, dated 07/10/26, and the “behavioral support plan” (BSP), dated 06/12/26. Observations of the resident were made and interviews were conducted. a. The BSP noted the resident’s verbal aggression, isolation and mental health, suicidal ideation and suicide attempts at the facility, information related to the resident’s diagnoses with resident-specific triggers and interventions for staff. Additionally, the BSP provided clear direction for crisis procedures and included a resident-specific weekly activity plan. On 08/17/26 at 12:20 pm, observations showed the BSP was in a locked medication room that was not readily available to care staff inside the resident’s clinical record binder. On 08/19/26 at 12:52 pm, Staff 3 (RCC) confirmed the BSP was not with the service plan and was not readily available to caregiving staff. She stated the BSP should be attached to the current service plan and in a location where staff could access it. b. The service plan was not reflective of the residents’ current care needs and/or did not provide clear direction regarding the delivery of services, in the following areas: * Instruction regarding the use of compression stockings; and * Resident-specific bathing instructions. On 08/18/26 at 12:10 pm, Resident 4 reported staff assisted with putting on and taking off his/her compression stockings daily. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were available to staff was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), Staff 3 and Witness 1 (Contract RN) on 08/20/26 at 12:02 pm. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 03/2021 with diagnoses including dementia, epilepsy and chronic renal disease. The resident’s clinical record was reviewed, including the service plan dated 05/14/26. Observations of the resident were made and interviews were conducted. The service plan was not reflective of the resident’s current care needs and/or did not provide clear direction regarding the delivery of services in the following areas: * Information related to the resident’s cannabis use, including clear direction, interventions and ability to smoke safely; * Information about the resident’s fall risk, interventions and instructions for staff; * Information related to the resident’s history of urinary tract infections, including clear directions related to peri-care and frequency of urinary incontinence checks; and * The resident’s dining preference to receive three meals a day in his/her room. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), Staff 3 (RCC) and Witness 1 (Contract RN) on 08/20/26 at 12:21 pm. They acknowledged the findings.

C260 1. What actions will be taken to correct the rule violation for each example/resident? Resident 4 Resident 4's Behavioral Support Plan (BSP) was placed in the Service Plan Binder and is readily accessible to staff. The service plan was updated to include instructions for application of compression stockings. Bathing assistance instructions were added to the service plan. Staff were notified of the updates and instructed to follow the revised service plan. Resident 6 The service plan was updated to include instructions for peri-care assistance. The resident's preference and approved care regarding meals served in the room were added to the service plan. Staff were notified of the updates and instructed to follow the revised service plan. Service plan updated to include documentation regarding cannabis use, ability to smoke safely, staff interventions, and supervision requirements. Service plan updated to reflect current fall risk status, interventions to reduce risk of falls and injuries, and staff instructions for monitoring and assistance. 2. How will the system be corrected so this violation will not happen again? Resident 4 and 6's Service plans and supporting documents will be reviewed upon admission, quarterly, and with any significant change in condition to ensure all care needs, resident preferences, and required supporting documents are accurately reflected and available to staff. A service plan audit process will be implemented to verify completeness, accuracy, and accessibility of resident care information. Any identified deficiencies will be corrected promptly and staff notified of revisions. 3. How often will the area needing correction be evaluated? Service plan audits will be conducted quarterly and whenever there is a significant change in condition, services, or resident preferences. Audit results will be reviewed to ensure ongoing compliance with documentation requirements. 4. Who will be responsible to see that the corrections are completed/monitored? The Wellness Services Director (WSD), will be responsible for ensuring corrections are completed, conducting audits, monitoring compliance, and maintaining documentation accuracy.

