OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 02/12/26 at 2:30 pm, Staff 1 (ED) stated the facility did not have a process for residents in the memory care community to report complaints and have those complaints responded to and resolved. The facility had previously utilized a grievance binder and suggestion box, both located in the attached assisted living facility. Review of the grievance binder on 02/12/26 showed there had been no recorded complaints or resolution. The need to ensure the facility had an effective system for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:40 pm. They acknowledged the findings.

1. The actions that were taken to correct the rule violation was the community implemented a suggestion box within the Meadows neighborhood. Additionaly there is a grievance binder located at the front desk that services both AL and MC. 2. The system will be corrected so that this violation will not happen again by checking the suggestion box and following up on any concerns, complaints, or suggestions. Grievances will be added to the grievance binder and follow up action will be logged immediately until the grievance is rectified. 3. The area needing correction will be evaluated on a weekly basis. 4. The Executive Director will be responsible for completing/monitoring the correction.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

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 report physical injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, for 1 of 1 sampled resident (#2) with injuries of unknown cause. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident's clinical record was reviewed, and staff were interviewed. The following was identified: a. On 11/20/25, staff documented a new cut, approximately 5 inches long, had been observed on the resident’s abdomen. There was no documented evidence the injury was reported to the local SPD office or an immediate investigation ruled out abuse or neglect. During an interview on 02/11/26 at 10:51 am, Staff 2 (Resident Care Manager/LPN) confirmed the lack of reporting or investigation. The survey team requested the injury be reported to the local SPD office, and confirmation was provided on 02/11/26 at 4:24 pm. b. On 01/27/26, staff transcribed a home health LPN visit note from 01/26/26 into the resident’s progress notes. The note described a wound to the resident’s “right toe.” There was no documented evidence the injury was reported to the local SPD office or an immediate investigation ruled out abuse or neglect. During an interview on 02/11/26 at 10:51 am, Staff 2 stated the facility had been unaware of the wound to the resident’s toe and confirmed no reporting or investigation had occurred. The survey team requested the injury be reported to the local SPD office, and confirmation was provided on 02/13/26 at 10:15 am. The need to ensure all injuries of unknown cause were immediately reported to the local SPD, unless an immediate investigation reasonably concluded the injury was not the result of abuse, was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

1. The actions that were taken to correct the rule violation were the community reported both cited incidents to APS. One was reported on 2/11/26 and the other was reported on 2/13/26. 2. The system will be corrected so that this violation will not happen again by the community ensuring all injuries of unknown cause are reported to the local SPD within 24 hours unless an immediate investigation can reasonably conclude the injury was not a result of abuse. 3. The area needing correction will be evaluated daily. 4. The Health Services Director and Executive Director will be responsible for monitoring and ensuring corrections are completed/monitored.

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

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to: During the survey, on 02/09/26, no activity program was observed. In an interview on 02/10/26 at 8:30 am, Staff 1 (ED) stated the current activity coordinator was responsible for providing activities to residents in multiple licensed facilities. She stated the coordinator worked Tuesday through Saturday, and on the days when the coordinator did not work, an activity program did not usually occur. In interviews from 02/10/26 through 02/12/26, Staff 6 (MT), Staff 7 (MT), Staff 8 (CG), and Staff 10 (CG) confirmed the lack of activity program on days the activities coordinator did not work. The need to ensure provision of a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

