OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse for 2 of 2 sampled residents (#s 2 and 4) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 08/2020 with diagnoses including dementia and hypertension. Progress notes and interim service plans, dated 05/01/25 through 08/03/25, and corresponding incident reports were reviewed. The following was revealed: Resident 4 had a laceration measuring 4 cm by 1.5 cm by 2 cm on both sides of the bottom, documented by Staff 16 (MT). On 08/05/25 at 9:36 am, an interview with the resident was attempted. Resident 4 was not able to recall what happened. There was no documented evidence of an investigation to rule out abuse of the injury of unknown cause. The facility was instructed to report the injury of unknown cause to the local SPD office. Proof of reporting was received by the survey team on 08/07/25 via email. The need to ensure all injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 07/2023 with diagnoses including dementia. The resident’s progress notes, dated 07/01/25 through 08/04/25, and an interim service plan, dated 06/30/25, were reviewed. On 06/30/25, staff identified a "Laceration" on Resident 2's "Left fourth toe". On 08/06/25 at 2:04 pm, an interview with the resident was attempted. Resident 2 was not interviewable. On 08/06/25 at 2:42 pm, Staff 1 (Interim ED) confirmed there was no documented evidence the facility investigated the incident to determine the origin of the injury. Survey requested the injury be reported to the local SPD office and verification of the notification was received on 08/07/25 at 10:04 am. The need to ensure injuries of unknown cause were immediately investigated and if abuse could not be ruled out, reported to the local SPD office was discussed with Staff 1, Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings.

1. Resident #4' and #2s injury of unknown cause was reported to the local SPD office on 8/7/25. 2. All care staff will be trained on the need to ensure all injuries of unkown cause are reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documents the physical injury was not a result of abuse. Staff will be trained on how to conduct investigations, how to rule out abuse and the process to report to SPD when abuse can not be ruled out. Staff will complete an incident report for all injuries, these will be reviewed by the RCC and Administrator at the scheduled morning clinical calls. 3. This area of correction will be evaluated on a monthly basis by RCCs, RN, and Administrator. 4. The RN and Administrator will be responable to see the correctons are completed/monitored.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required elements for 2 of 2 sampled residents (Residents #1 and 3) whose move in evaluations were reviewed, failed to ensure a smoking evaluation was completed for 1 of 1 sampled resident (#6) reviewed for smoking evaluation, failed to ensure evaluations were reflective of resident status for 2 of 4 sampled residents (#s 2 and 4) and/or failed to complete a quarterly evaluation for 1 of 6 sampled residents (#6) whose evaluations were reviewed. Findings include but are not limited to: 1. Resident 1 was admitted to the facility on 05/31/25 with diagnoses including major depression, anxiety, and vascular dementia. Resident 1’s move-in evaluation, completed on 05/30/25, lacked required information in the following areas: * Pronouns; * Gender identity; * Cultural preferences and traditions; * Mental health issues, including presence of depression, history of treatments and effective non-drug interventions; * Cognition, including decision making abilities; * Ability to use call system; * Housework; * Transportation; and * Emergency evacuation ability. The need to ensure move-in evaluations addressed all required elements was reviewed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/ LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:30 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 04/2025 with diagnoses including dementia. The resident’s move-in evaluation was reviewed, and the following required elements were not addressed: * Interests, hobbies, and social activities; * Cultural preferences and traditions; * Cognition, including decision making abilities; * Personality, including how the person copes with change or challenging situations; * Ability to understand and be understood; * Housework; * Non-pharmaceutical interventions for pain; * Emergency evacuation ability; * Recent losses; and * Preferred pronouns. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2023 with diagnoses including dementia and chronic pain. The resident’s quarterly evaluation, dated 05/28/25, was reviewed and care staff were interviewed. The following elements were not reflective of the resident’s current status: * Cardiovascular and pacemaker placement; * Assistance with dressing; * Mental health issues including delusions; * Psychosocial issues including repetitive concerns or behaviors relating to turning in his/her apartment key; * Toileting and PRN incontinence; * Identification of chronic pain; * Fluid preferences were not person-centered; and * Behavior issues that may require staff intervention. During an interview on 08/06/25 at 1:30 pm, the inaccuracies were confirmed by Staff 18 (CG). The need to ensure quarterly evaluations were the foundation of the service plan and were reflective of the resident’s current status was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings. 4. Resident 4 moved into the facility in 08/2020 with diagnoses including dementia and hypertension. The resident’s quarterly evaluation, dated 04/21/25, was reviewed, and care staff were interviewed. The evaluation was not completed quarterly, or with a significant change of condition, and the following elements were not reflective of the resident’s current status: * Customary routines: sleeping; * Leisure activities; * Cognition, including decision-making abilities; * Personality, including how the person copes with change or challenging situations; *ADL assistance: toileting, transfers, ambulation, and eating; * Ability to use the call system; * Pain management: pharmaceutical and non-pharmaceutical interventions; * Emergency evacuation ability; and * Nurse delegation tasks. The need to ensure quarterly or significant change of condition evaluations were the foundation of the service plan and were reflective of the resident’s current status was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings.