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 refer significant changes of condition to the facility nurse and failed to ensure weekly progress was noted until a change of condition resolved, for 3 of 6 sampled residents (#s 1, 4 and 6) who experienced significant changes of condition or conditions that required monitoring. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2026 with diagnoses including respiratory failure with dyspnea and wheezing, Alzheimer’s dementia and coronary artery disease. Review of the clinical record indicated on 07/17/26 the facility identified and documented an “open wound under the right breast.” Treatment orders were obtained and implemented, and staff documented on the status of the condition each shift until alert charting was discontinued on 07/21/26. The last progress notes, dated 07/20/26, indicated “No new concerns or changes related to the wound observed” and that the facility nurse took a photo of the area which she described as a “rash.” There was no documentation of the progress of the skin condition between 07/20/26 and 08/17/26 when the facility nurse documented “No redness noted under both breasts.” In an interview on 08/19/26 at 2:45 pm, Staff 2 (Wellness Director/LPN) was unable to provide additional documentation of monitoring of the skin condition. The facility failed to ensure weekly progress was noted until the skin condition resolved. The need to ensure the facility documented monitoring of changes of condition weekly until resolved was reviewed with Staff 1 (ED), Staff 2, Staff 3 (RCC) and Witness 1 (Contract RN). They acknowledged skin monitoring had not been completed and documented weekly until the condition resolved. 2. Resident 4 was admitted to the facility in 01/2021 with diagnoses including dementia. The resident's clinical record, including observation notes dated 05/17/26 through 08/17/26, were reviewed, and interviews with facility staff were conducted. The following was identified: a. From 03/03/26 to 06/03/26, Resident 4 was identified to have a significant weight loss of 19.0 pounds or 13.13% of his/her total body weight in three months. This constituted a significant change of condition which required staff to refer the weight loss to the facility nurse. There was no documented evidence the significant weight loss was referred to the facility nurse. b. From 06/11/26 to 07/09/26, the resident gained 10.8 pounds or 8.66% of his/her total body weight in one month. This constituted a significant change of condition which required staff to refer the weight gain to the facility nurse. On 08/19/26 at 11:16 am, Witness 1 (Contract RN) confirmed she was not notified of the significant weight changes. There was no documented evidence the significant weight gain was referred to the facility nurse, that the facility determined, documented and communicated what actions or interventions were needed for the significant weight gain. On 08/19/26 at 9:55 am, Staff 3 (RCC) confirmed there was no additional documentation for the significant weight gain. c. On 06/26/26 the resident reported having three unwitnessed falls in his/her room and bathroom, resulting in skin injuries. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed or documented on the progress of the resident’s condition weekly through resolution. On 08/19/26 at 11:44 am, Staff 2 (Wellness Director/LPN) confirmed there was no additional documentation related to skin injuries. The need to ensure resident significant changes of condition were referred to the facility nurse and actions or interventions were determined, documented and communicated to staff with weekly progress noted to resolution for short-term changes of condition was reviewed with Staff 1 (ED), Staff 2, Staff 3 and Witness 1 on 08/20/26 at 12:02 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 03/2021 with diagnoses including dementia, epilepsy, and chronic renal disease. The resident's clinical record, including observation notes dated 05/17/26 through 08/17/26, were reviewed, and interviews with facility staff were conducted. The following was identified: a. From 06/01/26 to 07/01/26, Resident 6 was identified to have significant weight gain of 8.4 pounds or 5.17% of his/her total body weight in one month. This constituted a significant change of condition which required staff to refer the weight gain to the facility nurse. There was no documented evidence the significant weight gain was referred to the facility nurse. b. From 05/01/26 to 08/01/26, the resident was identified to have a significant weight gain of 16.2 pounds or 10.49% of the resident’s total body weight in three months. This constituted a significant change of condition which required staff to refer the weight gain to the facility nurse. There was no documented evidence the significant weight gain was referred to the facility nurse. On 08/19/26 at 11:16 am, Witness 1 confirmed she was not notified of the significant weight changes. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed or documented on the progress of the resident’s condition weekly through resolution. On 08/19/26 at 9:55 am, Staff 3 (RCC) confirmed there was no additional documentation for the significant weight gain. On 08/18/26 at 10:53 am, Witness 1 (Contract RN) reported she had staff obtain the resident’s weight on 08/17/26 and she had initiated an assessment for the significant weight gain. Witness 1 provided the assessment, completed 08/18/26, for the resident’s weight gain, which included interventions to address the weight gain. The need to ensure resident significant changes of condition were referred to the facility nurse and actions or interventions were determined, documented and communicated to staff with weekly progress noted to resolution for short-term changes of condition was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), Staff 3 and Witness 1 on 08/20/26 at 12:21 pm. They acknowledged the findings.