1. The actions taken to correct the rule violation include the community hiring an Activity Director and three additional Activity Assistants to ensure activities are occurring daily. 2.The system will be corrected so that this violation does not happen again by the community ensureing provision of a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. 3. The area needing correction will be evaluated on a daily basis. 4. The Activities Director and Executive Director will be responsible to see that corrections are completed/monitored.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear instruction to staff, and included a written description of who should provide the services and what, when, how, and how often the services should be provided, for 1 of 2 sampled residents (# 2) whose service plan was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident's service plan was not reflective of his/her current needs and/or did not provide clear direction to staff in the following areas: * Resistance to receiving care; * Dentures; * Staff responsibility for communication devices, including glasses; * Communication ability; * Pain, including how the resident expresses pain, location of pain, use of pharmaceutical and non-pharmaceutical interventions; * Evacuation assistance; * Skin concerns, including hematoma to right thigh and swelling to lower extremities; * Who would provide incontinence care items, including briefs; and * Dining preferences, including location, use of straw with drinks, and increased time required during meals. The resident had a diagnosis of Parkinson’s disease and was observed to have a significant tremor and required increased time for ADL care, with ambulation, and when eating. Staff stated s/he had dentures until approximately one year prior, when the dentures were lost. Since that time, s/he has not had any dental appliances and had been on a mechanical soft diet texture since 07/2025. S/he required one person assistance for all ADLs and mobility, and staff stated s/he had no history of behaviors or care refusals. Staff stated the resident had significant pain since returning to the facility in 12/2025, benefiting from PRN pain medication and non-pharmaceutical interventions such as elevating and icing his/her leg. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear instruction to staff, and included a written description of who should provide the services and what, when, how, and how often the services should be provided, for 1 of 2 sampled residents (# 2) whose service plan was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident's service plan was not reflective of his/her current needs and/or did not provide clear direction to staff in the following areas: * Resistance to receiving care; * Dentures; * Staff responsibility for communication devices, including glasses; * Communication ability; * Pain, including how the resident expresses pain, location of pain, use of pharmaceutical and non-pharmaceutical interventions; * Evacuation assistance; * Skin concerns, including hematoma to right thigh and swelling to lower extremities; * Who would provide incontinence care items, including briefs; and * Dining preferences, including location, use of straw with drinks, and increased time required during meals. The resident had a diagnosis of Parkinson’s disease and was observed to have a significant tremor and required increased time for ADL care, with ambulation, and when eating. Staff stated s/he had dentures until approximately one year prior, when the dentures were lost. Since that time, s/he has not had any dental appliances and had been on a mechanical soft diet texture since 07/2025. S/he required one person assistance for all ADLs and mobility, and staff stated s/he had no history of behaviors or care refusals. Staff stated the resident had significant pain since returning to the facility in 12/2025, benefiting from PRN pain medication and non-pharmaceutical interventions such as elevating and icing his/her leg. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear instruction to staff, and included a written description of who should provide the services and what, when, how, and how often the services should be provided, for 1 of 2 sampled residents (# 2) whose service plan was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident's service plan was not reflective of his/her current needs and/or did not provide clear direction to staff in the following areas: * Resistance to receiving care; * Dentures; * Staff responsibility for communication devices, including glasses; * Communication ability; * Pain, including how the resident expresses pain, location of pain, use of pharmaceutical and non-pharmaceutical interventions; * Evacuation assistance; * Skin concerns, including hematoma to right thigh and swelling to lower extremities; * Who would provide incontinence care items, including briefs; and * Dining preferences, including location, use of straw with drinks, and increased time required during meals. The resident had a diagnosis of Parkinson’s disease and was observed to have a significant tremor and required increased time for ADL care, with ambulation, and when eating. Staff stated s/he had dentures until approximately one year prior, when the dentures were lost. Since that time, s/he has not had any dental appliances and had been on a mechanical soft diet texture since 07/2025. S/he required one person assistance for all ADLs and mobility, and staff stated s/he had no history of behaviors or care refusals. Staff stated the resident had significant pain since returning to the facility in 12/2025, benefiting from PRN pain medication and non-pharmaceutical interventions such as elevating and icing his/her leg. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear instruction to staff, and included a written description of who should provide the services and what, when, how, and how often the services should be provided, for 1 of 2 sampled residents (# 2) whose service plan was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident's service plan was not reflective of his/her current needs and/or did not provide clear direction to staff in the following areas: * Resistance to receiving care; * Dentures; * Staff responsibility for communication devices, including glasses; * Communication ability; * Pain, including how the resident expresses pain, location of pain, use of pharmaceutical and non-pharmaceutical interventions; * Evacuation assistance; * Skin concerns, including hematoma to right thigh and swelling to lower extremities; * Who would provide incontinence care items, including briefs; and * Dining preferences, including location, use of straw with drinks, and increased time required during meals. The resident had a diagnosis of Parkinson’s disease and was observed to have a significant tremor and required increased time for ADL care, with ambulation, and when eating. Staff stated s/he had dentures until approximately one year prior, when the dentures were lost. Since that time, s/he has not had any dental appliances and had been on a mechanical soft diet texture since 07/2025. S/he required one person assistance for all ADLs and mobility, and staff stated s/he had no history of behaviors or care refusals. Staff stated the resident had significant pain since returning to the facility in 12/2025, benefiting from PRN pain medication and non-pharmaceutical interventions such as elevating and icing his/her leg. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear instruction to staff, and included a written description of who should provide the services and what, when, how, and how often the services should be provided, for 1 of 2 sampled residents (# 2) whose service plan was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, staff and the resident were interviewed, and the resident was observed. The following was identified: The resident's service plan was not reflective of his/her current needs and/or did not provide clear direction to staff in the following areas: * Resistance to receiving care; * Dentures; * Staff responsibility for communication devices, including glasses; * Communication ability; * Pain, including how the resident expresses pain, location of pain, use of pharmaceutical and non-pharmaceutical interventions; * Evacuation assistance; * Skin concerns, including hematoma to right thigh and swelling to lower extremities; * Who would provide incontinence care items, including briefs; and * Dining preferences, including location, use of straw with drinks, and increased time required during meals. The resident had a diagnosis of Parkinson’s disease and was observed to have a significant tremor and required increased time for ADL care, with ambulation, and when eating. Staff stated s/he had dentures until approximately one year prior, when the dentures were lost. Since that time, s/he has not had any dental appliances and had been on a mechanical soft diet texture since 07/2025. S/he required one person assistance for all ADLs and mobility, and staff stated s/he had no history of behaviors or care refusals. Staff stated the resident had significant pain since returning to the facility in 12/2025, benefiting from PRN pain medication and non-pharmaceutical interventions such as elevating and icing his/her leg. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are as follows: Resident 2's service plan was corrected to provide clear direction to staff with regard to resistance to receive care, dentures, communication devices, communication ability, pain including how the resident expressed pain, location of pain, and the use of pharmaceutical and non-pharmaceutical interventions, evacuation assistance, skin concerns, who will provide incontinence care items, and dining preference including use of a straw with drinks and increased time required during meals. 2. The system will be corrected so that this violation will not happen again by ensuring all resident service plans reflect and provide clear direction to the staff on how to care for the residents. 3. The area needing correction will be evaluated at move in, quarterly or when there is a change of condition. 4. The Health Services Director and Executive Director will be responsible to see that the corrections are completed/monitored.

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

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans, including the resident as s/he was able and willing. During an interview on 02/11/26 at 3:20 pm, Staff 1 (ED) stated she was unsure of the current process around development of a resident’s service plan and involvement of a Service Planning Team. She acknowledged the lack of documented evidence of a Service Planning Team for Residents 1 and 2. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are the community will ensure service plans for both Residents 1 and 2 have documented evidence of a Service Planning Team reviewing and participating in the development of the service plans. 2. The systems will be corrected so that this violation will not happen again by the community reviewing the upcoming service plans and schedule service plan meetings with resident and/or resident family, any one the resident prefers to attend, the Administrator or designee, care team members, and anyone who is familiar with the resident. If the family or resident are unable to meet in person a service plan meeting will be conducted via email to ensure review and input of service plan by all required parties. Documentation will be reflected by printed email with each team members input. 3. The area needing correction will be evaluated quarterly or with change of condition. 4) The Executive Director and the Health Services Director will be responsible to see that the corrections are completed/monitored.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts for short-term changes of condition and residents were monitored consistent with their evaluated needs at least weekly until the condition resolved, for 1 of 2 sampled residents (# 2) who experienced changes of condition. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, the resident was observed, and staff and the resident were interviewed. The following was identified: a. On 11/09/25, staff documented in progress notes concern the resident had a urinary tract infection and had a “foul odor” coming from his/her groin. There was no documented evidence that actions or interventions were determined, communicated to staff, and progress was monitored at least weekly through resolution. b. On 12/23/25 the resident returned to the facility with skin concerns, including swelling to his/her right leg, a hematoma on his/her right thigh, bruising to his/her right arm, and a scab on his/her right cheek. There was no evidence the skin concerns were monitored at least weekly through resolution. On 02/10/26 at 1:40 pm, Staff 2 (Resident Care Manager/LPN) confirmed there was no additional documentation of monitoring these areas at least weekly. Staff 2 confirmed the resident continued to have a hematoma on his/her right thigh. During the survey, the resident was observed to have a scabbed area, with dried blood at times, on his/her right cheek. c. On 01/14/26 staff documented increased bilateral lower extremity swelling with pitting and sent a fax to the resident’s physician. There was no evidence actions or interventions were determined, communicated to staff on all shifts, or progress monitored at least weekly through resolution. d. On 01/22/26, staff identified a new skin concern consisting of redness in the resident’s groin. There was no evidence actions or interventions were determined, communicated to staff on all shifts, or progress monitored at least weekly through resolution. e. On 01/27/26 staff documented a home health LPN visit note from 01/26/26 which stated the resident had a wound on his/her “right toe.” There was no evidence actions or interventions were determined, communicated to staff on all shifts, and progress monitored at least weekly through resolution. The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition through resolution, with progress documented at least weekly, was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts for short-term changes of condition and residents were monitored consistent with their evaluated needs at least weekly until the condition resolved, for 1 of 2 sampled residents (# 2) who experienced changes of condition. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, the resident was observed, and staff and the resident were interviewed. The following was identified: a. On 11/09/25, staff documented in progress notes concern the resident had a urinary tract infection and had a “foul odor” coming from his/her groin. There was no documented evidence that actions or interventions were determined, communicated to staff, and progress was monitored at least weekly through resolution. b. On 12/23/25 the resident returned to the facility with skin concerns, including swelling to his/her right leg, a hematoma on his/her right thigh, bruising to his/her right arm, and a scab on his/her right cheek. There was no evidence the skin concerns were monitored at least weekly through resolution. On 02/10/26 at 1:40 pm, Staff 2 (Resident Care Manager/LPN) confirmed there was no additional documentation of monitoring these areas at least weekly. Staff 2 confirmed the resident continued to have a hematoma on his/her right thigh. During the survey, the resident was observed to have a scabbed area, with dried blood at times, on his/her right cheek. c. On 01/14/26 staff documented increased bilateral lower extremity swelling with pitting and sent a fax to the resident’s physician. There was no evidence actions or interventions were determined, communicated to staff on all shifts, or progress monitored at least weekly through resolution. d. On 01/22/26, staff identified a new skin concern consisting of redness in the resident’s groin. There was no evidence actions or interventions were determined, communicated to staff on all shifts, or progress monitored at least weekly through resolution. e. On 01/27/26 staff documented a home health LPN visit note from 01/26/26 which stated the resident had a wound on his/her “right toe.” There was no evidence actions or interventions were determined, communicated to staff on all shifts, and progress monitored at least weekly through resolution. The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition through resolution, with progress documented at least weekly, was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts for short-term changes of condition and residents were monitored consistent with their evaluated needs at least weekly until the condition resolved, for 1 of 2 sampled residents (# 2) who experienced changes of condition. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, the resident was observed, and staff and the resident were interviewed. The following was identified: a. On 11/09/25, staff documented in progress notes concern the resident had a urinary tract infection and had a “foul odor” coming from his/her groin. There was no documented evidence that actions or interventions were determined, communicated to staff, and progress was monitored at least weekly through resolution. b. On 12/23/25 the resident returned to the facility with skin concerns, including swelling to his/her right leg, a hematoma on his/her right thigh, bruising to his/her right arm, and a scab on his/her right cheek. There was no evidence the skin concerns were monitored at least weekly through resolution. On 02/10/26 at 1:40 pm, Staff 2 (Resident Care Manager/LPN) confirmed there was no additional documentation of monitoring these areas at least weekly. Staff 2 confirmed the resident continued to have a hematoma on his/her right thigh. During the survey, the resident was observed to have a scabbed area, with dried blood at times, on his/her right cheek. c. On 01/14/26 staff documented increased bilateral lower extremity swelling with pitting and sent a fax to the resident’s physician. There was no evidence actions or interventions were determined, communicated to staff on all shifts, or progress monitored at least weekly through resolution. d. On 01/22/26, staff identified a new skin concern consisting of redness in the resident’s groin. There was no evidence actions or interventions were determined, communicated to staff on all shifts, or progress monitored at least weekly through resolution. e. On 01/27/26 staff documented a home health LPN visit note from 01/26/26 which stated the resident had a wound on his/her “right toe.” There was no evidence actions or interventions were determined, communicated to staff on all shifts, and progress monitored at least weekly through resolution. The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition through resolution, with progress documented at least weekly, was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts for short-term changes of condition and residents were monitored consistent with their evaluated needs at least weekly until the condition resolved, for 1 of 2 sampled residents (# 2) who experienced changes of condition. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident’s clinical record was reviewed, the resident was observed, and staff and the resident were interviewed. The following was identified: a. On 11/09/25, staff documented in progress notes concern the resident had a urinary tract infection and had a “foul odor” coming from his/her groin. There was no documented evidence that actions or interventions were determined, communicated to staff, and progress was monitored at least weekly through resolution. b. On 12/23/25 the resident returned to the facility with skin concerns, including swelling to his/her right leg, a hematoma on his/her right thigh, bruising to his/her right arm, and a scab on his/her right cheek. There was no evidence the skin concerns were monitored at least weekly through resolution. On 02/10/26 at 1:40 pm, Staff 2 (Resident Care Manager/LPN) confirmed there was no additional documentation of monitoring these areas at least weekly. Staff 2 confirmed the resident continued to have a hematoma on his/her right thigh. During the survey, the resident was observed to have a scabbed area, with dried blood at times, on his/her right cheek. c. On 01/14/26 staff documented increased bilateral lower extremity swelling with pitting and sent a fax to the resident’s physician. There was no evidence actions or interventions were determined, communicated to staff on all shifts, or progress monitored at least weekly through resolution. d. On 01/22/26, staff identified a new skin concern consisting of redness in the resident’s groin. There was no evidence actions or interventions were determined, communicated to staff on all shifts, or progress monitored at least weekly through resolution. e. On 01/27/26 staff documented a home health LPN visit note from 01/26/26 which stated the resident had a wound on his/her “right toe.” There was no evidence actions or interventions were determined, communicated to staff on all shifts, and progress monitored at least weekly through resolution. The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition through resolution, with progress documented at least weekly, was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are the community will ensure resident-specific actions or interventions are determined and documented, and communicated to the team on all shifts for Resident 2 in regards to UTI, skin concerns, and any other short-term changes that may be occuring with this resident. These will be monitor until the conditions are resolved. 2. The system will be corrected so that this violation will not happen again by ensuring all resident specific actions or interventions are determined, documented, and communicated to staff through the use of a TSP for all short term changes of condiiton. The resident will be monitored consistent with the evaluated needs until the condition is resolved with progress documented. 3. The area needing correction will be evaluated weekly. 4. The Registered Nurse and Executive Director will be responsible to see that the corrections are completed/monitored.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#2) who experienced a significant change of condition. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident's clinical record was reviewed, the resident was observed, and staff were interviewed. The following was identified: On 09/19/25, the resident’s service plan was completed and stated the resident was independent with mobility/ambulation, had no pain, had a mechanical soft diet texture, was independent with eating, and did not require assistance from staff to transfer from sitting to standing. On 11/23/25, the resident sustained a fall and was admitted to the hospital and, subsequently, to a rehabilitation facility. Upon the resident’s return to the facility on 12/23/25, s/he had experienced a significant change of condition and required: * One person assistance with mobility/ambulation and at times use of a wheelchair; * One person assistance with transfers from sitting to standing; * Puree diet texture; * Assistance with eating; and * Use of a PRN narcotic medication for significant pain which at times inhibited his/her mobility. There was no documented evidence of an RN assessment until 12/29/25, six days after the resident returned to the facility. The RN assessment failed to include interventions made as a result of the assessment. There was no documented evidence of instructions to staff or an update to the resident’s service plan until 01/07/26, 15 days after the resident’s significant change of condition and return to the facility. During an interview with Staff 2 (Resident Care Manager/LPN) on 02/10/26 at 1:40 pm, she stated she was unable to state why the RN assessment and service plan update had not occurred timely, and the RN was no longer employed by the facility. She stated the facility was currently in the process of hiring a facility RN. The need to ensure an RN assessment, including interventions made as a result of the assessment, was completed timely after a significant change of condition was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are the RN will ensure assessments are completed on Resident 2 for significant changes of condition which include mobility and ambulation changes, transfer assistance, puree diet texture, assistance with eating, and use of PRN narcotic medications used for significant pain. This will include interventions, instructions to the team, and updated service plan. 2. The system will be corrected so that this violation will not happen again by the RN assessing all residents in a timely manner when there is a significant change of condition. This would include interventions, documenting instructions to the team, and updated service plans. 3. The area needing correction will be evaluated weekly or with significant changes of condition. 4. The RN, Health Services Director, and the Executive Director will be responsible to see that the corrections are completed/monitored.

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

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, and the service plan was adjusted if necessary, for 1 of 1 sampled resident (# 2) who received home health services. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident's clinical record was reviewed, and staff were interviewed. The following was identified: On 01/27/26, Staff 11 (MT) transcribed an outside provider note dated 01/26/26 from a home health LPN which described a wound to the resident’s “right toe” and noted the wound was healing. The LPN recommended applying lotion to the resident’s feet daily to help prevent cracking and drying. There was no evidence the communication had been reviewed by facility management or a licensed nurse. In an interview on 02/10/26 at 12:47 pm, Staff 2 (Resident Care Manager/LPN) stated that there were many home health notes she had not received for review and was not sure where many notes were. She stated she was unable to find any additional outside provider communication regarding when the resident’s right toe wound was identified or evaluated by home health and had previously been unaware of the note from 01/26/26, the wound to the resident’s right toe, or the recommendation to apply lotion to the resident’s feet. On 02/11/26, Staff 2 stated she had contacted the home health agency and provided a fax from the agency dated 02/11/26 which showed the resident had been evaluated by the agency on 01/12/26 and the case had been closed by the provider on 02/10/26. Staff 2 stated the facility had no record of these visits or communication with the outside provider regarding services rendered or recommendations. The need to coordinate on-site health services with outside service providers such as home health, and the need to ensure facility management or a licensed nurse was notified of the services provided to ensure staff were informed of new interventions, was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are that the community will ensure that all outside provider information is recorded as a visit, updates are completed in Resident 2's service plan, and that all care staff are informed of the new interventions. 2. The system will be corrected so that this violation will not happen again by ensuring on-site health services coordinate with outside service providers to obtain a record or documentation of all visits regarding services rendered and recommendations from the visit. The community will also ensure all management or licensed nurse are notifed of the services provided to ensure staff are informed of new interventions. 3. The area needing correction will be evaluated on a weekly basis. 4. The RN and the Executive Director will be responsible to see that the corrections are completed/monitored.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions were included for PRN medications for 1 of 2 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident's clinical record was reviewed, and staff were interviewed. The following was identified: a. The resident had two PRN medications for pain which did not have clear parameters for order of administration: * Tramadol 50 mg, one tablet every six hours as needed; and * Acetaminophen 500 mg, two tablets twice daily as needed. Between 01/01/26 and 02/08/26, PRN acetaminophen had been administered twice and PRN tramadol had been administered 28 times. On 02/11/26 at 10:51 am, Staff 2 (Resident Care Manager/LPN) confirmed there were no resident-specific parameters for the PRN medications. During an interview on 02/12/26 at 01:05 pm, Staff 7 (MT) stated s/he would decide which medication to administer based on the perceived level of pain or whether other medications had been administered recently. b. The resident had two PRN treatments which did not have parameters for use: * Nystatin powder, 100,000 unit/gm, applied to affected areas two to three times daily as needed; * Secura protective 10% cream, applied topically as needed. The need to ensure PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions were included for PRN medications for 1 of 2 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2017 with diagnoses including dementia, Parkinson’s disease, and dysphagia. The resident's clinical record was reviewed, and staff were interviewed. The following was identified: a. The resident had two PRN medications for pain which did not have clear parameters for order of administration: * Tramadol 50 mg, one tablet every six hours as needed; and * Acetaminophen 500 mg, two tablets twice daily as needed. Between 01/01/26 and 02/08/26, PRN acetaminophen had been administered twice and PRN tramadol had been administered 28 times. On 02/11/26 at 10:51 am, Staff 2 (Resident Care Manager/LPN) confirmed there were no resident-specific parameters for the PRN medications. During an interview on 02/12/26 at 01:05 pm, Staff 7 (MT) stated s/he would decide which medication to administer based on the perceived level of pain or whether other medications had been administered recently. b. The resident had two PRN treatments which did not have parameters for use: * Nystatin powder, 100,000 unit/gm, applied to affected areas two to three times daily as needed; * Secura protective 10% cream, applied topically as needed. The need to ensure PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are the community will ensure Resident #2 PRN medications have resident-specific parameters and instructions in the MAR. These medications are Tramadol 50 mg, Acetaminophen 500 mg, Nystatin Powder 100,000 unit/gm, and Secura protective 10%. 2. The system will be corrected so that this violation will not happen again by ensuring all resident PRN Medications include resident-specific parameters and instruction in the MAR. 3. The area needing correction will be evaluated weekly. 4. The Health Services Director and the Executive Director will be responsible to see that the corrections are completed/monitored.

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

OAR 411-054-0070 (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 2 of 2 newly hired direct care staff (#s 9 and 10) 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 1 (ED) on 02/11/26 and showed the following: Training records for Staff 9 (MT), hired 11/12/25, and Staff 10 (CG), hired 01/13/26, 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 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:58 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation will be ensuring staff #9 and #10 complete First Aid and abdominal thrust training immediately. 2. The system will be corrected so that this violation will not happen again by ensuring all current team members have completed First Aid and abdominal thrust training as well as ensuring all new team members receive this training within their first 30 days of employment. 3. The area needing correction will be evaluated weekly. 4. The Executive Director, Health Services Director, and Operations Assistant Director will be responsible to see that the corrections are completed/monitored.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their unit for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to: Current evaluations and service plans were reviewed for Residents 1 and 2. There was no documented evidence the residents were provided a key to their unit or the residents were evaluated and determined to be unable to utilize a key. In an interview with Staff 1 (ED) on 02/12/26, she stated she could not confirm all residents had been provided keys to their units. During the survey on 02/09/26 through 02/12/26, observation and interviews with staff confirmed residents did not have keys to their units. The need for residents and only appropriate staff to have a key to their units was discussed with Staff 1 and Staff 3 (Health Services Director) on 02/12/26 at 2:58 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are the community will immediately evalute both Resident #1 and Resident #2 for their ability to use a key. If it is determined that either resident is able, they will be provided a key. If unable, the community will service plan the results of the ability to manage their own key and state in the service plan where the key is being stored. The community will be ensuring keys are stored on a hook in the residents specific closet space. 2. The system will be corrected so this violation will not happen again by evaluating all current residents and each new resident at time of move into determine each persons ability to use a key. The results of the evaluation will be documented in the individuals service plan and a key provided to the resident or hung in the resident specific closet. 3. The area needing correction will be evaluated at the time of move in, during the quarterly service plan, or when there is a significant change of condition. 4. The Executive Director and Maintenance Director are responsible to ensure the corrections are completed/monitored.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. 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 3 of 3 newly hired staff (#s 5, 9, and 10) whose training records were reviewed. Findings include, but are not limited to: Refer to: Z155.

Please refer to 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: C154, C231, C242, and C372.

Please refer to C154, C231, C242, and C372.

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 3 of 3 newly-hired staff (#s 5, 9, and 10) completed all required pre-service orientation training topics and 2 of 2 newly-hired direct care staff (#s 9 and 10) completed all required pre-service dementia training topics and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 02/11/26 with Staff 1 (ED). The following was identified: a. There was no documented evidence Staff 5 (Acting Engagement Director), Staff 9 (MT), and Staff 10 (CG), hired 12/10/25, 11/12/25, and 01/13/26, respectively, had completed one or more of the following pre-service orientation topics before completing any job duties: * Department-approved Home and Community Based Services course; and * Department-approved LGBTQIA2S+ course. b. There was no documented evidence Staff 9 and Staff 10 completed one or more of the following pre-service dementia training topics for direct care staff: * Family support and the role the family may have in the care of the resident; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 9 and Staff 10 demonstrated competency in one or more of the following areas within 30 days of hire: * Changes associated with normal aging; * Identification, documenting and reporting of changes of condition; and * General food safety, serving and sanitation. The need to ensure the required pre-service training was completed by staff in the time frames specified in the rules and to ensure staff demonstrated competency in assigned job duties within 30 days of hire was discussed on 02/12/26 at 2:58 pm with Staff 1 and Staff 3 (Health Services Director). They acknowledged the findings.

1. The actions that will be taken to correct the rule violation are as follows: Staff #5 will immediately complete or show proof of completing the HCBS course and the LGBTQIA2S+ courses. Staff #9 and Staff #10 will immediately complete or show proof of completeing the HCBS course, the LGBTQIA2S+ course, Family support and role of the family course, use of supportive devices and restraining qualities training, changes associated with normal aging course, identification, documentating, and reporting of changes of condition course, and general food safety, serving, and sanitiation course. 2. The system will be corrected so that this violation will not happen again by ensuring the required pre-service training is completed by all current staff and all new staff in the time frames specified in the rules and to ensure the staff demonstate competency in their assigned job duties within 30 days of hire. 3. The area needing correction will be evaluated weekly. 4. The Operations Assistant Director and the Executive Director will be responsible to see that the corrections are completed/monitored.

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: C260, C262, C270, C280, C290, and C310.

Please refer to C260, C262, C270, C280, C290, and C310.

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(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 2 of 2 sampled residents (#s 1 and 2) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Residents 1 and 2’s current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop a nutrition and hydration plan based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:58 pm. They acknowledged the findings and no further documentation was provided.

1. The actions that will be taken to correct the rule violation are that both Resident #1 and Resident #2 service plans will be updated to provide individualized nutrition and hydration status, preferences, and the individualized needs of each resident. 2. The system will be corrected so that this violation will not happen again by ensuring all current and new resident service plans accurately reflect each resident's individualized nutrition and hydration status, preferences, and the individualized needs of each resident. 3. The area needing correction will be evaluated at the time of move-in, quarterly, and with change of condition. 4. The Health Services Director, RN, and Executive Director will be responsible to see that the corrections are completed/monitored.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. 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 each resident was evaluated for activities, addressing all required elements, and failed to develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose evaluations and services plans were reviewed. The most recent evaluations and current service plans were reviewed for Residents 1 and 2. The following was identified: a. There was no documented evidence an activity evaluation had been completed for sampled residents that addressed the following: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no documented evidence an individualized plan was developed for the sampled residents based on his/her activity evaluation which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/12/26 at 2:58 pm. The findings were acknowledged, and no further documentation was provided.

1. The actions that will be taken to correct the rule violation are both Resident #1 and Resident #2 will be evaluated and updated with the following: Past and current interests, current abilities and skills, emotional and social needs and patterns, physical abilties and limitations, adaptations necessary for the resdient to participate, and identification of activities for behavioral interventions. Each residents individualized plan will detail what, when, how, and how often the team should offer and assist each resident with more individualized activities. 2. The system will be corrected so that this violation will not happen again by ensuring all new and current residents have an activity evaluation completed and individualied activity plans developed immediately or upon move in. 3. The area needing correction will be evaluated at move in, quarterly, and change of condition. 4. The Engagement Director and the Executive Director will be responsible to see that the corrections are completed/monitored.

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: