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 immediately investigated and, if abuse could not be ruled out, were reported to the local Seniors and People with Disabilities (SPD) office for 1 of 2 sampled residents (# 1) who was reviewed for an injury of unknown cause. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and was on hospice services. The resident’s record, including progress notes, dated 10/12/25 through 01/11/26, and incident reports were reviewed. The following was identified: On 11/28/25, the facility documented that a hospice bath aide reported that the "[resident] has a swollen eye and wound to right wrist reported to MedTech." There was no documented evidence the facility immediately investigated the wound or was able to reasonably conclude that the physical injury was not the result of abuse. On 01/15/26 at 11:02 am, Staff 1 (ED) confirmed she was unable to locate the investigation. Survey requested the facility report the incident, and confirmation that the facility reported the injury of unknown cause to the local SPD unit was received on 01/15/26 at 1:08 pm. The need to ensure injuries of unknown cause were immediately investigated and, if the investigation could not rule out abuse, reported to the local SPD office was discussed with Staff 1, Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Upon identification of the deficiency on 01/15/2026, the facility immediately reported the injury of unknown cause involving Resident #1 to SPD. Resident #1 no longer resides in the facility; however, staff education, reporting procedures, and audit processes have been implemented to ensure ongoing compliance. 2. How will the system be corrected so the violation does not happen again? All staff were re-educated on: Recognizing injuries of unknown cause, Immediate reporting requirements, Documentation expectations, The requirement to report even when residents are on hospice or have cognitive impairment. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and or designee will conduct weekly audits for 30 days of: Incident reports, Progress notes, Injury documentation and SPD reporting logs After 30 days, audits will occur monthly for three months. Findings will be reviewed during Quality Assurance/Performance Improvement (QAPI) meetings, and corrective actions will be taken as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and type 2 diabetes. The move-in evaluation failed to address the following required elements: * Pronouns; * Physical health status including vital signs if indicated by diagnoses, health problems or medications; * Cognition, including decision-making ability; * Independent activities of daily living, including the ability to manage medications, use the call system, housework, and laundry; * Emergency evacuation ability; * Complex mediation regimen; * Recent losses; * Elopement risk or history; and * Alcohol use. The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/14/26 at 2:10 pm. Staff acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. 2. How will the system be corrected so the violation does not happen again? The facility revised its move-in evaluation process from a paper-based system to the facility’s electronic health record (EHR) system to ensure all required elements are addressed prior to move-in. Staff responsible for admissions were trained on the facility’s EHR admission workflow and the regulatory requirements outlined in OAR 411-054-0034. Ongoing audits of move-in evaluations completed in the facility’s EHR will be conducted to ensure continued compliance. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and or designee will conduct weekly audits for 30 days of all new move-in evaluations to ensure completion of required elements. After 30 days, audits will be completed monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services or were being implemented for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and type 2 diabetes and was on hospice services. The resident's clinical record was reviewed, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff in the following areas: * Wandering into other residents’ apartments; * Meal routines and where s/he chose to dine; * Dressing ability; * Favorite food and beverages; * Current ability to express the need to use the restroom; * Refusals, full and partial, to accept shower assistance from the hospice bath aide and direction to staff when the refusals occurred; * Conflicting information relating to the use of an oral medication to treat type 2 diabetes; * Elopement risk; * Fall interventions; * Sleep patterns; and * Frequency of checks while the resident was in his/her apartment. The need to ensure residents’ service plans provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 06/2023 with diagnoses including dementia. The resident's clinical record was reviewed, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff or was not being implemented in the following areas: * The use of an electric toothbrush; * Current frequency of being resistive to care; * The need to be in the sitting position while receiving dressing assistance; * Answering "yes" to all questions asked; and * Morning routine. On 01/12/26 during the noon meal, Resident 2 was observed being fed by a staff member. The resident’s service plan reflected that s/he needed “cueing, prompting and reminders for optimal intake.” The service plan did not direct staff to assist in feeding him/her. Resident 2 was observed multiple times during the survey, dated 01/12/26 through 01/15/26, not wearing glasses. The resident’s service plan directed staff to remind him/her to put glasses on in the morning, take them off at night, and for staff to clean and store them. Resident 2 was observed in the dining room on 01/14/26 at 10:30 am sitting in the dining room. The resident’s walker was approximately three feet away, and not within reach. The resident’s service plan directed staff to ensure the walker “is within safe reaching distance.” During an interview with Staff 22 (CG) on 01/14/26 at 10:49 am, she reported that the resident was supposed to be “reminded” to eat and that s/he can eat independently, but “gets distracted and can take a long time.” She confirmed that when the resident was taking “too long” was when staff would assist to feed Resident 2. Staff 22 stated she was not aware of the resident having glasses and had not seen Resident 2 wearing glasses. The need to ensure residents’ service plans provided clear direction to staff and were being implemented was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. Service plan for Resident #2 was comprehensively reviewed and updated to ensure clear, individualized direction for staff regarding care needs, preferences, routines, safety risks, and interventions. Staff were re-educated on the updated plans and expectations for implementation. 2. How will the system be corrected so the violation does not happen again? The facility revised its service plan development and review process to ensure service plans provide clear and consistent direction for staff. Service plans are reviewed to confirm alignment between documented care, observed practice, and staff understanding. Staff education was reinforced regarding adherence to service plans, timely communication of changes in resident needs, and updating service plans as indicated. Coordination with external providers is clarified to ensure roles and responsibilities are accurately reflected in the service plan. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? RCC and or designee will conduct weekly audits for 30 days of service plans and direct care observations for consistency and implementation. After 30 days, audits will occur monthly for three months. Findings will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine actions or interventions needed for short-term changes of condition, communicate actions or interventions to staff on all shifts, and monitor changes through resolution, with at least weekly documentation, for 3 of 4 sampled residents (#s 1, 3, and 4) reviewed with short-term changes of condition. Findings include but are not limited to: 1. Resident 4 moved into the MCC in 10/2020 with diagnoses including dementia. The resident’s clinical record was reviewed. Resident 4 experienced the following changes of condition between 11/04/25 and 12/17/25: a. On 11/04/25, staff documented in progress notes that the resident was congested and coughing. On 11/13/25, staff documented Resident 4 didn’t go to his/her adult day services due to a cold. There was no documented evidence the resident’s cold symptoms were monitored through resolution. b. On 12/17/25, staff documented in progress notes that the resident had an unwitnessed fall. The facility initiated a temporary service plan on 12/17/25 to monitor for mobility changes. There was no documented evidence the resident’s mobility was monitored through resolution. Staff 3 (RCC) confirmed the lack of documented monitoring through resolution for both short-term changes of condition on 01/14/26 at 11:27 am. The need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1(ED), Staff 2 (Interim RN), and Staff 3 on 01/15/26 at 10:25 am. The findings were acknowledged, and no additional documentation was provided. 2. Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and type 2 diabetes and was on hospice services. The resident’s clinical record was reviewed. Resident 1 experienced the following changes of condition between 10/01/25 and 12/24/25: a. On 10/23/25, Resident 1 punched a wall which resulted in a skin tear located on his/her right knuckles. There was no documented evidence the facility monitored the resident’s skin tear through resolution. b. On 10/30/25, hospice discontinued the following medications: * Donepezil (for dementia); * Pravastatin (for hyperlipidemia); and * Metformin (for type 2 diabetes). There was no documented evidence staff had been provided monitoring instruction for the change in medication, or the medication changes had been monitored through resolution. c. On 11/12/25, Resident 1 started a new scheduled medication, haloperidol (for dementia with behavioral disturbances). There was no documented evidence the facility monitored the addition of the medication through resolution. d. On 11/25/25, Resident 1’s scheduled haloperidol was decreased due to reports of sedation. There was no documented evidence the facility monitored the resident for decreased sedation with the change in dosage. e. On 12/19/25, the resident started a new medication, melatonin (for sleep management). There was no documented evidence the facility monitored the resident’s sleep due to the addition of the medication through resolution. The need to ensure actions or interventions were determined, documented, and communicated to staff on all shifts for changes of condition and those actions or interventions were monitored for effectiveness, with weekly progress noted in the resident record until the condition resolved, das discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings. 3. Resident 3 moved into the memory care facility in 11/2019 with diagnoses including Alzheimer’s disease and type 2 diabetes. The resident’s clinical record was reviewed. Resident 4 experienced the following changes of condition between 10/12/25 and 01/11/26: a. On 10/14/25, staff documented in progress notes that the resident was “on alert for missed insulin 9/30.” There was no documented evidence the resident’s condition related to the missed insulin was monitored and documented at least weekly through resolution. b. On 11/06/25, staff documented in progress notes that the resident was congested and coughing. There was no documented evidence the resident’s cold symptoms were monitored through resolution. On 01/14/26 at 2:10 pm, the above findings were shared and the need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC). They acknowledged the findings, and no additional documentation was provided.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. The facility reviewed the clinical records for Residents #3 and #4 and updated monitoring documentation as appropriate. Staff were re-educated on recognizing changes of condition and documentation requirements. 2. How will the system be corrected so the violation does not happen again? The facility utilizes a weekly change-of-condition and skin monitoring tool to ensure short-term changes of condition are identified, monitored, and documented at least weekly until resolution. In addition, the interdisciplinary team (IDT) reviews short-term changes of condition during daily clinical meetings to confirm appropriate interventions, communication to all shifts, and ongoing monitoring. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Registered Nurse and or designee will conduct weekly audits for 30 days of documentation related to changes of condition, including progress notes, alerts, temporary service plans, medication changes, and monitoring through resolution. Monthly audits will continue for three months, with findings reviewed during QAPI meetings and corrective actions implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 sampled resident (# 3) who received incontinence care and for multiple sampled and unsampled residents during meal service and medication administration. Findings include, but are not limited to: 1. Throughout the change of ownership survey, dated 01/12/26 through 01/15/26, the following observations were made to determine adherence to universal precautions for infection control: a. Multiple meals were observed in the dining room on the fourth floor between 01/12/26 and 01/15/26. Staff were observed delivering food and beverages, providing feeding assistance to residents, using keys to enter the kitchenette, cleaning spilled food items off the floor, touching their faces, maneuvering walkers and wheelchairs, touching a resident’s hand, holding glassware from the lip, moving a garbage can, and grabbing a ready-to-eat dessert with their bare hands then stating it was for a resident without changing their gloves and/or performing hand hygiene between dirty and clean tasks. b. Observations of medication passes were made between 01/12/26 and 01/15/26. MTs were observed pouring and passing medications, touching residents, touching a computer and medication cart, pouring a single pill into their hand prior to handing it to the resident, touching dining room chairs, entering residents’ rooms, touching their face and their cell phone without changing gloves and/or performing hand hygiene between dirty and clean tasks. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene during dining services and completing medication passes to the residents, was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 10:25 am. They acknowledged the findings. 2. Observations were made during the survey to determine adherence to universal precautions for infection control. On 01/12/26 at approximately 1:37 pm and on 01/13/26 at approximately 11:25 am, the surveyor obtained permission and observed Staff 8 (CG) and Staff 9 (CG) on 01/12/26 and Staff 8 and Staff 10 (CG) on 01/13/26 provide incontinence care to Resident 3. During the observations, Staff 8, 9, and 10 failed to change gloves after removing a soiled incontinence product and wiping fecal matter from Resident 3's bottom area. Staff 8 and Staff 9 applied a new brief to Resident 3 and touched the resident's pants and the manual wheelchair while wearing the same soiled gloves. When Staff 8, 9 and 10 were finished providing incontinence care, they removed the gloves and performed hand hygiene. During the observations, staff failed to change gloves between clean and dirty tasks. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (Interim RN) and Staff 3 (RCC) on 01/14/26 at 2:10 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility re-educated staff on infection prevention and control practices, including hand hygiene and proper glove use with supervisory staff providing real-time correction when improper practices are observed. Resident #3’s care was reviewed, and staff were instructed on appropriate glove changes and hand hygiene, with leadership reinforcing that gloves do not replace hand hygiene and must be changed between tasks or after contact with bodily fluids. 2. How will the system be corrected so the violation does not happen again? The facility reinforced its infection prevention and control program to require proper hand hygiene and glove use during all resident care activities. Infection control education was reinforced for staff involved in incontinence care, meal service, and medication administration. The facility implemented direct observational audits to monitor compliance, incorporated infection control expectations into new hire orientation and ongoing training, and directed supervisory staff to intervene immediately when improper practices are observed. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Registered Nurse and or designee will conduct random infection control audits for 30 days, including observation of incontinence care, meal service, and medication administration. After 30 days, audits will occur monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 4 sampled residents (#s 1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the MCC in 10/2020 with diagnoses including dementia, hypertension, and edema. The resident’s current physician orders and the 12/2025 and 01/2026 MARs were reviewed. The resident had a 12/02/25 physician order to take 20 mg of furosemide two times daily for high blood pressure. Resident 4’s MAR noted s/he received 20 mg once daily, not twice daily, from 12/03/25 to 01/06/26. Therefore, the facility failed to ensure the resident’s furosemide medication orders were carried out as prescribed on 35 occasions. On 01/14/26 at 10:41 am, Staff 2 (Interim RN) and Staff 3 (RCC) acknowledged there were no additional orders indicating the resident was to receive one 20 mg tablet of furosemide daily. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, and Staff 3 on 01/15/26 at 10:25 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and type 2 diabetes. A review of the resident's physician orders and MARs, dated 10/01/25 through 01/12/26, revealed the following: From 10/30/25 through 01/08/26, the facility did not administer the following medications due to Resident 1 sleeping: * Haloperidol (for dementia with behavioral disturbances) – nine occasions; * Senna (for bowel care) – 12 occasions; * Olanzapine (for dementia behavior management) – 19 occasions; and * Quetiapine (for dementia with behaviors) – one occasion. On 01/15/26 at 11:50 am, Staff 20 (MT) confirmed he did not want to wake the resident up to administer medications due to the resident having behaviors and received no other direction in addition to document that Resident 1 was sleeping. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. For Resident #4, medication orders were clarified and corrected as needed, and provider guidance was obtained regarding missed doses. 2. How will the system be corrected so the violation does not happen again? The facility revised its medication administration process to ensure accurate order verification, provider clarification when medications are not administered, and proper documentation. Staff education and routine MAR audits were implemented, with supervisory oversight to ensure compliance. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Registered Nurse and Resident Care Coordinator will conduct weekly MAR and medication administration audits for 30 days, followed by monthly audits for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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

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 keep an accurate MAR and ensure there were resident specific parameters and instructions for PRN medications for 1 of 4 sampled residents (# 1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2025 with diagnoses including dementia, type 2 diabetes, and had recently been admitted onto hospice services. The resident’s physician’s orders and MARs, dated 10/01/25 through 01/12/26, were reviewed. The following was noted: a. The MAR was blank for the following treatment, monitoring, and medication administration: * Triamcinolone ointment (for dry skin/other skin conditions) on 10/10/25; * Bowel monitoring on 10/10/25; * Meal monitoring on 10/10/25 and 11/07/25; * Behavior monitoring on 11/23/25, 11/26/25, and 12/03/25; and * Olanzapine (for dementia behavior management) on 12/03/25 and 12/14/25. b. Resident 1 was ordered scheduled Senna (for bowel management). The physician’s order directed staff to “hold for loose stools”. The instruction to staff was not transcribed onto the MAR. c. The resident had two PRN medications prescribed for pain, acetaminophen and morphine. The acetaminophen did not have the sequential order of use listed to instruct unlicensed staff on when to administer. d. Resident 1 had two PRN bowel medications ordered, bisacodyl tablets and suppository. Direction to staff for the bisacodyl suppository was to administer “every day as needed for morning of day [four] no [bowel movement] if no results from Milk of Magnesia.” The resident did not have a current order for the Milk of Magnesia nor was it listed on the MAR. The need to ensure the facility kept an accurate MAR and included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. 2. How will the system be corrected so the violation does not happen again? The facility revised its MAR review process to ensure accurate order verification, inclusion of resident-specific parameters and PRN instructions, and timely provider clarification of discrepancies. Routine MAR audits and staff education were implemented, with supervisory oversight to promptly address inaccuracies or unclear instructions. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Resident Care Coordinator and or designee will conduct weekly MAR audits for 30 days, followed by monthly audits for three months, with results reviewed during QAPI meetings and corrective actions implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document that non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (# 1) who was prescribed PRN psychotropic medications. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2025 with diagnoses including dementia. The resident’s physician’s orders, MARs, dated 10/01/25 through 01/12/26, and progress notes, dated 10/12/25 through 01/12/26, were reviewed. Staff were interviewed and the following was noted: Resident 1 had physician’s orders for the following PRN psychotropic medications: * Haloperidol 2 mgs by mouth every three hours, as needed, for breakthrough agitation or physical aggression; and * Lorazepam 1 mg every four hours, as needed, for severe agitation or physical aggression. The resident received PRN lorazepam five times from 10/31/25 to 11/23/25, and PRN haloperidol twice from 11/20/25 to 12/22/25. On 01/15/26 at 11:50 am, Staff 20 (MT) was able to show the pop-up screen in the electronic MAR system that prompted MTs to document the non-drug interventions tried and failed. Staff 20 confirmed there were no non-drug interventions tried and failed documented in Resident 1’s record. On 01/15/26 at approximately 12:15 pm, Staff 3 (RCC) stated the documentation of non-drug interventions tried and failed prior to the administration of the PRN psychotropic would be on the resident’s progress notes and confirmed the information would not be documented anywhere else. There was no documented evidence that non-drug interventions were tried and failed prior to the seven administrations of a PRN psychotropic in the resident’s progress notes between 10/31/25 and 12/22/25. The need to document that non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. Staff were re-educated on required documentation, and the resident’s service plan was reviewed to ensure non-pharmacological strategies were clearly identified. 2. How will the system be corrected so the violation does not happen again? The facility revised its psychotropic medication process to require documented non-pharmacological interventions prior to PRN psychotropic use and reinforced use of electronic MAR prompts. Staff education and routine audits were implemented to ensure appropriate use and documentation, with supervisory oversight to address noncompliance promptly. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Resident Care Coordinator and or designee will conduct weekly audits for 30 days of PRN psychotropic medication administration and documentation. After 30 days, audits will occur monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure adequate direct care staff were present at all times according to their staffing plan to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the Acuity Based Staffing Tool (ABST) review on 01/15/26, the following was identified: * The facility was a four-story memory care facility; * No residents lived on the third floor during the survey; * The facility was home to 42 residents at the time of survey; * Five residents on the first floor required two staff members’ assistance with transfers and/or ADL care; * Three residents on the first floor required assistance in the dining room, including cueing or physical assistance with eating; * Three residents on the first floor, one resident on the second floor, and one resident on the fourth floor exhibited behaviors that required supervision and redirection; and * All residents required support due to cognitive impairments. The current facility staffing plan was reviewed and indicated the following: * Day shift: Five direct caregiving staff and two Medication Technicians; * Evening shift: Five direct caregiving staff and two Medication Technicians; and * Night shift: Four direct caregiving staff and one Medication Technician. A review of the scheduled staffing for the period of 01/05/26 through 01/11/26 and timecards for the period of 01/09/26 through 01/11/26 revealed the following discrepancies in staffing level. On 01/09/26, 01/10/26 and 01/11/26, the night shift did not meet the posted staffing plan. The need to ensure direct care staff were present at all times according to their staffing plan to meet the 24-hour scheduled and unscheduled needs was reviewed on 01/15/26 at 9:57 am with Staff 1 (ED), Staff 2 (Interim RN) and Staff 3 (RCC). They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility reviewed staffing schedules and timecards, addressed immediate staffing gaps, and reinforced expectations with leadership and scheduling staff to ensure adherence to the posted staffing plan and adequate coverage to meet resident care needs. 2. How will the system be corrected so the violation does not happen again? The facility revised its staffing oversight process to ensure routine review of staffing plans against actual coverage, timely corrective action when staffing falls below plan, regular ABST review, and escalation of staffing concerns. Staffing expectations were reinforced through leadership and scheduling training. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and or designee will conduct weekly reviews for 30 days comparing posted staffing plans to actual staffing schedules and timecards. After 30 days, reviews will occur monthly for three months. Findings will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. 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 an Acuity Based Staffing Tool (ABST) evaluation was completed for each resident prior to admission for 1 of 1 sampled resident (#1) and multiple unsampled residents whose move-in ABST evaluations were reviewed. Findings include, but are not limited to: The facility’s ABST data and resident move-in dates were reviewed during the survey and revealed the following: * Resident 1 moved into the facility in 09/2025. The resident’s ABST evaluation was entered in 10/2025. Therefore, the resident's ABST evaluation was not completed prior to moving into the facility; and * Fifteen unsampled residents’, who moved into the facility within the last six months, ABST evaluations were not completed prior to admission. The need to ensure residents’ ABST evaluations were completed prior to move-in was discussed with Staff 1 (ED), Staff 2 (Interim RN) and Staff 3 (RCC) on 01/14/26 at 2:10 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. The facility reviewed and completed ABST evaluations for other potential affected residents and reinforced admission expectations with leadership and staff to ensure ABST completion prior to move-in. 2. How will the system be corrected so the violation does not happen again? The facility revised its admission process to require ABST completion prior to move-in, incorporated ABST verification into the pre-admission checklist, assigned responsibility for completion with RN or leadership review, reinforced staff education, and ensured ABST data is used to inform staffing plans. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and or designee will conduct weekly audits for 30 days of new admissions to ensure ABST completion prior to move-in. After 30 days, audits will occur monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 (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 4 of 4 newly hired direct care staff (#s 11, 12, 15, and 16) completed First Aid and abdominal thrust training within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 4 (Business Office Manager) on 01/13/26 and showed the following: Training records for Staff 11 (MT), hired 12/02/25, Staff 12 (MT), hired 12/02/25, Staff 15 (CG), hired 11/28/25, and Staff 16 (CG), hired 09/11/25, lacked documented evidence First Aid and abdominal thrust training were completed within 30 days of hire. The need to ensure staff completed First Aid and abdominal thrust training within 30 days of hire was reviewed with Staff 4 on 01/13/26 at 1:00 pm and with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/14/26 at 2:10 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility reviewed training records for Staff #11, #12, #15, and #16 and ensured First Aid and abdominal thrust training was assigned and completed. Required training was completed or scheduled as needed, documentation was placed in personnel files, and training expectations were reinforced with leadership and staff to ensure completion within 30 days of hire. 2. How will the system be corrected so the violation does not happen again? The facility revised its onboarding process to require verification of First Aid and abdominal thrust training within 30 days of hire, incorporated required trainings into a new-hire checklist with assigned responsibility, clarified tracking accountability, reinforced staff education, and implemented routine personnel file audits to ensure compliance. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and Business Office Manager will conduct weekly audits for 30 days of new hire training records. After 30 days, audits will occur monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 ensure fire drills were conducted every other month and recorded according to the Oregon Fire Code (OFC), and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Upon survey’s entrance to the facility on 01/12/26, six months of facility fire drill and fire and life safety records, dated 07/2025 through 12/2025, were requested. The following was determined: a. The facility lacked documented evidence unannounced fire drills were conducted and recorded at least every other month. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. On 01/13/26 at 1:45 pm, Staff 1 (ED) confirmed the facility’s lack of documentation of fire drills and fire and life safety training for caregivers. The need to ensure fire drills were conducted every other month according to the OFC and staff were provided fire and life safety instruction on alternate months was discussed with Staff 1, Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 10:56 am. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility reviewed fire drill and safety training records, reinforced regulatory requirements with leadership, resumed required fire drills and fire/life safety instruction, and emphasized timely and accurate documentation in accordance with the Oregon Fire Code. 2. How will the system be corrected so the violation does not happen again? The facility revised its fire and life safety compliance process to include an annual alternating schedule for fire drills and safety training, implemented standardized documentation, assigned leadership responsibility, incorporated requirements into staff training, and established routine record reviews to ensure compliance. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director or designee will conduct monthly reviews of fire drill and fire/life safety documentation to ensure compliance with alternating-month requirements. Compliance will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility consisted of four floors. On 01/12/26 at 9:05 am, Staff 1 (ED) reported the third floor was being renovated and there were no residents residing on that floor. On 01/12/26, the interior of the facility was toured, and the following observations were made: a. First Floor Kitchenette and Dining Room * There was chipped paint, scuffs, drips observed on the walls, doors and door frames (including the doors leading out of the dining room and into the kitchen), and baseboards; * The vinyl covering on the seats of the dining room chairs was worn and peeling off; * The interior of the microwave needed cleaning; * A cabinet underneath the microwave was missing a knob; * There were areas in the wooden cabinetry observed with exposed wood, deeming those areas to be uncleanable surfaces; * The lining of the drawers to the right of sink was bubbling up and areas of the lining were missing, deeming them uncleanable surfaces; * There was a panel, located in the ceiling, above the dining room table closest to the television, where the air vent appeared to be pulling away from the casing; * There was dust accumulation observed on the windowsills; * The light fixtures had dead bugs and debris inside of them; and * There was a chair missing a front caster wheel stored next to the activity closet. Resident Use Areas * The elevator casing was observed to be scuffed, there was chipped paint, and a strip of duct tape was located along the threshold; * The light fixtures throughout the floor had debris inside of them; * Multiple doors and doorframes (including the ones to stairwells, kitchen, exits, and resident apartments) had scuffs, drips, and chipped paint observed; and * Walls and baseboards were also observed throughout the first floor with scuff marks and chipped paint. b. Second Floor Kitchenette and Dining Room * There were areas in the wooden cabinetry observed with exposed wood, deeming those areas to be uncleanable surfaces; * Knobs were missing from the upper right cupboard and the lower right middle drawer; * The bottom of the lower, middle cupboard had black and brown debris observed; * The cupboard underneath the sink had black and brown matter located inside, on the bottom, and towards the back; * The right upper corner of the shelving, consisting of two pieces of wood, on top of the cabinetry where items were being stored, was pulling away from each other; * There were broken pineapple string lights circling the banister, to the right of the kitchenette, with sharp edges exposed; * The legs of the moveable chairs had built up food debris observed; * The lower part of the piano was observed to have a layer of dust present; * The stationary wood seating around the room had worn and exposed wood, deeming them uncleanable surfaces; * There was chipped paint behind the wall mounted light fixtures; and * There was dust build up observed on the windowsills, the backs of the stationary seating, and on the wood trim/molding around the room. Resident Use Areas * There was an incline going into apartment 219 which made it difficult for the resident to open the door and made the door close automatically; * Multiple doors and doorframes (including the ones to stairwells, dining room, offices, employee use rooms, and resident apartments) had scuffs, peeling varnish, partially ripped-off stickers, and gouges observed; * The closet door located outside of the dining room, had splintering wood by the doorknob; * The air vent, located across from the closet door outside of the dining room, had a thick layer of dust present; * The windowsills, located in the hallway by the elevator and in a seating area, had dead bugs and dust observed; and * The paint around the windowpanes and sills located in the seating area at the end of a hallway was chipped. c. Fourth Floor Kitchenette * The inside of the door had gray/brown matter observed, and the paint was chipped; * There was an accumulation of built-up ice in the freezer; * Cabinet doors were missing, in disrepair, or had exposed wood present which deemed them uncleanable surfaces; * The wood was coming apart under the counter where the coffee machine and water pitcher was stored; * There was chipped paint observed on the windowsill; and * There were drips, splatters, and chipped paint observed on the walls and baseboards. Resident Use Areas * The blinds in apartment 417 were in disrepair; * The paint around the windowpanes and sills located in the sunroom seating area off the dining room was chipped as was the windowsill across from apartment 404; * There were multiple areas on the flooring where duct tape was placed; * Between apartments 405, 406, 409, and 410, there were multiple, large pieces of clear tape stuck to the ceiling and walls; * The paint in the elevator casing was chipped and there was a gray build-up of debris located on the keypad; * Multiple doors and doorframes (including the ones to stairwells, the kitchenette, and resident apartments) had scuffs, drips, and chipped paint observed; and * Walls and baseboards were also observed throughout the fourth floor with scuff marks and chipped paint. The environment was toured and the need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 and Staff 5 (Maintenance Director) on 01/15/26 at 11:05 am. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility conducted an environmental review of resident-use and common areas to identify cleanliness and maintenance concerns and completed immediate cleaning and debris removal, prioritized repairs with leadership and maintenance, and removed unsafe or damaged items from resident-use areas pending repair or replacement. 2. How will the system be corrected so the violation does not happen again? The facility revised its environmental maintenance and housekeeping oversight process, implemented routine environmental inspections, assigned repair tracking and prioritization to the Maintenance Director, reinforced cleaning and reporting expectations with staff, and incorporated environmental standards into ongoing training with leadership monitoring through routine rounds. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Maintenance Director and or designee will conduct weekly environmental rounds for 30 days. After 30 days, rounds will occur monthly for three months. Findings and corrective actions will be reviewed during QAPI meetings to ensure sustained compliance. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. 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, for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

See C252.

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 pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 2 of 4 newly hired staff (#s 12 and 14) whose training records were reviewed. Findings include, but are not limited to: Refer to: Z 155.

See Z155.

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:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 231, C 295, C 360, C 363, C 372, C 420, and C 513.

See C231, C295, C360, C363, C372, C420, C513.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 11, 12, 13, and 14) completed all required pre-service orientation training, 4 of 4 staff (#s 11, 12, 13, and 15) completed pre-service dementia training and 4 of 4 staff (#s 11, 12, 15, and 16) completed competency training within 30 days of hire. Findings include, but are not limited to: The facility’s training records for Staff 11 (MT), hired 12/02/25, Staff 12 (MT), hired 12/02/25, Staff 13 (CG), hired 01/05/26, Staff 14 (Housekeeping), hired 11/19/25, Staff 15 (CG), hired 11/28/25, and Staff 16 (CG), hired 09/11/25, were reviewed with Staff 4 (Business Office Manager) on 01/13/26 at 1:00 pm. The following was identified: a. There was no documented evidence Staff 11, 12, 13, and 14 had completed pre-service orientation training in one or more of the following required topics: * Resident rights and values and CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious Disease Prevention; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 11, 12, 13, and 15 had completed pre-service dementia training in one or more of the following required topics: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging person with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety f residents with dementia including addressing pain, providing food/fluids, preventing wandering, sue of person-centered approach; * Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive deices with restraining qualities in memory care communities. c. There was no documented evidence Staff 11, 12, 15, and 16 had demonstrated competency in one or more of the following required topics: * 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; and * General food safety, serving and sanitation. d. Staff 11 and 12 failed to complete the required competency demonstration for the medication administration duty. During the survey, Staff 1 (ED), Staff 3 (RCC) and Staff 4 were instructed that Staff 11 and 12 should be removed from the schedule until they completed the competency demonstration, including the medication administration. The facility failed to ensure all required training was completed and staff demonstrated competency was discussed with Staff 1, Staff 2 (Interim RN) and Staff 3 on 01/14/26 at 2:10 pm. They acknowledged the findings.

See C360.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 252, C 260, C 270, C 303, C 310, and C 330.

See C252, C260, C270, C303, C310, C330.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure activity evaluations and individualized activity plans were completed for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s service plans and Resident Activities/Interests Assessments were reviewed and offered some information, but the facility had not fully evaluated the residents' activity needs in one or more of the following areas: * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities which could be used as behavioral interventions, if necessary. There were progress notes that documented Resident 1 enjoyed listening to classical music while in his/her apartment. On 01/15/26 at 10:37 am, Staff 18 (CG) reported she was not aware of a radio or any other device for the resident to listen to music on in his/her room. She stated that Resident 1 will watch television and listened to music in the dining room “sometimes”. Staff 18 confirmed the resident did not like a loud environment. Resident 1 lacked a resident-specific activity plan that was developed from the information gathered and detailed what, when, how, and how often staff should offer and assist with relating to his/her individualized activities. The need to ensure activity evaluations were completed for all residents and individualized activity plans were developed and implemented was discussed with Staff 1 (ED), Staff 2 (Interim RN), Staff 3 (RCC), and Staff 6 (Activity Director) on 01/14/26 and 01/15/26. They acknowledged the findings.

See C260.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: