Print Inspection: RL014352

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all required postings were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times. Findings include, but are not limited to: During the initial tour of the facility at 1:30 pm on 09/21/26, and the environmental walk-through with staff on 09/23/26 at 11:00 am, the facility lacked the following required postings: * Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections; and * LGBTQIA2S+ Nondiscrimination Notice. The need to ensure all required postings were posted in a routinely accessible and conspicuous location to residents and visitors was reviewed on 09/23/26 at 3:15 pm with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings.

C0152 - Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections; and * LGBTQIA2S+ Nondiscrimination Notice. ***Posted while Surveyor in community 9/24/26. Posters moved to the front of the community on 9/25/26. Postings added to monthly walk list with Maintenance Director and to QAPI. Will continue to monitor with Maintenance Director & ED during monthly walk & check off list. ED responsible for postings.

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 resident care needs and preferences, and provided clear direction to staff regarding the delivery of services, including a written description of who should provide the services and what, when, how, and how often the services should be provided, for 4 of 5 sampled residents (#s 1, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living community in 08/2026 with diagnoses including quadriplegia and chronic pain. The resident’s 06/21/26 through 09/21/26 clinical record was reviewed, and interviews with staff and the resident were conducted. The following was identified: In an interview on 09/22/26 at 8:30 am, Staff 1 (Executive Director) reported that Resident 4 had a private caregiver seven days a week who was with the resident from before breakfast through lunch and from dinner until the resident went to bed. On 9/22/26 at 10:30 am, Staff 4 (CG) reported that she did not know what hours the private caregiver was with the resident but that she knew the private caregiver fed the resident all meals. Staff 4 reported that sometimes the facility staff would get texts from the kitchen that the meal trays were ready to deliver, and sometimes the private caregiver would get the trays. a. The service plan was not reflective of the resident’s needs and preferences in the following areas: * Use of cell phone voice assistant for music and television access; * Call system access; * Dining location; * Motorized wheelchair charging; and * Use of contracture gloves. b. The service plan did not provide clear direction to staff, including who should provide the services and what, when, how, and how often the services should be provided in the following areas: * Grooming; * Communication/hearing aids; * Contacts/glasses; * Meal tray delivery; and * Incontinence care. On 09/25/26 at 3:00 pm, the need to ensure service plans were reflective of the residents’ current needs and preferences and provided clear direction to staff was discussed with Staff 1 and Staff 2 (Health Services Director/RN). They acknowledged the findings. 2. Resident 5 moved into the assisted living community in 11/2024 with diagnoses including amyotrophic lateral sclerosis and severe protein-calorie malnutrition. The resident’s 06/21/26 through 09/21/26 clinical record was reviewed, and interviews with staff and the resident were conducted. The following was identified: In an interview on 09/22/26 at 12:15 pm Staff 7 (Dining Services Manager) stated that the resident’s mother ordered breakfast for Resident 5 approximately two times per week, and that was the only meal the resident requested from the kitchen. a. The service plan was not reflective of the resident’s needs and preferences in the following areas: * Eating/diet plan; * Communication/ability to be understood: * Call system adaptations and use; * Medication administration; * Transportation to and from activities; and * Repositioning. b. The service plan did not provide clear direction to staff in the areas of: * Transferring; and * Protein shakes. On 09/25/26 at 3:00 pm, the need to ensure service plans were reflective of the residents’ current needs and preferences and provided clear direction to staff was discussed with Staff 1 and Staff 2 (Health Services Director/RN). They acknowledged the findings. 3. Resident 3 was admitted to the facility in 11/2022 with diagnoses including congestive heart failure and hemiparesis (weakness) of his/her left non-dominant side. The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, interviews with staff and the resident were conducted, and the resident was observed. The following was identified: a. The resident’s service plan did not provide clear direction to staff in the following areas: * Bilateral half side rails; * Use of manual versus electric wheelchair in case of evacuation; * Specialized laundry detergent; * Ensuring call pendant was placed after hospice care was provided; and * Catheter care. b. The resident’s service plan was not reflective of the resident’s current needs related to: * Who was responsible for changing bed linens; * Dressing frequency and preferences; and * Assistance required to attend activities. The need to ensure service plans were reflective of residents' status and provided clear direction to staff regarding the delivery of services was reviewed on 09/23/26 at 2:15 pm with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings. 4. Resident 1 moved into the facility in 11/2024 with diagnoses including corticobasal degeneration (a progressive neurological disorder). The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, interviews with staff and the resident were conducted, and the resident was observed. The following was identified: The resident’s service plan was not reflective and did not provide clear direction to staff in the following areas: * Who and how meal assistance was provided; * Assistance level needed for meals and hydration; and * Outside services provided dressing, grooming, and personal hygiene. The need to ensure service plans were reflective of residents' status and provided clear direction to staff regarding the delivery of services was reviewed on 09/24/26 at 9:23 am with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings.