C 270 1. What actions will be taken to correct the rule violation for each example/resident? Resident 1 The WSD entered the required monitoring orders and reviewed the resident record to ensure appropriate follow-up and documentation were completed. Documentation of Resident 1's skin condition was reviewed. Weekly progress monitoring was completed, including documentation of resolution and return to baseline when appropriate. Documentation requirements were reinforced with licensed and caregiving staff. Resident 4 The resident's weight records were reviewed. The RN was notified as indicated, and appropriate follow-up was completed. Documentation of resident 4's fall related skin injury was reviewed. Interventions were implemented and documented through resolution. Resident 6 The resident's weight records were reviewed. The RN was notified of the significant weight change, and appropriate follow-up was completed. 2. How will the system be corrected so this violation will not happen again? The WSD will review alert monitoring and resident weight reports weekly to ensure timely identification, RN notification, follow-up, and documentation of significant weight changes. Med Techs will receive education on timely reporting requirements. 3. How often will the area needing correction be evaluated? The WSD or designee will conduct weekly audits of alert monitoring and resident weight reports through the compliance date to ensure ongoing compliance. 4. Who will be responsible to see that the corrections are completed/monitored? A Change of Condition Tracking Log will be implemented to ensure all short-term and significant changes are referred to the RN and include the documentation of interventions, notification of staff, and charting of weekly progress notes until resolution. The Wellness Services Director (WSD) and Registered Nurse (RN) are responsible for ensuring implementation, monitoring, and ongoing compliance.

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 document an RN assessment including findings, resident status and interventions made as a result of the assessment for 2 of 3 sampled residents (#s 4 and 6) who had significant weight changes. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 01/2021 with diagnoses including dementia. The resident's clinical record, including observation notes dated 05/17/26 through 08/17/26, were reviewed, and interviews with facility staff were conducted. The following was identified: From 03/03/2026 to 07/09/26 Resident 4 experienced significant weight fluctuations and there was no documented evidence of an RN assessment to include findings, resident status and/or interventions made as a result. On 08/19/26 at 11:16 am, Witness 1 (Contract RN) confirmed she was not notified of the significant weight changes. Refer to C270, example 2. 2. Resident 6 was admitted to the facility in 03/2021 with diagnoses including dementia, epilepsy, and chronic renal disease. The resident's clinical record, including observation notes dated 05/17/26 through 08/17/26, were reviewed, and interviews with facility staff were conducted. The following was identified: From 06/01/2026 to 08/17/26 Resident 6 experienced significant weight gain and there was no documented evidence of an RN assessment to include findings, resident status and/or interventions made as a result. On 08/19/26 at 11:16 am, Witness 1 confirmed she was not notified of the significant weight changes. Refer to C270, example 3.

C 280 1. What actions will be taken to correct the rule violation for each example/resident? Resident 4 The resident's weight records were reviewed. The RN was notified as indicated, and appropriate follow-up was completed. Completed RN assessments were documented and entered into each resident record and updated service plan. Resident 6 The resident's weight records were reviewed. The RN was notified of the significant weight change, and appropriate follow-up was completed. Completed RN assessments were documented and entered into each resident record and updated service plan. 2. How will the system be corrected so this violation will not happen again? Resident 4 and 6 the RN completed a problem-focused assessment for each resident that included findings, resident status, and interventions related to the identified weight changes. The WSD will review alert monitoring and resident weight reports weekly to ensure timely identification, RN notification, follow-up, and documentation of significant weight changes. Med Techs will receive education on timely reporting requirements. 3. How often will the area needing correction be evaluated? The WSD or designee will conduct weekly audits of alert monitoring and resident weight reports through the compliance date to ensure ongoing compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Wellness Services Director (WSD) and Registered Nurse (RN) are responsible for ensuring implementation, monitoring, and ongoing compliance.

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 physician's orders were carried out as prescribed for 2 of 6 sampled residents (#s 2 and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2026 with diagnoses including chronic diastolic (congestive) heart failure. Review of the MAR, dated 08/01/26 through 08/16/26, and current physician's orders, dated 06/26/26, were reviewed and the following was identified: Resident 2 had a physician’s order for daily weights to be obtained. The order stated to “notify PCP if 3-pound increase in 2 days or 5-pound increase in one week (7 days).” * From 08/04/26 to 08/06/26 Resident 2’s weight increased from 252.6 pounds to 261 pounds, an increase of 3.6 pounds in 2 days; and * From 08/01/26 through 08/07/26 Resident 2’s weight went from 254.4 to 261.4, which constituted a gain of 7 pounds in 1 week. An interview with Staff 11 (MT) on 08/18/26 at 12:10 pm confirmed the facility's system was to notify the provider via fax for weight changes outside of the parameters stated. Staff 11 was unable to provide documented evidence the provider was notified of the weight changes for Resident 2. An interview with Staff 2 (Wellness Director/LPN) on 08/18/26 at 12:15 pm and Staff 3 (RCC) on 08/18/26 at 12:35 pm confirmed the facility lacked documented evidence the physician’s order was carried out as prescribed for Resident 2 related to weight changes. The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 2 and Staff 3 on 08/18/26 at 12:15 pm and 12:35 pm, respectively. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 03/2021 with diagnoses including dementia, epilepsy and chronic renal disease. Review of the MAR, dated 08/01/26 through 08/17/26, and current physician's orders, dated 06/04/26, were reviewed and interviews with facility staff were conducted. The following was identified: a. The following orders were discontinued on 06/04/26, however, documentation revealed facility staff continued to administer the orders through 08/17/26: * Chlorhexidine gluconate 0.12% (for gum bleeds); and * GenTeal Tears Ophthalmic Solution (for dry eye). The above orders were not administered as prescribed. b. The following new orders were prescribed on 06/04/26; however, documentation revealed the medications were not administered as ordered: * Lisinopril 40 mg, take one tab my mouth daily; * Ascorbic acid (vitamin C) 250 mg, one every other day with iron; * Ferrous Sulfate 325 mg (65 mg iron) one tablet by mouth, every other day; and * Hydrocortisone 1% topical ointment apply to affected area two times a day. On 08/18/26 at 11:42 am, Staff 3 (RCC) confirmed the above orders were not administered as ordered. The need to ensure physicians' orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), Staff 3 and Witness 1 (Contract RN) on 08/20/26 at 12:21 pm. They acknowledged the findings.

C 303 1. What actions will be taken to correct the rule violation for each Resident? Resident 2 Physician notification requirements related to weight parameters were reviewed and implemented. Physician notification documentation was completed. Will provide education to med techs on following physicians orders and physician notification, if needed additional training will occur in Relias for Med Management. Resident 6 Medication and treatment orders were reconciled with physician orders. Discontinued medications were stopped. Active orders were entered into the MAR/TAR and implemented as prescribed. The physician and pharmacy were notified as appropriate. Education for Med Techs on order processing review and training if needed. 2. How will the system be corrected so this violation will not happen again? Resident 6's discontinued medications will be stopped and monitored with documentation. New orders for medications will be initiated and monitored with documentation. A physician order reconcilliation process will be implemented requiring initial review by the Medication Technician and secondary review by the WSD/RCC within 24 hours of all new, changed, or discontinued orders. Orders will be audited against the MAR/TAR to ensure implementation. 3. How often will the area needing correction be evaluated? Weekly audits for 3 months; then monthly through QAPI by WSD/RCC. 4. Who will be responsible to see that the corrections are completed and monitored? WSD

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure an RN, PT or OT conducted a thorough assessment of a device with restraining qualities, the facility instructed care staff on precautions related to the use of the device and documentation of the use of the device was included in the resident’s service plan, for 3 of 3 sampled residents (#s 1, 2 and 4) who had side rails. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2026 with diagnoses including respiratory failure with dyspnea and wheezing, Alzheimer’s dementia and coronary artery disease. During a room observation with Staff 9 (CG) on 08/18/26 at 12:15 pm, half-length side rails were observed on both sides of Resident 1’s bed. They were both in the up position, positioned toward the head of the bed and were installed securely. Staff 9 stated Resident 1 could transfer in and out of the bed independently and only needed assistance when s/he wasn’t feeling well. In a follow-up interview on 08/19/26 at 10:39 am, Staff 9 stated the side rails were always kept in the up position except when staff were changing the bedding. She said Resident 1 used the side rails to hold onto during incontinence care in bed and also when standing up from or sitting down on the bed. When asked if she was aware of any risks or dangers associated with side rails, she stated that she “really can’t think of anything.” On 08/18/26 at 4:15 pm, Staff 2 (Wellness Director/LPN) provided the resident’s quarterly evaluation which she said included an assessment of the side rails. Review of the document indicated: * The document did not indicate whether an RN, PT or OT completed an assessment of the side rails; * The document did not indicate the resident specifically requested or approved the side rails and that the facility informed the resident of the risks and benefits associated with the side rails; and * The document did not indicate whether other less restrictive alternatives were evaluated prior to the use of the side rails. In an interview on 08/19/26, Witness 1 (Contract RN) acknowledged the current facility software form did not address the information required by the rule. The resident’s current service plan, dated 08/07/26, noted the resident used the side rails for bed mobility and repositioning but did not provide instructions regarding when the side rails should be raised or lowered, or how to monitor the side rails for safety. The need to ensure an RN, PT or OT conducted a thorough assessment of devices with restraining qualities and the facility instructed care staff on precautions related to the use of the devices was reviewed with Staff 1 (ED), Staff 2, Staff 3 (RCC) and Witness 1 on 08/20/26 at 11:30 am. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 01/2021 with diagnoses including dementia. During an interview on 08/18/26 at 1:22 pm, one half-length side rail was observed on the exit side of Resident 4’s bed. The side rail was in the up position and positioned toward the head of the bed. The resident stated the side rail was not secure and “would move” when s/he used it. The resident further stated s/he had informed facility care staff the side rail was loose but “no one did anything about it.” Review of Resident 4’s quarterly evaluation, dated 04/27/26, indicated: * The document did not indicate whether an RN, PT or OT completed an assessment of the side rails; * The document did not indicate the resident specifically requested or approved the side rails and that the facility informed the resident of the risks and benefits associated with the side rails; and * The document did not indicate whether other less restrictive alternatives were evaluated prior to the use of the side rails. In an interview on 08/19/26, Witness 1 (Contract RN) acknowledged the current facility software form did not address the information required by the rule. The resident’s current service plan, dated 07/10/26, noted the resident used the side rail for bed mobility, turning and repositioning. It also noted the resident was able to call for assistance when needed for side rail safety issues but did not include instructions for staff for how to monitor the side rails for safety. The need to ensure an RN, PT or OT conducted a thorough assessment of a device with restraining qualities and the resident’s service plan included instructions for staff for monitoring the safe use of the side rail was reviewed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 3 (RCC) and Witness 1 (Contract RN) on 08/20/26 at 12:00 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 05/2026 with diagnoses including chronic diastolic (congestive) heart failure. During an interview with Resident 2 on 08/17/26 at 11:35 pm, half-length side rails were observed on both sides of Resident 2’s bed. They were both in the up position, positioned toward the head of the bed and were installed securely. The resident stated s/he used the side rails to assist with mobility, getting in and out of bed and turning in bed. Resident 2’s current service plan, dated 07/08/26, did not indicate the resident used side rails. The need to ensure the resident’s service plan documented the use of side rails was reviewed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 3 (RCC) and Witness 1 (Contract RN) on 08/20/26 at 1:30 pm.

C340 1. What actions will be taken to correct the rule violation for each resident? Resident 1 A comprehensive side rail assessment will be completed by the Registered Nurse (RN). The resident's service plan will be updated to reflect the assessment findings, identified risks, safety interventions, and resident or representative consent for side rail use. Resident 2 A comprehensive side rail assessment completed by the Registered Nurse (RN). The resident's service plan was updated to reflect the assessment findings, identified risks, safety interventions, and resident or representative consent for side rail use. Resident 2's service plan was updated to reflect use of side rails, purpose of use, safety precautions, staff monitoring instructions, and resident consent. Resident 4: A comprehensive side rail assessment will be completed by the Registered Nurse (RN). The resident's service plan will be updated to reflect the assessment findings, identified risks, safety interventions, and resident or representative consent for side rail use. 2. How will the system be corrected so this violation will not happen again? The Wellness Services Director (WSD) and Registered Nurse (RN) will review all residents utilizing side rails to ensure a current assessment, documented risk evaluation, resident or representative consent, and appropriate service plan interventions are in place. A standardized side rail assessment process and documentation review will be implemented to ensure ongoing compliance. Update residents service plan to include staff having received training regarding side rail risks, entrapment, monitoring requirements, and documentation standards. 3. How often will the area needing correction be evaluated? The WSD will conduct on admission and quarterly audits of residents utilizing side rails and upon any significant change in condition. Audit results will be reviewed to ensure assessments, consents, and service plan documentation remain current and compliant. 4. Who will be responsible to see that the corrections are completed and monitored? The Wellness Services Director (WSD) is responsible for ensuring all corrective actions are completed. The WSD and RN will monitor compliance through admission and quarterly audits and review of resident records to verify ongoing adherence to side rail assessment and documentation requirements.

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 maintain a written record of fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 08/19/26 at 2:03 pm, fire drill records from 03/2026 through 08/2026 were reviewed with Staff 4 (Building Services Director) and revealed a lack of documentation of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. The need to ensure the facility maintained an accurate record of fire drills was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), Staff 3 (RCC) and Witness 1 (Contract RN) on 08/20/26 at 12:02 pm. They acknowledged the findings.

C420 1. What actions will be taken to correct the rule violation for each resident? All residents will continue to participate in required fire drills. The Fire Drill Report form was revised to include documentation of the specific escape route utilized and the total evacuation time for each drill. Staff responsible for conducting fire drills were re-educated on the documentation requirements to ensure all required information is accurately recorded for every fire drill. 2. How will the system be corrected so this violation will not happen again? The facility updated its fire drill documentation process by implementing a standardized Fire Drill Report that requires completion of the escape route used and evacuation time before the report can be finalized. Staff conducting fire drills received training regarding Oregon fire drill documentation requirements. The Executive Director and Maintenance Director will review completed fire drill reports to verify compliance and completeness. Fire Drill Report Forms were revised to include all OFC-required elements including simulated fire origin, escape route utiliazed, evacuation time, staff participating, problems encountered, resident participation issues and refusals, number of occupants evacuated, corrective actions, and documentation of alternate exit routes. 3. How often will the area needing correction be evaluated? Fire drill documentation will be reviewed following each fire drill. Monthly audits of fire drill records will be conducted for a period of three months to ensure all required elements, including escape routes and evacuation times, are consistently documented. 4. Who will be responsible to see that the corrections are completed and monitored? The Executive Director and Maintenance Director will be responsible for ensuring the corrective actions are implemented, monitoring ongoing compliance, reviewing fire drill records, and conducting monthly audits to verify continued adherence to documentation requirements.