1. The following required information will be added to Resident #1's move in evaluation and service plan: * Pronouns; * Gender identity; * Culteral preferences and traditions; * Mental health issues, including presence of depression, history of treatments and effective non-drug interventions; * Cognition, including decision making abilities; * Ability to use all system; * Housework; * Transportation; and * Emergency evacuation ability. 1. The following required information will be added to Resident #3's move in evaluation and service plan: * Interests, hobbies, and socail activities; * Cultural preferences and traditions; * Cognition, including decision making abilities; * Personality, including how a person copes with change or challenging situations; * Ability to undersand and be understood; * Housework; * Non-pharmaceutical interventions for pain; * Emergency evacuation ability; * Recent losses; and * Preferred pronouns. 1. The following required information wil be added to Resient 2's quarterly evaluation and service plan; * Cardiovascular and pacemaker replacement; * Assistance with dressing; * Mental health issues including delusions; * Psycosocial issues including repetitive concerns or behaviors relating to turning in his/her apartment key; * Toileting and PRN incontinence; * Identification of chronic pain; * Fluid preference (person centered) and * Behavior issue that may require staff intervention. 1. The following required information will be added to Resient #4's quarterly evaluation or in a significant change of condition / service plan: * Customary routines: sleeping; * Leisure activities; * Cognition, including decision-making abilities; * Personality, including how the person copes with changes or challenging situations; * ADL assistance; toileting, transfers, ambulation, and eating; * Ability to use the call system; * Pain management: Pharmaceutical and non-pharaceutical interventions; * Emergeny evacuation ability; and * Nurse delegation tasks. 2. All required elements will be added to our evaluation tool. All staff conducting evaluations will be trained on the new tool and required elements. 3. This area of correcton will be evaluated on a monthly basis by RCC, RN and Administrator. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of the residents’ needs, updated quarterly, were readily available to staff, provided clear direction to staff regarding the delivery of services, updated when residents’ experienced a significant changes of condition, and were being implemented for 4 of 6 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to: 1. Resident 2 moved into the facility in 07/2023 with diagnoses including dementia. The resident’s service plan, dated 05/30/25, interim service plans, dated 06/30/25 and 07/25/25, and progress notes, dated 07/01/25 through 08/04/25, were reviewed. Resident 2 was observed, and staff were interviewed. The resident’s service plan was not reflective of his/her needs, did not provide clear direction to staff, and/or was not implemented in the following areas: * Communication, including how the resident communicates and the most effective way to communicate with him/her; * Pacemaker placement and instructions to staff; * When staff needed to provide direction and reminders for the resident; * Current behaviors and interventions needed depending on the time of day; * Conflicting wandering/exit seeking information; * Direction to staff relating to the resident's mobility device; * Resident 2’s collection of various items (e.g. coffee cups, paper cups, etc.) and interventions for removal when needed; * The use of underwear versus briefs; * Assistance with dressing; * Assistance with bathing; * Family supplying alcoholic beverages to the resident; * Preference of wearing shorts year around; and * Being the facility’s "door greeter.” During interviews on 08/06/25, Staff 6 (Onsite PT) and Staff 18 (CG) confirmed Resident 2’s current needs. The need to ensure service plans were reflective of the resident’s needs, provided clear direction to staff, and were being implemented was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 04/2025 with a diagnosis of dementia. The resident’s service plan, dated 05/12/25, and progress notes, dated 04/22/25 through 05/04/25, were reviewed. Resident 3 and staff were interviewed. The resident’s service plan was not reflective of his/her needs and/or did not provide clear direction to staff in the following areas: * Assistance needed when the resident attempted to do his/her own laundry; * Reminders to Resident 3 confirming administration of his/her medications; and * Current daily routine, including time spent with his/her partner. On 08/05/25 at 10:31 am, the resident stated that someone had “stolen” his/her laundry and that s/he “didn’t get my morning medications”. On 08/05/25 at 10:54 am, Staff 19 (MT) confirmed providing “daily” reminders to Resident 3 that s/he did receive his/her medications. On 08/06/25 at 12:12 pm, Staff 15 (MT) confirmed that the resident “tries to do [his/her] own laundry” and reported the washing machines were too complicated for Resident 3 to use. The need to ensure service plans were reflective of the resident’s needs and provided clear direction to staff was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings. 3. Resident 4 moved into the facility in 08/2020 with diagnoses including dementia and hypertension. The resident’s service plan, dated 01/20/25, an interim service plan, and progress notes, dated 05/02/25 through 08/03/25, were reviewed, and care staff were interviewed. The resident’s service plan was not updated with a change of condition, was not readily available to staff, and was not reflective of the resident’s current needs, nor provided clear direction to staff in the following areas: * Mobility status; * Transfer status; * ADL assistance, grooming, dressing, and toileting; * Eating assistance; and * Safety checks frequency. The need to ensure the service plan was updated quarterly or with significant change of condition, was reflective of the resident’s current status, provided clear direction to staff and was readily available to staff was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings. 4. Resident 1 was admitted to the facility on 05/31/25 with diagnoses including major depression, anxiety, and vascular dementia. The resident’s service plan, dated 07/18/25, and progress notes, dated 05/31/25 through 08/03/25, were reviewed, and care staff were interviewed. The resident’s service plan was not reflective of the resident’s current needs, nor provided clear direction to staff in the following areas: * The presence of depression, history of treatment, and effective non-drug interventions; * Safety check instructions; and * Suicidal ideation interventions. The need to ensure service plans were reflective of the resident’s current needs and provided clear direction to staff was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:45 am. They acknowledged the findings.

1. Resident #2's service plan will be updated to reflect his/her needs and provide a clear direction to staff, and/or implement in the following areas: * Communication, including how the resident communicates and the most effective way to communicate with him/her; * Pacemaker placement and instructions to staff; * When staff neeed to provide direction and reminders for the resident; * Current behaviors and interventions needed depending on the time of day; * Clarification of wandering/exit seeking information; * Direction to staff relating to the resident's mobility device; * Resident 2's collection of various items (e.g. coffee cups, paper cups, etc.) and intervention for removal when needed; * The use of underwear versus briefs; * Assistance with dressing; * Assistance with bathing; * Family supplying alcoholic beverages to the resident; * Preference of wearing shorts year around; and * Being the facilitlies "door greeter". 1. Resident #4's service plan will be updated to reflect his/her needs and/or provide clear direction to staff in the following areas: * Assistance needed when the resident attemps to do his/her laundry; * Reminders to Resident #3 confirming administration of his/her medications; and * Current daily routine, including time spent with his/her partner. 1. Resident #4's service plan will be updated to a change of condition, it will be readily available to staff, and reflective of the resident's current needs and provide clear direction to staff in the following areas: * Mobility status; * Transfer status; * ADL assistance, grooming, dressing, and toileting; * Eating assitance; and * Safety checks frequently. 1. Resident #1's service plan will be updated to reflect the resident's current needs, and provide clear direction to staff in the following areas: * The presence of depression, history of treatment, and effective non-drug interventions; * Safety checks instructions; and * Suicidal ideation interventions. 2. All staff completing service plans will be trained on person centered service plans to ensure service plans are reflective of the resident's needs, provide clear direction to the staff, and are being implemented. 2. All staff providing care will be trained on reviewing person centered service plans and how to ensure they are implemented. 3. This area needing correction will be evaluated on a monthly basis by RCCs, RN, and Administrator. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored

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

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 6 sampled residents (#s 2, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: Resident 2, 4, 5 and 6's current service plans were reviewed during the survey. The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), Staff 4 (Health Services Specialist/RN) and Witness 3 (Agency RN) on 08/07/25 at 12:45 pm. They acknowledged the findings.

1. Mt. Bachelor will hold Service Planning Team meetings that includes the resident, the resident's legal repesentative, if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who is familiar with or who is going to provide service to the resident for residents # 2, #4, #5, and #6. From these meetings the service plans for residents #2, #4, #5, and #6 will be updated. 2. During all 90 day reviews and at change of condition, Mt. Bachelor will hold Service Planning Team meetings that include the resident, the resident's legal representative, if applicable, and any person of the resident's choice, the Administrator or designee, and at least one other staff person who is familiar with or who is going to provide service to the resident.This team will review and participate in the development of the quarterly or change of condition service plan as well as document the outcomes in the resident's chart. 3. This area needing correction will be evaluated on a monthly basis by RCCs, RN, and Administrator. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to evaluate changes of condition and refer significant changes of condition to the facility RN, failed to develop actions or interventions and communicate the actions or interventions to staff on each shift, and/or failed to monitor short term changes of condition through resolution for 4 of 7 sampled residents (#s 2, 3, 4, and 7) reviewed with changes of condition. Resident 4 experienced ongoing weight loss. Findings include, but are not limited to: 1. Resident 4 moved into the community in 08/2020 with diagnoses including dementia and hypertension. The resident was identified by the staff during the acuity interview on 08/04/25 to have experienced severe weight loss. Resident 4's progress notes and interim service plans, dated 05/02/25 through 08/03/25, service plan, dated 01/20/25, and weight records, dated 04/21/25 through 08/2025, were reviewed, and interviews with staff were conducted. The following was identified: a. Resident 4’s weight record review showed the following: * 04/21/25 – 180.2 pounds; * 05/2025 – no weight available; * 06/2025 – no weight available; * 07/2025 – 158.6 pounds; and * 08/2025 – 149.2 pounds. Resident 4 had a severe weight loss of 21.6 pounds or 11.98% of his/her body weight in three months between 04/2025 and 07/2025. There was no documented evidence the facility completed an evaluation of the resident’s weight loss, referred the weight loss to the RN, determined and communicated interventions to staff on each shift, or that the resident was monitored following the severe weight loss. An observation was made of Resident 4 on 08/04/25 at 4:30 pm. The resident was served cheese manicotti, green beans, a breadstick, and a milkshake. The resident was able to eat independently and ate approximately 75% of his/her meal. Staff checked on the resident during mealtime. On 08/05/25 at 11:50 am, the resident was served a Cuban sandwich, celery, carrots, chips, watermelon, soda and a milkshake. Staff were assisting the resident by cueing and holding a drink with a straw. The resident ate some chips, watermelon, and drank the soda. The intake was approximately 10%. On 08/05/25 at 1:43 pm, Witness 3 (Agency RN) stated “I have not dealt with weights in the facility so far.” On 08/06/25 at 12:15 pm, the resident’s weight record was reviewed with Staff 2 (RCC). Staff 2 acknowledged she would enter weights in the electronic record, then the facility RN would review, and the weights for July and August 2025 had not been entered. The facility's failure to evaluate the resident for weight loss, refer to the facility RN, determine actions or interventions, communicate the interventions to staff, and monitor put the resident at risk for further weight loss. The resident experienced further severe weight loss of 9.4 pounds or 5.92% in one month between July and August 2025. b. Resident 4 was identified in the acuity interview on 08/04/25 as a fall risk and had a history of falls. A review of the resident’s progress notes indicated the resident had five falls between 05/02/25 and 05/25/25. A review of the service plan available to staff, dated 01/20/25, indicated the resident required cueing for memory. The following falls lacked evidence that interventions were resident-specific and/or were monitored weekly to resolution: * 05/02/25- Unwitnessed injury fall--resident bumped head and injured hip; * 05/09/25- Witnessed noninjury fall, resident slid out of chair; * 05/11/25- Unwitnessed noninjury fall; * 05/13/25- Witnessed noninjury fall, tripped on toes while walking to bathroom; and * 05/25/25- Unwitnessed noninjury fall. During the survey from 08/04/25 through 08/07/25, the resident was observed to be bed-bound. c. The following short-term changes of condition for Resident 4 lacked documentation of actions or interventions needed for the resident were developed, communicated to the staff on all shifts, and/or monitored at least weekly through resolution: * 05/27/25- Blood in brief; * 07/05/25- Slept 90% of the day; * 07/11/25- Resident declining and “might be appropriate for hospice”; * 07/17/25- Decreased intakes, fell asleep with food in mouth; * 07/24/25- Bloody urine-soaked chuck, abdominal pain; and * 07/24/25- Hospice admit. The need to ensure the facility evaluated changes of condition, referred to the facility RN, determined and documented what actions or interventions were needed for changes of condition, communicated the actions or interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (Interim ED), Staff 2, Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings. No additional documentation was provided. 2. Resident 7 was admitted to the facility in 03/2025 with diagnoses including acute respiratory failure with hypoxia (oxygen deprivation). Resident 7’s MARs, dated 07/01/25 through 08/04/25, noted the resident took warfarin, an oral anticoagulant (blood thinner) and had weekly PT/INR tests (a blood test that measures how long it takes your blood to clot). A progress note dated 07/03/25 noted the resident returned to the facility from a stay in the hospital. There was no documented evidence Resident 7 received his/her warfarin between 07/03/25 through 07/11/25, nor was there evidence the resident was being monitored for the missed doses of warfarin. Resident 7 returned to the facility and missed doses of warfarin. There was no documented evidence interventions or actions were determined, the interventions or actions were communicated to staff on each shift, or the resident was monitored for missing his/her medication. The change of condition, including a lack of monitoring for any side effects relating to missed medication, was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN) and Staff 4 (Health Services Specialist/RN) on 08/06/25 at 3:20 pm. 3. Resident 2 moved into the facility in 07/2023 with diagnoses including dementia, high blood pressure, and high cholesterol. The resident’s progress notes, dated 07/01/25 through 08/04/25, MARs, dated 07/01/25 through 08/04/25, and interim service plans (ISPs), dated 06/30/25 and 07/25/25, were reviewed. Resident 2 was observed, and staff were interviewed. The resident experienced the following changes of condition: a. On 06/30/25, the facility identified a laceration on Resident 2’s toe. There was no documented evidence the laceration was monitored through resolution. b. Facility documentation noted the following: * 07/25/25: The resident “displayed symptoms of weakness and chest pain”, “staff called 911” and Resident 2 was transferred to the Emergency Department (ED). * 07/29/25: “the resident was having chest pain”, staff called 911, and Resident 2 was transported to the hospital. Progress notes also revealed Resident 2 had a pacemaker and had been having complaints of weakness, chest pains, chest “sensations,” lethargy, and the resident reported that s/he “just didn’t feel right.” There was no documented evidence the resident was evaluated upon returning from the ED and hospital, provided staff the signs and symptoms of what to monitor Resident 2 for, and who to contact if the resident did experience further signs or symptoms. The need to ensure the facility evaluated residents after experiencing changes of condition and monitored the resident per their evaluated needs was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings. 4. Resident 3 moved into the facility in 04/2025 with diagnoses including dementia. The resident’s progress notes, dated 04/22/25 through 05/04/25, and MARs, dated 07/01/25 through 08/04/25, were reviewed. Resident 3 and staff were interviewed. The facility failed to monitor the resident for the following: * Moving from another state into the facility; and * Missing two doses of levothyroxine (for hypothyroidism) on 07/04/25 and 07/10/25. On 08/05/25 at 10:31 am, Resident 3 confirmed not knowing s/he was moving to the facility and missing his/her family and friends from his/her previous state. The resident also confirmed mourning the loss of his/her spouse who passed away “not even a year ago.” The need to ensure the facility monitored the resident through resolution was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings.

1. RN will evaluate changes of condition, develop an action plan or interventions and communicate the actions or interventions to staff on each shift on an ISP, as well as monitor short term changes of condition through resolution for residents #2, #3, #4, and #7. These will include, but are not limited to: 1. Resident #4, ensure monthly weights are taken, reviewed, and specific resident focused information will be added to the service plan that directs staff to encourage higher calorie intake. Staff will be advised to notify the RN immediately upon realizing weight loss. RN will conduct an assessment and thorough review of all falls and all conditions found during the assessment as well as all previously documented conditions regarding Resident #4. RN will create a short-term change of condition for all care needs not currently being addressed, documenting the actions or interventions needed for the resident. The short term change of condition and actions/intervention will be communicated to the staff on all shifts, and/or monitored at least weekly through resolution. This assessment will include, but not be limited to the following already identified: * 5/2/25 Unwitnessed injury fall --resident bumped head and injured hip; * 5/9/25 Witnessed noninjury fall, resident slid out of chair; * 5/11/25 Unwitnessed noninjury fall; * 5/13/25 Witnessed noninjury fall, tripped on toes while walking to bathroom and; *5/25/25 Unwitnessed noninjury fall. 1. RN will review Resident #7's MAR, looking for missed medication, patterns and opportunities for educating staff on actions/interventions going forward. 1. RN will assess Resident #2's toe to confirm the laceration has healed. Any skin condition will be documented and monitored until resolved. 1. RN will assess Resident #2 for weakness and chest pain. RN and RCC will look at historical patterns of weakness and chest pain to determine if specific areas of daily activity may benefit from additional monitoring. If so, this will be documented and shared with staff on all shifts. It will be noted on his/her service plan and staff will be advised to inform medical transport of his/her pacemaker. 1. Staff will monitor Resident #3 as a new move in. 2. All Med Techs will be provided re-training on August 25th, 26th, and 27th. Another training will be scheduled for any Med Techs who happen to miss the first one. The training will focus on ensuring timely medicaiton deliver as well as documentation standards - staff will be completing the education with a return demonstration and competency check upon completion. Med Techs will also be trained on ensuring medications are given to residents returning to the community, documentation for interventions or actions, how to communicate it to staff on each shift and monitoring residents for missing medications. 2. Med Techs, Charge Nurses and RCC's have reviewed short term/significant changes of condition - with a focus on intervention and monitoring throught to resolution. This was completed with the Central Office Health Care Department Team on August 13th, 2025. It also included locating change of conditions, looking for actions or interventions and monitoring short term conditions through resolution. 2. Med Techs will be re-trained on monthly weights, how to review and report to RN any significant changes. This will be monitored y the RCC's to ensure completion. 2. Med Techs will be re-trained on ensuring residents are evaluated upon returning from the ED and hospital, providing all staff the signs and symptoms of what to monitor resident for, and how to know who to contact if the resident did experience further signs or symptoms. 2. Staff will be re-trained on why to and how to monitor new residents, also how to ensure their medications are available, entered properly and administered on time. 3. This area needing correction will be evaluated on a weekly basis by RCCs, RN, and Administrator at weekly clinical meetings. 4. The RCC's, RN and Administrator will be responsible to ensure the corrections are completed and monitored

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 2 of 2 sampled residents (#s 4 and 5) who experienced significant changes of condition for severe weight loss and admission to hospice. Resident 4 experienced ongoing severe weight loss. Findings include, but are not limited to: 1. Resident 4 moved into the community in 08/2020 with diagnoses including dementia and hypertension. During the acuity interview on 08/04/25, staff reported Resident 4 had significant weight loss and a recent hospice admission. a. Resident 4 experienced a weight loss of 21.6 pounds or 11.98% in three months between April and July 2025, and an additional weight loss of 9.4 pounds or 5.92% in between July and August 2025. There was no documented evidence of an RN assessment for the significant change of condition related to the severe weight loss, that included RN findings, resident status, and interventions made as a result of the weight loss. The facility failure to ensure an RN assessment was completed put the resident at risk for further weight loss. The resident experienced further severe weight loss of 9.4 pounds or 5.92% in one month between July and August 2025. Refer to C 270, example 1a. b. Resident 4 experienced a decline and was admitted to hospice services on 07/23/25. There was no documented evidence of an RN assessment for the significant change of condition related to hospice admission. Refer to C 270, example 1c. The need to ensure an RN assessment was completed for residents who experienced a significant change of condition to include findings, status, and interventions made as a result was reviewed with Staff 1 (Interim ED), Staff 2, Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings. No additional documentation was provided. 2. Resident 5 moved into the community in 07/2024 with diagnoses including dementia and hypertension. Observations of the resident, interviews with staff, and review of the resident's 05/28/25 service plan, progress notes and interim service plans (ISPs) were completed. The following was identified: Staff documented in a progress note, dated 05/28/25, reporting a significant change of condition and indicated Resident 5 was full assist with ADLs. An ISP dated 05/28/25 noted Resident 5 had been admitted to hospice and needed full assist with dressing and toileting. There was no documented evidence the facility RN had completed an assessment to include findings, resident status and interventions. The need to ensure the facility RN performed timely assessments, and developed interventions was reviewed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), Staff 4 (Health Services Specialist/RN) and Witness 3 (Agency RN) on 08/07/25 at 12:45 pm. They acknowledged the findings.

1. RN will complete an assessment for significant change of condition for Resdient #4 related to the weight loss, that includes RN findings, resident status, hospice involvement and interventions made as a result of the weight loss. The changes will be documented in the assessement and the service plan will be updated. 1. RN will complete an assesement of Resident #5 to include findings, resident status and interventions. 2. All staff will be trained on notifying RN of the need for an assessment/change of condition. 2. RN will ensure assessments and changes of condition are completed as needed and timely and develop interventions for staff according to the assessed needs of the resident. RN will ensure RCC's are aware, RCCs will notify care staff each shift of any changes. 3. This area needing correction will be evaluated on a weekly basis by RCCs, RN, and Administrator during weekly clinical meetings. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored

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

OAR 411-054-0050(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 implement effective methods of infection control for 1 of 1 sampled resident (# 4) whose ADL care was observed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 08/2020 with diagnoses including dementia and hypertension. Observations were made during the survey on 08/04/25 through 08/07/25 to determine adherence to universal precautions for infection control. a. During an ADL observation on 08/05/25 at 9:36 am, the following was noted: * Staff 7 (CG) and Staff 10 (CG) provided incontinence care for Resident 4; * Both CGs were wearing gloves upon the surveyor’s arrival to the room; * Staff 10 was assisting to reposition the resident, and Staff 7 removed Resident 4's soiled incontinence product, placed it in the garbage can, and proceeded to provide perineal care, then removed the walkie-talkie from his/her shirt and placed it on the bedside table with the soiled gloves; * Staff 7 put on a new incontinence product and then opened the resident’s dresser and removed clean clothes, and both CGs dressed the resident using the same soiled gloves; * Staff 7 and 10 assisted with the resident’s repositioning with pillows, and Staff 7 used the bed control to elevate the head of the bed, then proceeded to place the walkie-talkie back on the shirt, removed a plate from the table, and placed it in the sink using the same soiled gloves; and * Staff 7 and 10 both removed gloves as they walked out of the room with trash and dirty laundry. No hand hygiene was observed. b. On 08/06/25 at 9:00 am, an ADL observation was made, and the following was noted: * Staff 10 and Staff 9 (CG) provided incontinence care for Resident 4; * Both CGs were wearing gloves upon the surveyor’s arrival to the room; * Both Staff 10 and 9 assisted with peri care, then removed soiled gloves. No hand sanitization was observed before applying clean gloves; and * Staff 9 applied barrier cream, then wiped off barrier cream on gloves with wet wipes and proceeded to apply a new incontinence product and repositioned the resident’s pillows using the same gloves. Both CGs removed gloves after care. No hand hygiene was observed. The observations and the need to implement effective methods of infection control were discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings.

1. Staff #7, Staff #9 and Staff #10 will be trained on overall effective methods of infection control as well as specific mothods of infection control regading the care of Resident #4. 2. All care staff will be trained on effective methods of infection control at the all staff meeting August 28th, 2025 by the Infection Control Specialist. 3. This area needing correction will be evaluated on a monthly basis by RCCs, RN, and Administrator. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored

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:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 7 sampled residents (#s 3 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility 04/2025 with diagnoses including dementia and hypothyroidism. The resident’s MARs, dated 07/01/25 through 08/04/25, and physician’s orders, dated 04/07/25 through 07/17/25, were reviewed and the following was identified: a. Resident 3 had a physician’s order for famotidine (to treat acid reflux). The medication had not been transcribed to the MAR and had not been administered to the resident. b. On 04/07/25, the resident’s physician signed that he wanted to be notified "When resident misses any scheduled medication/treatment". The facility did not administer Resident 3's levothyroxine (for hypothyroidism) on 07/04/25 and 07/10/25 due to "drug not available" and "drug not given". On 08/05/25 at 11:39 am, Staff 1 (Interim ED) verified there was no documented evidence the resident’s physician was notified when the medication was not administered. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1, Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. No additional information was received. 2. Resident 4 moved into the facility in 08/2020 with diagnoses including dementia and hypertension. Resident 4's most recent physician orders, dated 07/29/25, and MARs, dated 07/01/25 through 08/04/25, were reviewed and revealed that the facility was not following the orders as written. Resident 4 had orders to discontinue cephalexin 250 mg every other day for urinary tract infection prevention on 07/29/25. MAR review indicated the medication was administered on 7/31/25 and 8/4/25. In an interview on 08/07/25 at 10:30 am, Staff 2 (RCC) confirmed the order was still active in MAR. The need to ensure facility staff carried out all orders as prescribed was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings. No additional documentation was provided.

1. The MARs of Residents #3 and #4 will be reviewed by RN and RCC in the effort to find patterns or cause of missed meds. All MTs will be re-trained on any issues found from this review. Med Tech training is scheduled for August 25th, 26th, 27th 2. All Med Techs will be retrained on medicaion managmemnt and safe distribuion, ensuring medication orders are carried out as prescribed. 3. This area needing correction will be evaluated on a daily basis by RCCs, RN, and Administrator during the daily dashboard meetings. These meetings focus on the previous 24 hrs looking a the missed meds, not available/not given medications and incidents. RCC's follow up the same day with concers. 4. The RCC's, RN and Administrator will be responsible to ensure the corrections are completed and monitored

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR which included resident-specific parameters for 2 of 7 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 07/2023 with diagnoses including dementia. The resident’s progress notes, dated 07/01/25 through 08/04/25, MARs, dated 07/01/25 through 08/04/25, and interim service plan, dated 06/30/25, were reviewed and staff were interviewed. The following was noted: On 06/30/25, staff identified a "Laceration" on Resident 2's "Left fourth toe". Staff documented on 07/01/25, “changing” the resident’s bandage, and “cleansed the wound with wound cleanser spray, applied [antibiotic] ointment, and dressed with pad”. There was no documented evidence the facility transcribed the treatment onto the resident’s MAR. The need to ensure MARs were accurate and included resident specific treatments was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. No additional information was received. 2. Resident 3 moved into the facility in 04/2025 with diagnoses including dementia. The resident’s MARs, dated 07/01/25 through 08/04/25, were reviewed and the following inaccuracies were identified: a. Resident 3 had a signed physician's order for the facility to administer famotidine (to treat acid reflux), scheduled, every morning, at 8:00 am. The medication was transcribed onto the resident’s MAR, instructing staff to administer the medication, "[one] tablet by mouth every morning as needed". b. The following PRN medications lacked the sequential order for administration: * Antacid-antigas liquid (to treat acid reflux); * Famotidine; * Acetaminophen (to treat pain); and * Tramadol (to treat pain). The need to ensure MARs were accurate and included resident specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. No additional information was received.

1. Resident #1s MAR will be reviewed and updated to ensure all treatments are transcribed onto the resident's MAR, including but not limited to specific directons regarding the change of bandage. 1. Resident #3's MAR will be reviewed and updated to accurately reflect orders and include resident-specific parameters. This will include, but will not limited to: * Antacid-antiga liquid (to treat acid reflux); * Acetaminiphen (to treat pain) and * Tramadol (to treat pain). 2. The RN, RCCs and all Med Techs will be trained on ensuring all treatmens are transcribed onto the residen's MAR as well as ensuring MARs are accurate and include resident-specific parameters, noting reasons for the medication. 3. This area needing correction will be evaluated on a monthly basis by RCCs, RN, and Administrator. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0060 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 potentially restraining qualities was assessed by an RN, PT or OT prior to use, documented other less restrictive alternatives prior to use, provided instruction to caregivers on correct use and precautions, and documented use of the rails in the resident's evaluation and service plan for 2 of 2 sampled residents (#s 4 and 5) who had side rails. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2024 with diagnoses including dementia and hypertension. On 08/05/25, Resident 5's hospital bed was observed to have half-length side rails on both sides of the bed. The side rails were in the up position and securely fastened to the bed. There was no documented evidence the device with potentially restraining qualities had been assessed by an RN, PT, or OT, including documentation of less restrictive alternatives evaluated prior to use, the resident had been informed of the risks and benefits of the device, or the service plan had identified the correct use and precautions related to the device. On 08/06/25, Staff 3 (Health Services Manager/LPN) and Staff 4 (Health Services Specialist/RN) confirmed there was no documented evidence an assessment of the device with restraining qualities had been completed. The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3, Staff 4 and Witness 3 (Agency RN) on 08/07/25 at 12:45 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2020 with diagnoses including dementia and hypertension. On 08/04/25, Resident 4's hospital bed was observed to have quarter-length side rails on both sides of the bed. The side rails were in the up position and securely fastened to the bed. There was no documented evidence the device with potentially restraining qualities had been assessed by an RN, PT, or OT, including documentation of less restrictive alternatives evaluated prior to use, the resident had been informed of the risks and benefits of the device, or the service plan had identified the correct use and precautions related to the device. On 08/05/25 at 1:10 pm, Staff 3 (Health Services Manager/LPN) and Staff 4 (Health Services Specialist/RN) confirmed there was no documented evidence an assessment of the device with restraining qualities had been completed. The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements were discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3, and Staff 4 on 08/07/25 at 11:00 am. They acknowledged the findings. No additional documentation was provided.

1. RN will complete required assessment of Resident #4 and #5's hospital beds for potential restraining qualities, documenting other less restrictive alternatives prior to use and quarterly, providing instruction to caregivers on correct use and precautions, and documenting use of the rails in the residen't evaluaiton and service plan. 2. On August 20th, 2025 RN was trained on ensuring assessments of all supportive devices with potential restraining qualites are assesed prior to use and quarterly, documenting other less restrictive alternatives prior to use, providing instruction to caregivers on correct use and precautions, and documenting use of supportive devices in resident evaluations and service plans. RN will be attending "The Role of the RN October 13-16, 2025. 2. Care staff will be re-trained to alert RN when they become aware of a supportive device with potential restraining qualities that has not been assessed and/or there is no documentation in the service plan providing instruction to caregivers on correct use and precautions, documenting the resident's ability to use the supportive device. 3. This area needing correction will be evaluated on a monthly basis by RCCs, RN, and Administrator. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored

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:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 6 sampled residents (#s 2, 3, and 4) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 07/2023 with diagnoses including dementia, high blood pressure, and high cholesterol. The resident’s service plan, dated 05/30/25, MARs, dated 07/01/25 through 08/04/25, and corresponding ABST individual minutes were reviewed. Interviews with staff were conducted. Resident 2’s care time and care elements were not reflective in the following areas: * Medication administration, passing out medications; * Cueing or redirecting due to cognitive impairment or dementia; and * Monitoring physical symptoms. The need to ensure the facility’s ABST accurately captured care time in all care elements that staff were providing was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 04/2025 with diagnoses including dementia. The resident’s service plan, dated 05/12/25, MARs, dated 07/01/25 through 08/04/25, and corresponding ABST individual minutes were reviewed. Interviews with staff were conducted. Resident 3’s care time and care elements were not reflective in the following areas: * Medication administration, passing out medications; and * Cueing or redirecting due to cognitive impairment or dementia. The need to ensure the facility’s ABST accurately captured care time in all care elements that staff were providing was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:32 am. They acknowledged the findings. 3. Resident 4 moved into the facility in 08/2020 with diagnoses including dementia and hypertension. The resident’s service plan, dated 04/21/25, interim service plans, and corresponding ABST individual minutes were reviewed. Interviews with staff were conducted. Resident 4’s care time and care elements were not reflective in the following areas: * Bowel and bladder management; * Supervising, cueing, or supporting while eating; and * Safety checks. The need to ensure the facility’s ABST accurately captured care time in all care elements that staff were providing was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings.

1. Facility Management will review the ABST tool for accuracy and ability to capture time in all care elements that staff are providing, specifically regarding; Resident #2 in the areas of : * Medication administration, passing out medications; * Cueing or redirecting due to cognitive impairment or dementia; and * Monitoring physical symptoms. Resident #3 * Medication administration, passing out medications; and * Cueing or redirecting due to cognitive impairment or dementia. Resident #4: * Bowel and bladder management; * Supervising, cueing, or supportiing while eating; and * Safety checks 2. Facility Management will review ABST tool to ensure it accurately captures care time and all care elements that staff are providing. Any errors noted will be corrected. As part of service plan reviews going forward, all service plans completed will be reviewed and compared to the ABST tool to ensure all care time and care elements are reflecive. 3. This area needing correction will be evaluated on a monthly basis by RCCs, RN, and Administrator as well as each assessment/evaluation and care plan will be compared to ABST tool upon completion to confirm accuracy. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in and whenever there was a significant change of condition for 2 of 6 sampled residents (#s 3 and 4) whose ABST evaluations were reviewed. Findings include but are not limited to: The facility’s ABST was reviewed during the survey on 08/04/25 through 08/07/25. The following was identified: a. Resident 3 did not have an ABST evaluation completed prior to move-in. b. Resident 4’s ABST evaluation did not have evidence that it was updated with a significant change of condition. The need to ensure residents’ ABST evaluations were updated before move-in and whenever there was a significant change of condition was discussed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/LPN), and Staff 4 (Health Services Specialist/RN) on 08/07/25 at 11:00 am. They acknowledged the findings.

1. RN will complete an ABST evaluation for Resident #3. 1. RN will update Resident #4s ABST evaluation to include the significant change of condition. 2. RCCs, RN and Administrator will be trained on ensuring ABST evaluations are complete and accurate for all assessments and service plans. Going forward, at the completion of each assessment and service plan, they will be cross referenced with ABST to ensure accuracy. 3. This area needing correction will be evaluated on a monthly basis by RCCs, RN, and Administrator as well as each assessment/evaluation will be compared to ABST evaluation upon completion to confirm accuracy. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 20, and 21) completed all required pre-service orientation training and pre-service dementia training prior to beginning their job responsibilities. Findings include but are not limited to: Staff training records were reviewed on 08/06/25 with Staff 13 (Business Office Manager) at 10:00 am. 1. Staff 8 (MT), hired on 04/08/25, lacked documented evidence pre-service orientation and pre-service dementia training was completed prior to beginning job responsibilities in the areas of: * Fire Safety and emergency procedure; * Infectious Disease Prevention; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors, reducing use of antipsychotics; * Strategies for addressing social needs & engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing flood/fluids, preventing wandering, use of person-centered approach. 2. Staff 20 (CG), hired on 03/17/25, lacked documented evidence pre-service orientation training and pre-service dementia training was completed prior to beginning job responsibilities in the areas of: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency preparedness; * Infectious disease prevention * Approved Home and Community-Based Services (HCBS) course; * Approved LGBTQIA2S+ course; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors, reducing use of antipsychotics; * Strategies for addressing social needs & engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing flood/fluids, preventing wandering, use of person-centered approach. 3. Staff 21 (MT), hired on 04/08/25, lacked documented evidence pre-service orientation training and pre-service dementia training was completed prior to beginning job responsibilities in the areas of: * Resident right and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency preparedness; * Infectious disease prevention * Approved Home and Community-Based Services (HCBS) course; * Approved LGBTQIA2S+ course; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors, reducing use of antipsychotics; * Strategies for addressing social needs & engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing flood/fluids, preventing wandering, use of person-centered approach. The requirements for pre-service orientation and pre-dementia training for all employees prior to starting their job duties was discussed with Staff 13 (Business Office Manager) on 08/06/25 at 10:00 am. The findings were additionally reviewed with Staff 1 (Interim ED), Staff 2 (RCC), Staff 3 (Health Services Manager/ LPN), and Staff 4 (Health Services Specialist/RN) 08/07/25 at 11:30 am. They acknowledged the findings.

1. Staff #8, #20, and #21's training file will be audited to ensure all required training has been completed, including the below trainings already noted. All missing training will be completed by alleged compliance date. Staff #8 * Fire Safety and emergency procedue; * Infectious Disease Prevention; * Dementia disease process including progression, memory loss, psychiatric and behavior symptoms; * Techniques for understanding, communicating and responding to behaviors, reducing use of antipsychotics; *Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. Staff #20 * Resident rights and values of CBC care; *Abuse reporting requirements; * Fire safety and emergency preparedness; * Infectious disease prevention * Approved Home and Community-Based Servcies (HCBS) Course; * Dementia disease process includign progression, memory loss, psychiatric and behavioral symptoms; * Techniques for undersanding, communicating and responding to behaviors, reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activies; and * Specific aspects of dementia includign addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. Staff #21 * Resident right and values of CBC care; *Abuse reporting requirements; * Fire safety and emergency preparedness; * Infectious disease prevention * Approved Home and Community-Based Services (HCBS) course; * Approved LGBTQIA@S+ course; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors, reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 20 and 21) demonstrated satisfactory performance in assigned duties prior to working independently. Findings include, but are not limited to: Staff training records were reviewed on 08/06/25 with Staff 13 (Business Office Manager) at 10:00 am. There was no documented evidence Staff 8 (MT), hired 04/08/25, Staff 20 (CG), hired 03/17/25, and Staff 21 (MT) hired 04/08/25, had demonstrated competency in the following required topics within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Medication Pass (Staff 8 and Staff 21); and * First Aid and abdominal thrust training (Staff 8 and Staff 21). The lack of documented competency in medication pass was shared with Staff 1 (Interim ED) on 08/06/25 at 1:00 pm. Staff 1 removed Staff 8 and Staff 21 from med pass assignments until competency was demonstrated and documented by Witness 3 (Agency RN). Documentation of the demonstration of competency was provided to the survey team on 08/07/25. The need to ensure staff had documented demonstration of competence in assigned duties and completed First Aid and abdominal thrust training within 30 days of hire was reviewed with Staff 13 (Business Office Manager) on 08/06/25 at 10:00 am. The findings were additionally reviewed with Staff 1, Staff 2 (RCC), Staff 3 (Health Services Manager/ LPN), and Staff 4 (Health Services Specialist/RN) 08/07/25 at 11:30 am. They acknowledged the findings.

1. Regarding all areas identified for Staff #8 and Staff #21 that were listed in the survey as being required prior to working were corrected on 8/7/25 and provided to the survey team. 1. RN or RCC will conduct a competancy review of Staff #8, #20, and #21, re-training them on any areas that result in less than satisfactory performance in assigned duties, including, but not limited to the already noted areas: * Role of service plans in providng individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Medication pass (Staff 8 and Staff 21); 2. Staff #13, RN and RCCs will be trained on ensuring and documenting all staff can demonstrate competency in required topics. 3. This area needing correction will be evaluated on a monthly basis by BOM, RCCs, RN, and Administrator. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 04/2025 through 07/2025 were reviewed on 08/05/25. The facility conducted four fire drills and failed to document the following required components: * 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. On 08/05/25 at 1:30 pm, the need to ensure all required components of fire drills were documented and evidence of alternate routes were used during fire drills was discussed with Staff 1 (Interim ED) and Staff 12 (Maintenance Manager). Staff acknowledged the findings.

1. Maintenance Manager, BOM, RN, RCCs and Administrator will be trained on the requirements of fire drills. 2. The below requirements will be added to Facility fire drill forms and be executed and documented property. * 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 * Alternate routes used during fire drills.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at least annually. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 08/05/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities at least annually. The need to ensure residents were instructed in fire and life safety procedures at least annually was discussed with Staff 1 (Interim ED) and Staff 12 (Maintenance Manager) on 08/05/25 at 11:25 am. Staff acknowledged the findings.

1. A full assessent of our resident fire and safety instructions will be completed. All required topics will be added to our checklist. 2. We will ensure our process for instructing residents in general safety procedures, evacuation methods, and responsiblities at move in and at least annually meet the requirements. We will add all required topics to our training documents. We will hold a resident meeting 2x year to cover all required resident training, instructing them on general safety procedues, evacuation methods, responsibilities during fire drills, and designated meetings places outside the building or within the fire safe area in the event of actual fire. We will complete written record of fire safety training including content of the training sessions and the residents attending. All residents absent will receive individual training and documentation will be kept. Maintenance Manager, RN, RCCs and Administrator will be trained on requirements for facilty's fire and life safety procedures. 3. This area needing correction will be evaluated on a monthly basis by Maintenance Manger, RN, and Administrator. 4. The Maintenance Manager, RN and Administrator will be responsible to ensure the corrections are completed and monitored.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 08/05/25 and the following was identified as needing repair: Exterior concrete pathways located in the courtyard and in front of the facility, contained multiple drop-offs measuring greater than two inches from the concrete to the planting bed surface. These drop-offs created potential hazards for residents that frequently walked the pathways. The facility’s exterior was toured with Staff 1 (Interim ED) and Staff 12 (Maintenance Manager) on 08/06/25. They acknowledged the findings.

1. Before alleged compliance date, the drop offs located in the exterior concrete pathways located in the courtyard and in front of the facility will have ground cover added to ensure there are no drop offs measuring greater than two inches from the concrete to planting bed surface. 2. Maintenance Manager and Administrator will be trained on the required exterior pathways and how to ensure they are maintained and in good repair with no drop offs greater than two inches form the concrete to planting bed surface. 3. This area needing correction will be evaluated on a monthly basis by Maintenance Manger and Administrator. 4. The Maintenance Manager and Administrator will be responsible to ensure the corrections are completed and monitored.

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

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including pronouns and gender identity, for 2 of 2 sampled residents (#s 1 and 3) whose move-in evaluations were reviewed. Findings include, but are not limited to: Refer to: C 252.

1. Residents #1 and #3's move in evaluations will be updated as required. Refer to C 252. 2. Refer to C252 3. This area needing correction will be evaluated on a monthly basis by RCCs, RN and Administrator. 4. The RN and Administrator will be responsible to ensure the corrections are completed and monitored

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by:

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired staff (#s 20 and 21) completed the department-approved LGBTQIA2S+ training prior to beginning their job responsibilities. Findings include, but are not limited to: Refer to: C 370.

1. Staff #20 and #21 will complete the department-approved LGBTQIA2S+ training. 2. BOM and Administrator will trained on required training for staff prior to beginning their job. All required training will be added to the facility's Orientation Checklist to ensure all is complete. The completion of the checklist will be required prior to staff starting their job. Refer to C 370. 3. This area needing correction will be evaluated on a monthly basis by BOM and Administrator. 4. The BOM and Administrator will be responsible to ensure the corrections are completed and monitored.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: