OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose new move-in evaluation was reviewed. Findings include, but are not limited to: Resident 2 was admitted into the facility in 12/2025 with diagnoses including chronic low back pain, anxiety, major neurocognitive disorder, and osteoporosis. The resident’s record was reviewed and revealed the new move-in evaluation failed to address the following required elements: * Customary routines, including eating; * Interests and hobbies; * Spiritual and cultural preferences and traditions; * Physical health status, including visits to the health practitioner(s), emergency room, hospital, or nursing facility in the past year; * Mental health, including presence of depression, thought disorders or mood problems, history of treatment, and effective non-drug interventions; * Decision making ability; * Activities of daily living, including personal hygiene, dental status, and assistive devices used; * Pain, including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort; * Fall risk or history; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident’s behavior including, but not limited to: noise, lighting, and room temperature. The need to ensure move-in evaluations included all required elements was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:15 pm. They acknowledged the findings.

1.The residents cited were immediately reviewed to complete and document their move-in evaluations. Missing elements were added and verified by the LPN. Care plans were updated accordingly. 2. A standardized Move-In Evaluation Checklist has been developed and incorporated into the admission process. The LPN or RCC will complete and sign off on the checklist within 24 hours of admission. Staff received re-training on admission evaluation requirements. 3.The Administrator or LPN will audit 100% of new admissions weekly for 4 weeks, then monthly moving forward, to ensure evaluations are complete and accurate. 4.The Administrator and the Health Services Director (LPN) are responsible for completion and ongoing monitoring.

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

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled resident (#s 1 and 3) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2025 with diagnoses which included diabetic mellitus with polyneuropathy and chronic pain. The resident's 02/01/26 through 02/17/26 MAR and signed physician orders, dated 02/09/26, were reviewed. The following was identified: The resident had an order for oxycodone 10 mg tablet every four hours as needed for chronic pain, max dose six tablets. a. The 02/01/26 through 02/17/26 MAR revealed the resident was administered the PRN narcotic on 58 occasions. * The Controlled Substance log contained 73 entries for 02/2026. Fifteen of the entries on the controlled substance log were not reflected on the MAR. * The number of tablets remaining noted in the Controlled Substance log matched the number of tablets remaining in the corresponding medication packet. b. On the 02/01/26 through 02/17/26 MAR, the area where MTs documented the effectiveness of PRNs administered showed the oxycodone was administered on 61 occasions. * The Controlled Substance log contained 73 entries for 02/2026. Twelve entries were not reflective on the PRN oxycodone date and time stamp on the electronic MAR. Inconsistencies between the MAR and Controlled Substance Disposition log were reviewed with Staff 3 (Health Services Director) and Staff 4 (Regional RN) on 02/18/26 at 2:20 pm. They reviewed the documentation and acknowledged the discrepancies. During an interview on 02/18/26 at 2:50 pm, Staff 2 (RN) acknowledged the discrepancies. He stated the software system for the electronic MAR had an issue when there was a medication administration overnight, which may account for some of the errors. The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 3, and Staff 4 on 02/19/26 at 1:00 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including lumbar radiculopathy (compression of a nerve), spinal stenosis (narrowing) of the lumbosacral (low back) region, and pain of left lower extremity. The resident's 02/01/26 through 02/17/26 MAR, signed physician orders, dated 02/09/26, and corresponding Controlled Substance Disposition logs were reviewed. The following was identified: The resident had an order for oxycodone five mg tablet, two tablets twice daily every four hours as needed for chronic pain and that the resident could “self direct” for PRN medications. The 02/01/26 through 02/17/26 MAR revealed the resident was administered the PRN narcotic on six occasions. a. The corresponding medication packet contained oxycodone 10 mg tablets with instructions to take one tablet by mouth every hour as needed for pain. Additionally, there was a small, sealed envelope attached to the packet labeled 02/12/26, on which the resident’s first name and “PRN Oxy” was written. There was also an entry in the corresponding Controlled Substance log that was not dated but stated “added 1 back to count.” The number of tablets remaining noted in the Controlled Substance log matched the number of tablets remaining in the corresponding medication packet, including the tablet in the envelope. During an interview on 02/17/26 at 1:47 pm, Staff 23 (Lead Medication Coordinator) stated the packet contained a PRN oxycodone tablet that was signed for and sent out with Resident 4 and family in case s/he experienced pain while out of the facility. Staff 23 stated the process was to put the medication back in an envelope and attach to the medication packet. During an interview on 02/18/26 at 11:30 am, Staff 2 (RN) stated the facility procedure is to immediately destroy any medication returned back to the facility, and the medication would be destroyed with a nurse and a witness. He acknowledged the discrepancy between the signed physician order and the instructions on the medication packet from the pharmacy and stated he would obtain correct order instructions. b. On 02/12/26, the PRN narcotic was signed out on the corresponding Controlled Substance log twice, and one instance lacked a time stamp. However, the MAR reflected only one administration. c. On 02/13/26, the PRN narcotic was signed out on the MAR twice for lunch and evening, but there was no data entered on 02/13/26 in the corresponding Controlled Substance log. d. On 02/14/26, the PRN narcotic was signed out on the corresponding Controlled Substance log once, but there was no data entered on the MAR. During an interview on 02/18/26 at 11:35 am, Staff 2 acknowledged the discrepancies. He stated the software system for the electronic MAR had an issue when there was a medication administration given overnight, the entry was placed on the previous day, which may account for some of the discrepancies. The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 12:50 pm. The findings were acknowledged.

1. What actions will be taken to correct the rule violation for each example/resident? 1.All controlled substance logs cited were immediately reconciled and corrected. Any discrepancies were investigated and resolved, and involved staff received immediate re-training. 2. Shift-to-shift controlled substance counts with dual staff signatures have been implemented. The controlled substance tracking form was updated to include detailed verification fields. All medication staff received refresher training on reconciliation procedures. 3. Weekly audits of controlled substance logs will be conducted moving forward. Results will be reviewed by the Administrator and/or Health Services Director monthly. 4. The HSD and Resident Care Coordinator will ensure corrective actions are completed and monitored. RCC or lead med tech will conduct weekly audits April 8th 2026

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legal prescriber and for which the facility was responsible to administer for 3 of 5 sampled residents (#s 2, 4, and 5). Findings include, but are not limited to: 1. Resident 4 was admitted into the facility in 02/2024 with diagnoses including hypertension, degenerative joint disease, and anxiety. The resident’s 02/01/26 through 02/17/26 MAR and current physician’s orders were reviewed. The following medications lacked a reason for use: * Buspirone 30 mg, one tablet twice daily; * Docusate sodium 100 mg, one capsule twice daily; * Lorazepam 0.5 mg, one tablet three times daily; * Tramadol 50 mg, one tablet four times daily; * Vitamin D3 50 mcg, one tablet daily; * Reguloid SF orange powder, 15 grams daily; * Divalproex ER 500 mg 24 hour, one tablet daily; * Pantoprazole 40 mg, one tablet daily; * Fluticasone/salmeterol 500-50 mcg, one puff twice daily; and * Magnesium citrate 1.745 gram/30 ml, 296 mL for one dose. During an interview on 02/18/26 at 11:45 am, Staff 2 (RN) confirmed the above medications lacked a reason for use. The need for MARs to be accurate and include a reason for use was discussed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN), on 02/19/26 at 12:50 pm. The findings were acknowledged. 2. Resident 2 was admitted into the facility in 12/2025 with diagnoses including osteoporosis. The resident’s 02/01/26 through 02/17/26 MAR and current physician’s orders were reviewed, and the following medications lacked a reason for use: * Alendronate 70mg tablet, one tablet every seven days; * Cal/Mag/Zinc/Vitamin D, one tablet daily; * Centrum adult tablets, one tablet daily; * Vitamin B-6 100mg, one tablet daily; * Losartan 100 mg, one tablet daily; and * Acetaminophen 500 mg, two tablets every six hours as needed. On 02/19/26 at 11:33 am, the above was reviewed with Staff 3 (Health Services Director) and Staff 4 (Regional RN), who confirmed the MAR lacked a reason for use for the above medications. The need to ensure MARs were accurate and included a reason for use for each medication was reviewed with Staff 1 (Executive Director), Staff 3, and Staff 4 on 02/19/26 at 1:15 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 06/2023 with diagnoses including atrial fibrillation and memory impairment. The resident’s 02/01/26 through 02/17/26 MAR and current physician’s orders were reviewed. The following medication lacked a reason for use: * Mirtazapine 30mg tablet, Take 1.5 tablet (45mg) daily. On 2/18/26 at 1:00 pm Staff 4 (Regional RN) confirmed the above medication lacked a reason for use. The need to ensure the MAR was accurate and included a reason for use for each medication, was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 on 02/19/26 at 2:00 pm. They acknowledged the findings. No further documentation was provided.

1.The medication administration records for residents cited were immediately reviewed and corrected. The medication techs involved received targeted re-education on the seven rights of medication administration. 2. A weekly audit of least 20% of all MARs has been implemented by the LPN to ensure accurate documentation. 3. Weekly MAR audits will be conducted weekly for 60 days, then monthly afterwards. 4.The LPN and Administrator are responsible for monitoring and ensuring compliance.

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed upon move-in, and at least quarterly thereafter, to assure their ability to safely self-administer medications for 2 of 2 sampled residents (#s 3 and 4) reviewed for self-administration of medication. Findings include, but are not limited to: 1. Resident 3 was admitted into the facility in 04/2025 with diagnoses including lumbar radiculopathy (compression of a nerve) and spinal stenosis (a narrowing) of the lumbosacral (low back) region. During review of current physician orders, dated 02/09/26, and the 02/01/26 through 02/17/26 MAR, it was identified that Resident 3 self-administered diclofenac sodium 1% gel for low back pain four times daily. In an interview on 02/17/26 at 11:30 am, Resident 3 stated s/he kept the medication in a personal bag for self-administration but was unable to locate it upon surveyor request. There was no documented evidence a self-administration evaluation had been completed for Resident 3. On 02/17/26 at 2:03 pm, Staff 3 (Health Services Director) confirmed there was no evaluation of the resident's ability to self-administer his/her medication. The need to ensure residents who self-administered their medications were evaluated upon move-in and at least quarterly thereafter was discussed with Staff 1 (Executive Director), Staff 3, and Staff 4 (Regional RN), on 02/19/26 at 12:45 pm. The findings were acknowledged. 2. Resident 4 was admitted to the facility in 02/2024 with diagnoses including stenosis (narrowing) of the external ear canal and constipation. During review of current physician orders, dated 02/09/26, and of the 02/01/26 through 02/17/26 MAR, it was identified that Resident 4 self-administered the following medications: * Soothe Extra Protection drops for dry eyes as needed daily; * Bisacodyl suppository daily as needed for constipation; and * Sodium chloride nasal spray daily as needed for nasal dryness, and estradiol cream daily. During an interview on 02/18/26 at 10:15 am, Resident 4 stated s/he kept the medications in the bathroom or at the bedside, and all medications were observed by surveyor. There was no documented evidence a self-administration evaluation had been completed for Resident 4. On 02/18/26 at 11:50 am, Staff 2 (RN) confirmed there was no evaluation of the resident's ability to self-administer his/her medications. The need to ensure residents who self-administered their medications were evaluated upon move-in and at least quarterly thereafter was discussed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 12:50 pm. The findings were acknowledged.

1.All residents currently self-administering medications were reassessed for appropriateness. Missing documentation was completed, and secure storage was verified. 2. Quarterly reassessments will be scheduled for all residents approved for self-administration. Written approval by the LPN will be required prior to initiation. Secure storage verification has been added to routine checks. 3. Quarterly audits of all self-administering residents will be conducted. 4. The RCC conducts assessments and reassessments. The Administrator will monitor documentation compliance.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to review the ABST evaluation no less than quarterly at the same time the resident’s service plan was updated for 2 of 5 sampled residents (#s 4 and 5) and multiple unsampled residents. Findings include, but are not limited to: The facility’s ABST data was reviewed on 02/17/26 through 02/19/26 and revealed the following: 1. Resident 4 was admitted to the facility in 02/2024. Review of Resident 4’s ABST and clinical records identified the facility failed to update and review the ABST no less than quarterly at the same time the resident’s service plan was updated. Resident 4’s service plan was updated on 01/20/26, however, the last ABST update was on 03/07/25. The need to ensure resident ABST evaluations were reviewed at least quarterly was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN), on 02/19/26 at 2:00 pm. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 06/2023. Review of Resident 5’s ABST and clinical records identified the facility failed to update and review the ABST no less than quarterly at the same time the resident’s service plan was updated. Resident 5’s service plan was updated on 02/07/26; however, the last ABST update was on 11/20/25. The need to ensure resident ABST evaluations were reviewed and updated at least quarterly was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 2:00 pm. They acknowledged the findings. 3. Facility census during survey was 53. Facility ABST evaluations updates were reviewed on 02/19/26. It was determined that 30 unsampled residents’ ABST evaluations had not been updated within the past quarter. and one unsampled resident who had been out facility since 12/2025 was still active on the ABST. On 02/19/26 at 11:45 am, Staff 3 (Health Services Director) and Staff 4 (Regional RN) confirmed the ABST lacked updates at least quarterly for Resident 4, Resident 5, and multiple unsampled residents. They also confirmed the unsampled resident who was still active on the ABST was discharged to the hospital in 12/2025. The need to ensure resident ABST evaluations were reviewed and updated at least quarterly was discussed with Staff 1 (Executive Director), Staff 3, and Staff 4 on 02/19/26 at 2:00 pm. They acknowledged the findings.

1. Resident 4 and Resident 5’s ABST evaluations were reviewed and updated to reflect their current service needs and to align with their most recent service plans. The discharged resident who remained active on the ABST was removed from the ABST census. A 100% audit of all 55 residents was conducted. All residents identified as overdue for quarterly ABST review had their ABST evaluations updated. The ABST census was reconciled to ensure accuracy of active residents. 2.The ABST will be reviewed and updated concurrently with each resident’s quarterly service plan review. The RCC is responsible for completing the ABST update at the time of the service plan review. Upon discharge, residents will be removed from the ABST census the same day as discharge documentation. 3. The RCC will conduct a 100% audit of ABST evaluations monthly. 4. The RCC is responsible for completion of quarterly ABST updates and monthly audits.The Executive Director is responsible for oversight and review of audit findings. Any additional support will be provide by the HSD.

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly-hired staff (#5) completed required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed with Staff 10 (Business Office Manager) on 02/19/26. The following was identified: There was no documented evidence Staff 5 (CG), hired 10/17/25, had completed one or more of the following pre-service dementia care training topics: * Dementia disease process, including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia, including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for staff to complete all required pre-service dementia training was discussed with Staff 1 (ED), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:00 pm. They acknowledged the findings.

1. All staff lacking required pre-service training completed the required training immediately. Documentation was updated in personnel files. 2. A New Hire Orientation Checklist has been implemented. Staff may not provide resident care independently until all required pre-service training is completed and documented. 3.100% of new hires will be audited for compliance for 90 days. Thereafter, quarterly personnel file audits will be conducted. 4. The Administrator oversees compliance. Department supervisors verify training completion prior to independent work.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 5, 11, and 26) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 10 (Business Office Manager) on 02/19/26. The following was identified: There was no documented evidence Staff 5 (CG), Staff 11 (CG), and Staff 26 (MT), hired on 10/17/25, 11/26/25, and 10/30/25, respectively, demonstrated competency within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Other duties as applicable (medications and treatments); and * First Aid/Abdominal thrust training. The need to ensure there was documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:00 pm. They acknowledged the findings.

1. All employees exceeding the 30-day competency requirement were immediately evaluated. Documentation was completed and filed. 2.A 30-day competency tracking system has been implemented using a hire-date-based calendar reminder. 3. Monthly audits of employees within their first 60 days of employment will be conducted. 4.RCC will complete competency evaluations. The Administrator will monitor the tracking system.

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month and in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: On 02/19/26 at 10:43 am, fire drill records for the previous six months were reviewed with Staff 9 (Building Services Director) and revealed fire drills were conducted in the independent living area of the building, but had not been conducted in the assisted living. The need to conduct unannounced fire drills every other month and in accordance with the OFC was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:15 pm. They acknowledged the findings.

1. A fire drill was conducted in the Assisted Living area immediately after the deficiency was identified. The last six months of drill records were reviewed. Leadership (Executive Director, Health Services Director, and Building Services Director) reviewed the requirement for unannounced fire drills every other month in accordance with the Oregon Fire Code. 2. A standardized fire drill documentation form has been implemented to clearly identify the location (Assisted Living), with all information required under Oregon Fire Code. The Executive Director will verify monthly that drills are completed as scheduled. 3.The Executive Director will review fire drill logs monthly with the building services director moving forward, drills are conducted in Assisted Living, drills are unannounced, drills occur every other month, documentation is complete accurately. 4. • The Building Services Director is responsible for scheduling and conducting fire drills. The Executive Director is responsible for oversight and monthly monitoring.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: On 02/19/26 at 10:43 am, the facility fire and life safety records for the previous six months were reviewed with Staff 9 (Building Services Director) and revealed the facility lacked documented evidence residents were instructed within 24 hours of admission and re-instructed, at least annually, on general safety procedures, evacuation methods, and responsibilities. The need to ensure residents received instruction in general safety procedures, evacuation methods, and responsibilities during fire drills within 24 hours of admission, and were re-instructed at least annually, was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:15 pm. They acknowledged the findings.

1. Residents lacking documentation of fire safety education received training immediately. Signed acknowledgments were placed in our 2026 fire life & safety binder. 2. Fire and life safety education has been added to the Move-In Checklist and must be completed within 24 hours of admission. An annual resident fire safety re-education schedule has been implemented and added to the community training calendar. 3. The Executive Director will audit: 100% of new admissions for 60 days to ensure instruction occurs within 24 hours. A quarterly random sample of five resident files to verify annual re-instruction documentation. 4. The Building Services Director (or designee) is responsible for providing resident instruction. The Executive Director is responsible for oversight and monitoring compliance.

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