C0260- OAR 411-054-0036 (1-4) Service Plan: General - Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and preferences, and provided clear direction to staff regarding the delivery of services, including a written description of who should provide the services and what, when, how, and how often the services should be provided, for 4 of 5 sampled residents (#s 1, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living community in 08/2026 with diagnoses including quadriplegia and chronic pain. The resident’s 06/21/26 through 09/21/26 clinical record was reviewed, and interviews with staff and the resident were conducted. The following was identified: In an interview on 09/22/26 at 8:30 am, Staff 1 (Executive Director) reported that Resident 4 had a private caregiver seven days a week who was with the resident from before breakfast through lunch and from dinner until the resident went to bed. On 9/22/26 at 10:30 am, Staff 4 (CG) reported that she did not know what hours the private caregiver was with the resident but that she knew the private caregiver fed the resident all meals. Staff 4 reported that sometimes the facility staff would get texts from the kitchen that the meal trays were ready to deliver, and sometimes the private caregiver would get the trays. a. The service plan was not reflective of the resident’s needs and preferences in the following areas: * Use of cell phone voice assistant for music and television access; * Call system access; * Dining location; * Motorized wheelchair charging; and * Use of contracture gloves. b. The service plan did not provide clear direction to staff, including who should provide the services and what, when, how, and how often the services should be provided, in the following areas: * Grooming; * Communication/hearing aids; * Contacts/glasses; * Meal tray delivery; and * Incontinence care. On 09/25/26 at 3:00 pm, the need to ensure service plans were reflective of the residents’ current needs and preferences and provided clear direction to staff was discussed with Staff 1 and Staff 2 (Health Services Director/RN). They acknowledged the findings. Resident 5 moved into the assisted living community in 11/2024 with diagnoses including amyotrophic lateral sclerosis and severe protein-calorie malnutrition. The resident’s 06/21/26 through 09/21/26 clinical record was reviewed, and interviews with staff and the resident were conducted. The following was identified: In an interview on 09/22/26 at 12:15 pm, Staff 7 (Dining Services Manager) stated the resident’s mother ordered breakfast for Resident 5 approximately two times per week, and that was the only meal the resident requested from the kitchen. a. The service plan was not reflective of the resident’s needs and preferences in the following areas: * Eating/diet plan; * Communication/ability to be understood; * Call system adaptations and use; * Medication administration; * Transportation to and from activities; and * Repositioning. b. The service plan did not provide clear direction to staff in the areas of: * Transferring; and * Protein shakes. On 09/25/26 at 3:00 pm, the need to ensure service plans were reflective of the residents’ current needs and preferences and provided clear direction to staff was discussed with Staff 1 and Staff 2 (Health Services Director/RN). They acknowledged the findings. 3. Resident 3 was admitted to the facility in 11/2022 with diagnoses including congestive heart failure and hemiparesis (weakness) of his/her left non-dominant side. The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, interviews with staff and the resident were conducted, and the resident was observed. The following was identified: a. The resident’s service plan did not provide clear direction to staff in the following areas: * Bilateral half side rails; * Use of manual versus electric wheelchair in case of evacuation; * Specialized laundry detergent; * Ensuring call pendant was placed after hospice care was provided; and * Catheter care. b. The resident’s service plan was not reflective of the resident’s current needs related to: * Who was responsible for changing bed linens; * Dressing frequency and preferences; and * Assistance required to attend activities. The need to ensure service plans were reflective of residents' status and provided clear direction to staff regarding the delivery of services was reviewed on 09/23/26 at 2:15 pm with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings. 4. Resident 1 moved into the facility in 11/2024 with diagnoses including corticobasal degeneration (a progressive neurological disorder). The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, interviews with staff and the resident were conducted, and the resident was observed. The following was identified: The resident’s service plan was not reflective and did not provide clear direction to staff in the following areas: * Who provided meal assistance and how meal assistance was provided; * Assistance level needed for meals and hydration; and * Outside services provided dressing, grooming, and personal hygiene. The need to ensure service plans were reflective of residents' status and provided clear direction to staff regarding the delivery of services was reviewed on 09/24/26 at 9:23 am with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings. ***C-260 Service plans for Resident #1, 3, 4, & 5 have been reviewed and updated on 9/23/26 to reflect needs, preferences, and clear direction of who conducts what care need. The ED, HSD, and RCC will review all service plans to ensure they reflect current preferences and have clear communication of whoever provides which service. The ED or RCC will audit 6 service plans weekly for 8 consecutive weeks, then 8 service plans monthly for 3 months, with continuation if compliance is under 90% until compliance is over 90% threshold to verify service plans accurately reflect preferences. The audit will consist of resident care needs & preferences, ability to transport to/from activities, dining: i.e. meal location, hydration assistance and/or who is responsible for providing the service (community staff or outside/private caregiver), frequency of service, personal hygiene preferences & who is to perform the service (community staff or outside/private caregiver), emergency service and/or call system preference, any adaptive devices with safety measures or resident specific instruction, coordination of outside agency, hospice, private caregiver, or family. Any discrepancies found during the audit will be promptly corrected & service plan will be communicated to direct care staff. Audit to start 10/12/26 and continue. HSD to provide direct care staff education on the service planning process, updating service plans to reflect needs, preferences, equipment, change in condition, role & responsibilities of community staff, private caregiver, family, and outside provider and the requirement to follow current service plan and report discrepancies or changes to HSD, ED, and/or RCC. Re-education will be documented. HSD & ED are responsible.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#3) who was bedbound and whose ADL care was observed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 11/2022 with diagnoses including congestive heart failure and hemiparesis (weakness) of his/her left non-dominant side. The resident was dependent on staff for all ADL care, including incontinence and catheter care and personal hygiene. At 9:51 am on 09/24/26, Staff 4 (CG) and Staff 5 (CG) were observed providing incontinence care for Resident 3 in his/her bed. Both staff donned gloves, removed the resident’s soiled brief, and provided peri care. Staff 4 removed the resident’s soiled incontinence pad and placed it on the floor. Staff 4 and 5 did not remove their soiled gloves and don clean gloves prior to beginning clean tasks, including putting a clean brief on the resident and moving the resident’s catheter tubing. Both staff members continued to wear soiled gloves while placing blankets and pillows around and on the resident’s legs. Staff 4 and 5 then removed their soiled gloves but did not complete hand hygiene before completing additional tasks in the resident’s room, including pulling an ice cube tray out of the resident’s freezer to refresh his/her cup of water. Staff 4 picked up the soiled incontinence pad from the floor with ungloved hands and did not complete hand hygiene prior to leaving the apartment. The need to maintain infection prevention and control protocols was reviewed on 09/23/26 at 2:15 pm with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings.

C0295 OAR 411-054-0050(1-5) Infection Prevention & Control - Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#3) who was bedbound and whose ADL care was observed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 11/2022 with diagnoses including congestive heart failure and hemiparesis (weakness) of his/her left non-dominant side. The resident was dependent on staff for all ADL care, including incontinence and catheter care and personal hygiene. At 9:51 am on 09/24/26, Staff 4 (CG) and Staff 5 (CG) were observed providing incontinence care for Resident 3 in his/her bed. Both staff donned gloves, removed the resident’s soiled brief, and provided peri care. Staff 4 removed the resident’s soiled incontinence pad and placed it on the floor. Staff 4 and 5 did not remove their soiled gloves and don clean gloves prior to beginning clean tasks, which included putting a clean brief on the resident and moving the resident’s catheter tubing. Both staff members continued to wear soiled gloves while placing blankets and pillows around and on the resident’s legs. Staff 4 and 5 then removed their soiled gloves but did not complete hand hygiene before completing additional tasks in the resident’s room, including pulling an ice cube tray out of the resident’s freezer to refresh his/her cup of water. Staff 4 picked up the soiled incontinence pad from the floor with ungloved hands and did not complete hand hygiene prior to leaving the apartment. The need to maintain infection prevention and control protocols was reviewed on 09/23/26 at 2:15 pm with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings. ***C-0295 The community immediately reviewed the infection prevention and control practices with Resident #3 incontinence & catheter care. Immediate re-education to staff #4 & #5 happened on 9/24/26 regarding hand hygiene, glove use, glove change, clean vs contaminated tasks, catheter care, and handling of incontinence products. Direct care staff re-education and competencies to be completed through HSD and ED. Competencies to include: hand hygiene, clean vs. contaminated tasks & care, glove use, glove change, soiled garment/product disposal. Audit of all residents who require staff assistance with incontinence, catheter care, personal hygiene, & wound care to ensure infection prevention and control policies are in place. Community will continue with infection control re-education on policy & procedure- with a heavy focus on: hand hygiene (before & after care performed), when to wear gloves (contact with bodily fluids, non-intact skin, contaminated items, and blood), proper removal of gloves (when and when to change gloves), disposal of soiled incontinence items (when and where to place), catheter care infection control, clean vs contaminated surfaces (what to touch, when) and when contamination occurs via All-Staff meetings monthly to ensure staff are consistently following infection control practice. All direct care staff re-education conducted on 10/7/26 through Deschutes County Infection Control Specialist- included PPE standard precautions, hand hygiene, glove use & changes, 5 important parts of infection prevention, environmental cleaning, laundry & soiled materials. Make-up training to anyone who missed this course scheduled for 10/22/26. HSD & ED will conduct weekly routine audits of direct care staff (different staff, different shifts) providing personal care of incontinent and/or catheter care for 2 months, 4 staff members a week, to verify hand hygiene, glove usage (removal and replacement between tasks), handling and disposal of soiled incontinence items, contamination of clean, and catheter care. Audit to start 10/12/26. Education to be provided in the moment with immediate correction and review of competencies. Competencies to be completed by 11/9/26. Competencies added to new-hire orientation. After the completion of the audit, continued monitoring will continue through QAPI quarterly and education monthly through All-Staff meetings. ED & HSD are responsible.

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, the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) for whom the facility was responsible for administering medications. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2022 with diagnoses including congestive heart failure and hemiparesis (weakness) of his/her left non-dominant side. The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, and interviews with staff were conducted. The following was identified: The resident had a signed physician’s order for metoprolol succinate (for atrial fibrillation), one 25 mg tablet to be administered daily. The order instructed staff to hold administration of the medication if the resident’s heart rate was less than 55 beats per minute or systolic blood pressure was less than 100. a. There was no documented evidence staff were checking the resident’s heart rate prior to administering the medication. During an interview on 09/22/26 at 11:20 am, Staff 2 (Health Services Director/RN) confirmed the resident’s heart rate was not being checked prior to staff administering the medication. b. The medication was not administered to the resident on 07/27/26, 07/31/26, and 08/24/26, with notes stating, “vitals outside of parameters for administration.” There was no documented evidence the resident’s blood pressure or heart rate had been checked or which vital was outside of the parameters for administration. c. On 07/03/26 and 08/23/26, the medication was noted as administered, despite the resident’s systolic blood pressure documented as less than 100. The need to ensure medication orders were carried out as prescribed was reviewed on 09/23/26 at 2:15 pm with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including stage 4 kidney disease and heart failure. The resident's 09/01/26 to 09/21/26 MARs and physician orders dated 04/02/26 were reviewed, and the following was identified: The physicians order specified: * Digoxin 125 MCG 1 tablet by mouth related to heart failure: take 60 second radial pulse, hold for pulse less than 60. On 09/19/26, the MAR documented the radial pulse as 59, and the medication as administered. The need to ensure medication orders were carried out as prescribed was reviewed on 09/23/26 at 3:15 pm with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings.

C0303 OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders - Based on interview and record review, the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) for whom the facility was responsible for administering medications. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2022 with diagnoses including congestive heart failure and hemiparesis (weakness) of his/her left non-dominant side. The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, and interviews with staff were conducted. The following was identified: The resident had a signed physician’s order for metoprolol succinate (for atrial fibrillation), one 25 mg tablet to be administered daily. The order instructed staff to hold administration of the medication if the resident’s heart rate was less than 55 beats per minute or systolic blood pressure was less than 100. a. There was no documented evidence staff were checking the resident’s heart rate prior to administering the medication. During an interview on 09/22/26 at 11:20 am, Staff 2 (Health Services Director/RN) confirmed the resident’s heart rate was not being checked prior to staff administering the medication. b. The medication was not administered to the resident on 07/27/26, 07/31/26, and 08/24/26, with notes stating, “vitals outside of parameters for administration.” There was no documented evidence the resident’s blood pressure or heart rate had been checked or which vital was outside of the parameters for administration. c. On 07/03/26 and 08/23/26, the medication was noted as administered, despite the resident’s systolic blood pressure being documented as less than 100. The need to ensure medication orders were carried out as prescribed was reviewed on 09/23/26 at 2:15 pm with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including stage 4 kidney disease and heart failure. The resident's 09/01/26 to 09/21/26 MAR and physician orders dated 04/02/26 were reviewed, and the following was identified: The physicians order specified: * Digoxin 125 MCG 1 tablet by mouth related to heart failure: take 60 second radial pulse, hold for pulse less than 60. On 09/19/26, the MAR documented the radial pulse as 59 and the medication as administered. The need to ensure medication orders were carried out as prescribed was reviewed on 09/23/26 at 3:15 pm with Staff 1 (Executive Director) and Staff 2 (Health Services Director/RN). They acknowledged the findings. *** C-303 The community Health Services Director immediately reviewed the medication orders, MARs & parameters for Resident #2 & #3 and corrected on 9/24/26. Physician's for both residents were notified and checked for side effects. Resident #2- the physician’s order for digoxin was reviewed. Order required a 60-second radial pulse & the medication to be held for pulse less than 60 beats per minute. MAR & medication process were reviewed, staff were instructed that the required pulse must be obtained & documented prior to administration. The medication is not administered when the ordered hold parameter is met. Resident #3- the physician’s order for metoprolol succinate requiring the resident’s heart rate and systolic blood pressure to be assessed prior to administration, with the medication held when the heart rate is less than 55 beats per minute or systolic blood pressure is less than 100 mmHg. Orders and MAR were reviewed for accuracy. The medication plan & MAR were updated to uphold the parameters. Staff were educated and instructed the required vital signs must be obtained & documented prior to administration and held when either ordered parameter is met. HSD and/or RCC will conduct an audit of all current residents receiving medications or treatments with physician ordered parameters: Hold parameters for heart rate or blood pressure, blood pressure checks, weight based parameters, oxygen parameters, pulse checks, blood glucose, pain, and sedation parameters. The audit will compare orders to the MAR: order is entered correctly on MAR, parameters are clearly identified, staff education of what their assessment should be prior to administration, that medications are held when parameter is not met, all held medication is documented along with assessment and reason. Weekly audits for 8 continuous weeks of medications with hold parameters to follow- audit will be conducted in daily SMART meeting to ensure the correct order is placed, vitals/assessment were obtain before administration, documentation with reasoning, any required follow up was completed. Staff re-education and additional competency assessment to take place if discrepancies are found. Vitals are required to be entered before these medications can be signed off. Staff education which will address: following physician orders as written, reading and following medication hold parameters, obtaining vitals and/or assessment before administration, documenting appropriately when medication is held, notification. HSD responsible for competencies. Competencies to be completed by 11/09/26. HSD/RCC to document competency. Re-education will be documented. HSD is responsible.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed at least quarterly to assure their ability to safely self-administer medications, and failed to have a physician’s or other legally recognized practitioner’s written order of approval for self-administration of prescription medications, for 2 of 2 sampled residents (#s 4 and 5) reviewed for self-administration of medications. Findings include, but are not limited to: 1. Resident 5 moved into the assisted living community in 11/2024 with diagnoses including amyotrophic lateral sclerosis and severe protein-calorie malnutrition. During the acuity interview on 09/21/26, the resident was identified as self-administering his/her medications. On 09/22/26 at 10:00 am, Staff 2 (Health Services/RN) acknowledged that at the time of survey entrance on 09/21/26 the facility had no documented evidence of a physician’s order for approval of self-administration of medications or an evaluation by the facility to assure their ability to safely self-administer medications. The need to ensure residents who self-administered their medications had a physician’s written order of approval for self-administration of prescription medications and were evaluated by the facility to assure their ability to safely self-administer medications was discussed with Staff 1 (Executive Director) and Staff 2 on 09/24/26 at 3:00 pm. They acknowledged the findings. 2. Resident 4 moved into the assisted living community in 08/2026 with diagnoses including quadriplegia and chronic pain. Review of the resident’s clinical record identified the resident self-administered their own medications. On 09/23/26 Staff 2 (Health Services Director/RN) acknowledged the facility had no documentation of a physician’s order of approval for self-administration of prescription medications. The need to ensure residents who self-administered their medications had a physician’s order of approval for self-administration of prescription medications was discussed with Staff 1 (Executive Director) and Staff 2 on 09/24/26 at 3:00 pm. They acknowledged the findings.

C0325 OAR 411-054-0055 (5) Systems: Self-Administration of Meds - Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed at least quarterly to assure their ability to safely self-administer medications, and failed to have a physician’s or other legally recognized practitioner’s written order of approval for self-administration of prescription medications, for 2 of 2 sampled residents (#s 4 and 5) reviewed for self-administration of medications. Findings include, but are not limited to: 1. Resident 5 moved into the assisted living community in 11/2024 with diagnoses including amyotrophic lateral sclerosis and severe protein-calorie malnutrition. During the acuity interview on 09/21/26, the resident was identified as self-administering his/her medications. On 09/22/26 at 10:00 am, Staff 2 (Health Services/RN) acknowledged that at the time of survey entrance on 09/21/26 the facility had no documented evidence of a physician’s order for approval of self-administration of medications or an evaluation by the facility to assure their ability to safely self-administer medications. The need to ensure residents who self-administered their medications had a physician’s written order of approval for self-administration of prescription medications and were evaluated by the facility to assure their ability to safely self-administer medications was discussed with Staff 1 (Executive Director) and Staff 2 on 09/24/26 at 3:00 pm. They acknowledged the findings. 2. Resident 4 moved into the assisted living community in 08/2026 with diagnoses including quadriplegia and chronic pain. Review of the resident’s clinical record identified the resident self-administered their own medications. On 09/23/26 Staff 2 (Health Services Director/RN) acknowledged the facility had no documentation of a physician’s order of approval for self-administration of prescription medications. The need to ensure residents who self-administered their medications had a physician’s order of approval for self-administration of prescription medications was discussed with Staff 1 (Executive Director) and Staff 2 on 09/24/26 at 3:00 pm. They acknowledged the findings. *** C-0325 The community immediately reviewed the medication self-administration for residents #4 & #5. The HSD immediately completed a self administer medication evaluation for resident #5 and determined resident is able to safely administer medications. HSD faxed physician and received physician orders for both resident #4 & #5. HSD completed on 9/24/26. HSD & RCC to complete an audit of all self administered residents to determine: Evaluation is complete & reviewed quarterly, resident can safely administer own medication, and a current order from the physician approving self medication administration. HSD is responsible for ensuring that self medication administration evaluations are completed and physician order is in placebefore self administration is initiated; quarterly re-evaluation is completed & documented, and any change in the resident’s cognition, physical ability, medication regimen, or ability to self administer triggers a reassessment. Quarterly reminders set in PCC. For 90 days, the HSD or RCC will conduct a monthly audit of all self administering residents to verify. Continued tracking through QAPI to prevent reassessment from being missed. HSD & ED are responsible.

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 a supportive device with restraining qualities was assessed by an RN, PT, or OT, failed to document evaluation of other less restrictive alternatives prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to use of the device for 1 of 1 sampled resident (#3) with bilateral half side rails. Findings include, but are not limited to: Resident 3 was admitted to the facility in 11/2022 with diagnoses including congestive heart failure and hemiparesis (weakness) of his/her left non-dominant side. The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, interviews with staff and the resident were conducted, and the resident was observed. The following was identified: During the acuity interview on 09/21/26 at 1:00 pm, Staff 2 (Health Services Director/RN) and Staff 3 (MT) identified Resident 3 as being bedbound, completely dependent on staff for all ADL care, and having a side rail. On 09/22/26 at 10:00 am, the resident was observed in his/her bed, which had bilateral half side rails located in the up position. There was no documented evidence the following required elements were completed related to the side rail: * The facility RN, PT, or OT conducted a thorough assessment; * The facility documented other less restrictive alternatives evaluated prior to the use of the device; and * The facility had instructed caregivers on the correct use and precautions related to the use of the device. On 09/22/26 at 12:50 pm, Staff 2 (Health Services Director/RN) confirmed an assessment had not been completed. The need to ensure the use of a supportive device with restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives were evaluated prior to the use of the device, and caregivers were instructed on the correct use and precautions related to the device was reviewed on 09/23/26 at 2:15 pm with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.

C0340 - OAR 411-054-0060 Restraints and Supportive Devices -Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT, or OT, failed to document evaluation of other less restrictive alternatives prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (#3) with bilateral half side rails. Findings include, but are not limited to: Resident 3 was admitted to the facility in 11/2022 with diagnoses including congestive heart failure and hemiparesis (weakness) of his/her left non-dominant side. The resident’s 06/22/26 through 09/21/26 clinical record was reviewed, interviews with staff and the resident were conducted, and the resident was observed. The following was identified: During the acuity interview on 09/21/26 at 1:00 pm, Staff 2 (Health Services Director/RN) and Staff 3 (MT) identified Resident 3 as being bedbound, completely dependent on staff for all ADL care, and having a side rail. On 09/22/26 at 10:00 am, the resident was observed in his/her bed, which had bilateral half side rails located in the up position. There was no documented evidence the following required elements were completed related to the side rail: * The facility RN, PT, or OT conducted a thorough assessment; * The facility documented other less restrictive alternatives evaluated prior to the use of the device; and * The facility had instructed caregivers on the correct use and precautions related to the use of the device. On 09/22/26 at 12:50 pm, Staff 2 (Health Services Director/RN) confirmed an assessment had not been completed. The need to ensure the use of a supportive device with restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives were evaluated prior to the use of the device, and caregivers were instructed on the correct use and precautions related to the device was reviewed on 09/23/26 at 2:15 pm with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings. ***C-0340 The community immediately reviewed the use of bilateral half side rails for resident #3. Immediate correction with comprehensive assessment for Resident #3.The HSD completed a thorough assessment for the residents need for the supportive device, purpose of, residents current status, risk & benefits and whether the device has restraining properties. The HSD included the resident and offered less restrictive alternatives. Resident elects to have the side rails and acknowledges and understands the risks. A re-evaluation of resident #3 devices will happen quarterly or with a change of condition. This was completed on 9/23/26. Education for direct care staff to resident #3 and side rails completed 9/30/26. HSD and RCC to do a complete audit of 100% of residents currently utilizing supportive devices and determine: assessment has been completed, documentation of less restrictive alternatives, documentation of supporting and continued needs, that each device is documented in the service plan, and direct care staff have been instructed on use and precautions. Education provided to staff on correct use, potential risks, monitoring the resident for discomfort, changes in condition, or injury, reporting to the HSD, and following the service plan. Re-education will be documented by 11/9/26. Health Services Director & Resident Care Coordinator to conduct community wide audit to identify any supportive devices with restraining qualities (side rails, positioning devices and other devices that may restrict freedom of movement). Once identified, each will be reviewed with an assessment, documented alternatives, updated resident service plan, staff instruction and ongoing evaluations. The ED and/or HSD will conduct a supportive device audit monthly for 3 months then quarterly to ensure continued compliance. Audit to start 10/12/26. HSD to provide direct care staff education on the service planning process, updating service plans to reflect needs, preferences, equipment, change in condition, role & responsibilities of community staff, private caregiver, family, and outside provider and the requirement to follow current service plan and report discrepancies or changes to HSD, ED, and/or RCC. Re-education will be documented by 11/9/26. Audits for supportive devices with restraining qualities will happen monthly for 90 days to verify assessments, alternatives, and service plan intervention, and direct care staff education are complete and current. Concerns will be immediately corrected and education provided as necessary. After the 90 day monitoring period, audits will continued quarterly. HSD & ED are responsible.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to ensure the required postings, Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections, and the LGBTQIA2S+ Nondiscrimination Notice were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times. Findings include, but are not limited to: Refer to C152.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to ensure the required postings, Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections, and the LGBTQIA2S+ Nondiscrimination Notice were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times. Findings include, but are not limited to: Refer to C152. ******Posted while Surveyor in community. Postings added to monthly walk list with Maintenance Director and to QAPI. Will continue to monitor with Maintenance Director & ED during monthly walk & check off list. Posters moved to the front of the commuity on 9/25/26. ED responsible for checking postings monthly.