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 develop and implement an effective method for responding to and resolving resident complaints. Findings include, but are not limited to: From 03/02/26 to 03/06/26, several sampled and unsampled residents reported grievances to surveyors regarding dining services and slow response times to call lights. On 03/06/26 at 10:33 am, Staff 1 (ED) confirmed she was aware of the resident grievances and reported there was not an established grievance process to respond and resolve complaints. The need to ensure the facility developed and implemented effective methods for responding to and resolving resident complaints was reviewed with Staff 1 on 03/06/26 at 11:30 am. She acknowledged the findings.

1. By 4/10/2026, the RDHS/RDO will educate the ED and the HSD on the Sinceri grievance process. The ED and the HSD will then educate all staff on the process by 4/20/2026. All Residents will be educated on how to report concerns through both verbal and written methods to ensure concerns are identified and addressed timely by the ED by 4/20/2026. 2. Concerns identified during Resident Council and Town Hall meetings are documented by the Executive Director using the grievance form and entered into the grievance log for tracking and follow-up. 3. The Executive Director or designee will review the grievance log at least 5 days/week during stand-up to ensure timely response and follow-up. The ED will audit the grievance log weekly x 4 weeks, bi-weekly x 4 weeks and then monthly x 1 month toensure concerns are addressed and resolved. The results of these audits will be reported monthly to the Continuous Quality Improvement committee. 4. ED/Designee

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 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare for 1 of 1 sampled resident (# 1) and one unsampled resident who required a modified texture diet and/or fluid consistency. Findings include, but are not limited to: 1. Resident 1 was admitted into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). During the acuity interview on 03/02/26, the resident was identified as having a mechanical soft diet texture and nectar-thick liquids. The resident’s 12/03/25 through 03/02/26 clinical record was reviewed, and the following was identified: * Signed physician orders, dated 03/03/26, identified Resident 1 was on a pureed diet with thickened liquids, effective 01/15/26. * The most recent service plan, dated 01/14/26, indicated Resident 1 required a mechanical soft diet texture, nectar-thick prepackaged liquids, and cut-up food. Not reflective of the physician’s order dated 03/03/26. On 03/04/26 at 12:06 pm, Resident 1 was served lunch that consisted of minced broccoli, mashed potatoes with gravy, and pre-thickened nectar thick apple juice. At 12:09 pm the resident was served apple cake. At 12:10 pm the apple cake was removed and replaced toward the end of the meal with chocolate ice cream (which is considered a thin liquid). During an approximate five-minute period at 12:49 pm, the resident was observed coughing intermittently, his/her tablemates alerted staff “[s/he] was choking” and a caregiver checked on him/her. During an interview at 1:05 pm on 03/04/26, Staff 5 (Culinary Services Director) acknowledged the meal provided at lunch was “minced and moist” and she had never been aware of Resident 1 requiring a pureed diet in the year she had been working at the facility. On 03/04/26 at 3:30 pm, Staff 1 (ED) provided a discontinue order for the pureed diet, signed 03/04/26 with an effective discontinue date of 01/15/26, and indicated Resident 1 was “never supposed to be on a pureed diet” per hospice, despite hospice orders indicating a pureed diet signed on 03/03/26. On 03/04/26 at 4:20 pm, Staff 2 (Director of Nursing/LPN) indicated Resident 1 should be on a minced and moist diet texture and nectar-thick liquids and provided hospice admission orders, dated 12/23/25, that confirmed the modified diet and fluid consistency. On 03/04/26 at 4:25 pm Resident 1 was served for dinner thin pureed beef stew and regular thin coffee. Not following the current order diet order dated, 12/23/25, of minced and moist diet texture and nectar-thick liquids. During an interview on 03/04/26 at 4:30 pm, Staff 22 (Dining Staff/Cook) acknowledged he prepared dinner for Resident 1 and indicated he was told Resident 1 required a mechanical soft diet and instructions were “to blend it up.” Staff 23 (Resident Assistant) confirmed the resident was served regular coffee, not nectar thick. At 4:40 pm the surveyor shared findings with Staff 2 and requested the stew and coffee be removed, as it was not the resident’s ordered diet consistency. On 03/04/26 at 4:48 pm the resident was observed eating cut up hot dogs, macaroni salad, a slice of bread and pre-thickened nectar-thick water. The hot dogs, macaroni salad and bread were not minced, and the bread was not softened and moist as required for a minced and moist diet texture. At 4:49 pm the survey team requested the meal be replaced with one reflective of the resident’s ordered diet texture, and observations confirmed the resident received the correct diet texture. On 03/05/26 at 12:50 pm, Staff 1 (ED) acknowledged the facility had not followed the proper diet texture and fluid consistency for Resident 1 and instructed Staff 2 (Director of Nursing/LPN) to provide training for all of the cooks responsible for preparing food and only having pre-thickened fluid available. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents, including ensuring residents received the appropriate therapeutic diet texture, was discussed with Staff 1 and Staff 2 on 03/06/26 at 12:15 pm. They acknowledged the findings. 2. During the acuity interview on 03/02/26, an unsampled resident was identified as requiring a mechanical soft diet texture, which is a fork-mashable consistency. A physician’s order, noted 02/19/26, confirmed a diet texture of “Soft and Bite-Sized (aka [otherwise known as] Mechanical Soft, Level 3)”. On 03/05/26 during an observation, the survey team requested the lunch that was prepared for the unsampled resident, which consisted of a chopped-up vegetarian burger that contained corn and was not fork-mashable. On 03/05/26 at 12:25 pm, Staff 5 (Culinary Services Director) confirmed corn was not considered mechanical soft and provided the resident with an alternative meal that was reflective of the resident’s ordered diet texture. On 03/05/26 at 12:50 pm, Staff 1 (ED) acknowledged the facility had not followed the proper diet texture and fluid consistency for the unsampled resident. She had instructed Staff 2 (Director of Nursing/LPN) to provide training for all of the cooks responsible for preparing food. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents, including ensuring residents received the appropriate therapeutic diet texture and fluid consistency, was discussed with Staff 1 and Staff 2 on 03/06/26 at 12:15 pm. They acknowledged the findings.

1. Resident #1 diet order was clarified and updated on 3/7/2026 by the HSD. Diet orders were verified and communicated to staff to ensure appropriate food and fluid consistency is provided. On 3/5/2026, Culinary Staff received education on the requirement to follow prescribed diet orders, including texture-modified diets and fluid consistencies, to ensure resident safety. 2. The ED and the HSD will be educated on the correct diet process and notification to all staff, including culinary staff. Diet orders will be reviewed during service planning, with any change in condition, and as needed to ensure accuracy by the HSD or designee. The HSD/ED will update the diet roster and provide a current and up to date copy to the kitchen at least monthly or with any changes. 3. The ED/HSD/Designee will audit at least 4 meals a week x 4 weeks, 3 meals a week x 4 weeks, and then randomly for correct diet service. 4. The HSD or designee is responsible for oversight of the process.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. 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 available to staff, reflective of the resident’s care needs, provided clear direction regarding the delivery of services, and were implemented for 4 of 4 sampled residents (#’s 1, 2, 4 and 5), whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living facility in 09/2025 with diagnoses including shortness of breath. The resident’s 01/27/26 service plan and 12/02/25 through 03/02/26 temporary service plans (TSP’s) were reviewed, interviews with the resident and staff were conducted, and observations of the resident were made. The following was identified: The service plan was not reflective of the resident’s care needs, lacked clear direction to staff and was not implemented in the following areas: * Assistance with oxygen concentrator, including the need to fill the humidifier bottle with distilled water PRN and clean the air filter weekly; * Use of bedside commode including assistance with emptying the commode and cleaning it PRN; and * The need to anticipate the resident’s needs by offering assistance before and after meals with toileting, transfers and nighttime cares and to ensure s/he had personal items within reach was documented in a TSP dated 01/07/26; however the information was not included in the 01/27/26 service plan. On 03/06/26 at 11:45 am, Staff 1 (ED) acknowledged the information included on the 01/07/26 TSP was still pertinent, however was not transferred to the 01/27/26 service plan. The need to ensure service plans were reflective of the resident’s care needs, provided clear direction regarding the delivery of services, and were implemented was discussed with Staff 1 on 03/06/26 at 11:45 am. She acknowledged the findings. 2. Resident 2 moved into the facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s clinical record, including the 03/01/26 service plan, was reviewed, interviews with staff and the resident were conducted, and observations were made. The service plan was not reflective of the resident’s current care needs, lacked clear direction regarding the delivery of services, or was not implemented in the following areas: * Current status, including independence with toileting, transferring, repositioning, oral hygiene, grooming, and personal hygiene and will call for assistance as needed; * Hospice information including use of assistive devices and services provided; * Daily weights; * Oxygen assistance including cleaning, maintenance, and safety instruction; * Edema management instruction including interventions and what and when to report to the RN and/or hospice provider; * Assistive devices used for toileting, including use of a raised toilet seat and commodes, and instruction related to cleaning and safety; * Maintenance of assistive devices to ensure devices were safe and in working condition related to the resident’s four wheeled walker and commodes; * Assistive devices used for hearing including use of a pocket sound amplifier with headphones, and instruction related to use, cleaning, and charging; * Self-administration of medication information and instructions; * Sleep schedule and use of recliner at times to sleep; * Dining needs and preferences including desire for finger foods and instructions related to when meals were delivered to the resident’s room; * Emergency evacuation assistance, including number of staff needed; and * Assistance with room temperature, including the use of a fan and instruction related to when to open/close the window beside the resident’s recliner. On 03/02/26 at 1:45 pm, Resident 2 was observed to use continuous oxygen, to transfer independently out of his/her recliner and ambulate to the kitchen. The resident reported the need to be escorted long distances in his/her wheelchair and needed assistance with the oxygen tubing at times. On 03/06/26 at 9:26 am, Staff 15 (Resident Assistant) reported to assist the resident with dressing/undressing, setting up meals, and responding to the call light when the resident used his/her pendant for stand-by assistance. The need to ensure service plans were reflective of residents’ needs and preferences, provided clear direction regarding the delivery of services, and were implemented, was reviewed with Staff 1 (ED) on 03/06/26 at 11:30 am. She acknowledged the findings. 3. Resident 1 moved into the facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The following was identified: a. During the acuity interview on 03/02/26, facility staff reported service plans were stored in the service plan binder located in the Neighborhood Room for direct care staff to review. Upon observation of the binder at 11:53 am on 03/02/26, the service plan for Resident 1 was dated 12/08/25. An updated service plan following a significant change of condition, dated 01/14/26, was provided by the facility at 11:15 am on 03/05/26, but this was not available to staff at the time of survey entrance. b. The 12/08/25 service plan was not reflective of the resident’s current care needs, lacked clear instructions and was not implemented in the following areas: * Aspiration precautions including distant supervision “within arm's reach”, remain upright at 90 degrees for 60 minutes following food or beverage intake, mechanical soft diet texture and nectar thickened fluids, and oral care at least twice a day; * Fall precautions including leaving call pendant within reach, hazards removed from the walkway in room, and instructions regarding placement of wheelchair for accessibility; * How the resident exhibited agitation and non-pharmaceutical interventions; * Incontinent of bowel; * Cognition, including poor short-term memory and impulsivity; and * Preferences for keeping door open and location for toileting assistance. The resident’s service plan indicated the resident was continent of his/her bowels, and instructed staff to keep items within reach including the call light and his/her assistive device in resident’s sight for a visual reminder. The service plan lacked information on the resident’s cognition. The resident was taking a PRN psychotropic medication for anxiety and restlessness, but the non-pharmaceutical interventions were not on the service plan for staff to try prior to administering the medication. During interviews with the resident, it was noted s/he preferred to have toileting assistance in front of the recliner chair and indicated the door was left open for staff convenience, but s/he preferred to be asked whether to keep the door open or closed. Observations during the survey revealed the following: * The resident’s door remained open the majority of the time. Staff were not observed to ask the resident if s/he preferred the door to be closed when they left the residents room; * Staff provided toileting assist in front of the recliner and in the bathroom; * The resident was served the incorrect diet texture and fluid consistency during lunch and dinner service on 03/04/26, was assisted into a reclined position less than 30 minutes after finishing lunch and a white substance was observed between his/her teeth after breakfast on two occasions; and * On 03/05/26, when staff left the room a ceramic dog, approximately 9-inches tall, was left in the resident’s pathway creating a trip hazard, the call pendant was not within reach, and the wheelchair was not in sight or accessible. Interviews with care staff during the survey noted the resident was incontinent of his/her bowel and was forgetful. Staff were unaware the resident had a PRN medication for agitation or restlessness and what non-pharmaceutical interventions could be provided for when s/he displayed the behavior. The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, provided clear instructions to staff regarding the delivery of services, and was implemented was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings. 4. Resident 5 moved into the facility in 10/2023 with diagnoses including diabetes and hypertension. The resident’s 01/13/26 service plan and 12/01/25 through 03/02/26 temporary service plans were reviewed. Observations and interviews with staff and the resident were conducted. The service plan was not reflective of resident care needs and lacked clear direction to staff in the following areas: a. The service plan indicated the resident was independent with dressing, bathing, and toileting. However, interview(s) with staff and the resident during the survey on 03/02/26 through 03/06/26 indicated resident required one staff assistance with above care. b. Resident 5 had a suprapubic catheter and required staff assistance to empty and to change to/from an overnight bag to a leg bag in the morning and at bedtime. The service plan lacked clear directions to staff on providing catheter care. The need to ensure service plans were reflective of resident care needs and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 9:31am. They acknowledged findings.

1. Residents 1, 2, 4, and 5 service plans will be updated to be reflective of care by the HSD by 4/10/2026. 2. An audit of all current resident service plans will be completed by 4/15/2026 by the HSD or designee. Any service plan that does not provide clear instruction for staff to follow will be updated by the HSD/ED/Designee by 4/30/2026. 3. Service plans will be reviewed and updated at least every 90 days and as needed with any change of condition to ensure they reflect current resident needs and provide clear direction for care. Temporary service plans will be reviewed at least 4 days/week in the clinical huddle meeting and as needed to ensure information is incorporated into the permanent service plan. Service plans will be printed and placed in a binder for staff to view/read/access. 4. The HSD/ED/Designee are responsible for ensuring this happens

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 residents’ service plans were reflective of current care needs and provided clear instruction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). The resident’s 06/09/26 to 07/08/26 clinical record and a Supportive Device Assessment dated 03/27/26 were reviewed, interviews with the resident and staff were conducted, and observations were made. The service plan, dated 04/05/26, was not reflective of the resident’s current care needs and did not provide clear instruction to staff in the following areas: * The need for two-person transfers; * The resident’s inability to use the call pendant; and * The resident’s inability to operate the remote to his/her electric lift recliner. On 07/08/26 at 12:00 pm, Staff 28 (Resident Assistant) knocked, entered Resident 1’s room, and asked if s/he would like to go to lunch. After Resident 1 nodded, Staff 28 retrieved the recliner remote and lowered the leg rests and raised the seat back. Staff 28 then requested assistance from a second CG and the two used a gait belt to pivot Resident 1 from the recliner to the wheelchair. Staff 28 and Staff 25 (Medication Technician/Resident Assistant) both confirmed Resident 1 required the assistance of two CGs for transfers and standing ADLs (e.g., toileting and dressing). Staff 25 also verified Resident 1 was not able to independently operate the recliner remote or the call pendant, so care staff performed safety checks every 30 minutes, as instructed by a temporary service plan dated 07/08/26 (prior to survey entry). The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 24 (ED), Staff 4 (Business Office Director), and Staff 2 (Health and Wellness Director/ LPN) on 07/09/26 at 2:30 pm. They acknowledged the findings. 2. Resident 8 moved into the facility in 04/2025 with diagnoses including hypertension. The resident’s 06/05/26 to 07/08/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations were made. The service plan, dated 07/01/26, was not reflective of the resident’s current care needs and did not provide clear instruction to staff in the following areas: * Behaviors, including a history of suicidal ideation and how staff should respond. Observation notes were reviewed and identified the resident had a recent history of suicidal ideation on 06/01/26. A 06/02/26 temporary service plan (TSP) provided instructions to staff that included contacting a local mental health crisis line and call 911 and the ED if the resident was in “immediate danger of self [sic] or toward others.” Review of the 07/01/26 service plan did not reflect Resident 8’s past suicidal ideation behavior nor instructions to staff regarding how to respond should the behavior be identified again. Interviews with multiple staff on 07/09/26 indicated they were not clear about what to do for Resident 8 other than “support the resident,” notify the MT, and perform more frequent safety checks, ranging from every 30 minutes to an hour. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 24 (ED), Staff 2 (Health and Wellness Director/LPN), and Staff 4 (Business Office Director) on 07/09/26 at 3:15 pm. They acknowledged the findings. Staff 2 acknowledged the 06/02/26 TSP was no longer available to staff to review at the time of the survey.

1. Resident 1’s service plan to be updated to reflect the following changes in addition to overall review to ensure accuracy and up-to-date information by Health Services Director by target date of 7/31/2026: (1) Resident need for two-person assist with transfers (2) Resident’s inability to use call pendant and staff interventions (3) Resident’s inability to safety use the remote to electric lift recliner and staff interventions. Resident 8’s service plan to be updated to reflect resident history of suicidal ideation and staff directives on how to respond/intervene in the event of an occurrence of above behavior by target date of 7/31/2026. 2. The Regional Director of Health Services will provide education to the Health Services Director and Resident Care Coordinator(s) on person-centered Service Plans. 3. 10% of Service Plans to be audited by Health Services Director or Designee on a monthly basis x 3 months then ongoing quarterly to ensure accuracy. Service plans will be reviewed upon completion by Health Services Director and Executive Director. Changes in condition to be updated on Service Plans by Health Services Director/Designee within 48 hours. Significant changes in condition to be coordinated/communicated with Community Oversight RN immediately, and Service Plan to be updated within 48 hours by Health Services Director/Designee. Initial Service Plans to be reviewed and/or implemented by Health Services Director in addition to reviewing within the 30 days of move-in timeframe. Health Services Director to review any resident changes/updates daily along with clinical leadership team during daily Clinical Huddle meetings. 4. The Health Services Director and the ED are responsible to see that corrections are implemented and monitored.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident’s choice, the administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 4 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living facility in 09/2025 with diagnoses including shortness of breath and pain. The resident’s most recent service plan, dated 01/27/26, lacked evidence that the resident participated in the development of the service plan. In an interview with Resident 4 on 03/04/26 at 9:45 am, the resident stated s/he had not participated in the development of the 01/27/26 service plan and was not aware of the details noted in the service plan. The need to ensure Resident 4 participated in the development of his/her service plan was discussed with Staff 1 (ED) on 03/06/26 at 11:45 am. She acknowledged the findings. 2. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements) and had a history of difficulty swallowing. The resident’s most recent service plan, dated 01/14/26, lacked evidence that the resident, or the resident’s legal representative, participated in the development of the service plan. During an interview on 03/06/26 at 10:35 am with Staff 1 (ED), she confirmed she had not started meeting with residents and their families to discuss the service plans in the last 90 days “with the new system”. The need to ensure Resident 1 participated in the development of his/her service plan was discussed with Staff 1 (ED) on 03/06/26 at 12:30 pm. She acknowledged the findings. 3. Resident 6 was admitted to the facility in 11/2024 with diagnoses including epilepsy and dementia. The resident’s most recent service plan, dated 01/03/26, lacked evidence that the resident, or the resident’s legal representative, participated in the development of the service plan. During an interview at 12:25 pm on 03/04/26, the surveyor was approached by Resident 6 and Witness 2 (Family). Witness 2 shared concerns of multiple attempts since January of attempting to get a copy of Resident 6’s service plan and denied having had a service plan meeting in the last year. The need to ensure Resident 6 participated in the development of his/her service plan was discussed with Staff 1 (ED) on 03/06/26 at 12:30 pm. She acknowledged the findings. 4. Resident 2 moved into the assisted living facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s most recent service plan, dated 03/01/26, lacked evidence the resident participated in the development of the service plan. On 03/02/26 at 1:45 pm, the resident reported s/he had not participated in the development of the service plan. The need to ensure service plans were developed by a Service Planning Team that included the resident was reviewed with Staff 1 (ED) on 03/06/26 at 11:30 am. She acknowledged the findings.

1. Residents 1, 2, 4, and 6 were offered a care conference by the HSD on 3/5/2026. 2. By 4/10/2026, the Regional Director of Health Services (RDHS) will educate the Executive Director (ED) and the Health Services Director (HSD) on the notification, documentation and involvement of residents and/or their representatives in the service planning process. 3. Scheduled care conferences will be discussed at daily stand up at least 4 days/week. Care conferences will be held at a minimum of: at move-in, quarterly, and with any change of condition service plan updates. Evaluations/service plans due and care conferences scheduled with be reviewed at least 5 days per week in daily stand-up. The ED and/or designee will audit care conference schedules weekly x 4 weeks, bi-weekly x 4 weeks, and then monthly to review participation and documentation. The results of these audits will be reported to the monthly Continuous Quality Improvement Committee. 4. ED/HSD/Designee

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 interview and record review, it was determined the facility failed to determine and document actions or interventions for changes of condition, monitor and note progress of the conditions, at least weekly, to resolution, and monitor residents consistent with his or her evaluated needs and service plan for 3 of 4 sampled residents (#s 1, 2, and 5) who had documented changes of condition, including multiple falls. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). Resident 1's clinical record, service plan, temporary service plans, incident reports, and observation notes reviewed from 12/02/25 through 03/02/26 revealed the following: * Fall interventions identified on the 12/08/25 service plan available to staff indicated reminders to use the wheelchair, keep the device in sight, within reach and locked, safety rounding, wear supportive footwear, keep personal possessions and call light within reach, remove hazards from room and walkway, provide meal escort, stand-by assist for transfers, safety checks and a toileting schedule. Observations of the resident during the survey revealed Resident 1 received wheelchair escorts to meals, staff provided assistance with transfers and toileting, the call pendant and wheelchair were not consistently placed within sight and reach, s/he wore supportive footwear, and staff provided safety checks. * On 12/02/25 Resident 1 had a non-injury fall with interventions noted on the incident report to keep the assistive device in sight as a visual reminder. There was no documented evidence the determined intervention was communicated to staff on each shift, and implemented. * On 12/06/25 Resident 1 had a non-injury fall after sliding from the chair. Interventions identified from the incident report included “Increase observation of resident during waking hours.” There was no documented evidence the facility communicated the new intervention to staff, was implemented and monitored for effectiveness. * On 12/10/25 Resident 1 attempted to self-transfer and had a non-injury fall. Interventions identified from the incident report included escort to meals and “Increase observation of resident during waking hours.” Although providing meal escorts was on the service plan, there was no documented evidence “increase observation of resident during waking hours” was communicated to staff on all shifts, and no documented evidence either intervention were implemented or reviewed for effectiveness. * On 12/25/25 Resident 1 had a non-injury fall after falling out of his/her chair. Interventions identified from the incident report included the same interventions from the 12/10/25 fall and no documented evidence the interventions were communicated to staff on all shifts, implemented or reviewed for effectiveness. There was no documented evidence the facility consistently communicated fall interventions to staff on all shifts, monitored the interventions for implementation and effectiveness consistent with the resident’s evaluated needs and service plan. On 03/06/26 at 12:15 pm, Staff 1 (ED) confirmed the interventions following multiple falls were not communicated to staff on all shifts and monitored for implementation and effectiveness. The need to ensure the facility communicated identified interventions to staff on all shifts, and monitored fall interventions consistent with evaluated needs and service plan was discussed with Staff 1 and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings. 2. Resident 5 moved into the assisted living facility in 10/2023 with diagnoses including diabetes and hypertension Resident 5's clinical record, service plan, temporary service plans, incident reports, and observation notes reviewed from 12/02/25 through 03/02/26, revealed the following: Fall interventions identified on the 01/13/26 service plan available to staff indicated safety checks for increased fall risks. Report to Health Services Director (HSD) and/or designee any observed or reported falls, change in gait/balance, change in toileting ability, and any observed safety hazards in Resident 5’s environment (cluttered walkways, poor lighting, adaptive equipment needing repair). Observation of resident during the survey revealed Resident 5 was utilizing a walker for ambulation, wearing slippers, had call pendant on over neck, and was able to call staff for assistance as needed. *On 12/30/25 Resident 5, had a non-injury fall from rolling out of bed and bumping back of his/her head. Interventions identified on incident report included “increase observation during waking hours”. However, there was no documented evidence the determined intervention was communicated to staff on each shift and implemented. * On 01/24/26 Resident 5 had a non-injury fall while ambulating his/her walker. Intervention identified on incident report included “to keep assistive device in sight”. However, there was no documented evidence the facility reviewed interventions from previous fall, communicated the new intervention to staff, implemented and monitored for effectiveness. * On 02/16/26 Resident 5 had a non-injury fall due to power being out, resident stated was attempting to go find out what happened to the power and slipped. Intervention identified on incident report investigation included to ensure proper footwear and night lights. However, there was no documented evidence the facility reviewed interventions from previous fall, communicated the new intervention to staff, implemented and monitored for effectiveness. Observation of resident’s room on 03/06/26, there were no night lights in the bedroom, living room or bathroom. Interview with the resident conducted on 03/06/26, stated s/he was not aware of night lights in his/her unit. There was no documented evidence the facility consistently communicated fall interventions to staff on all shifts, monitored the interventions for implementation and effectiveness consistent with the resident’s evaluated needs and service plan. On 03/06/26 at 09:31 am, Staff 1 (ED) confirmed the interventions following multiple falls were not communicated to staff on all shifts and monitored for implementation and effectiveness. The need to ensure the facility communicated identified interventions to staff on all shifts, and monitored fall interventions consistent with evaluated needs and service plan was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 9:31 am on 03/06/26. They acknowledged the findings. 3. Resident 2 moved into the facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s 02/02/26 through 03/06/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations of the resident were made. Resident 2 was identified to have the following changes of condition: a. On 02/05/26 the resident returned from the emergency department to the facility with diagnoses including shortness of breath and hyponatremia (low sodium). An RN assessment was completed on 02/06/26 with documented interventions; however, there was no documented evidence the determined interventions were documented and communicated to staff on each shift, and were implemented. b. Resident 2 had a diagnosis of lower leg edema and on 02/10/26 the facility RN implemented instruction to notify the nurse of a three-pound gain or loss from the previous weight. Additional interventions were to monitor respiratory status, edema, and fluid balance. However, there was no documented evidence the nurse was notified of a three-pound weight gain or loss or documentation the additional interventions were implemented or communicated to staff on each shift. c. On 02/19/26 the resident was sent to the emergency department for shortness of breath and increased lower leg edema. A RN assessment was completed on 02/20/26 with documented interventions, however, there was no documented evidence the determined interventions were documented and communicated to staff on each shift, and were implemented. d. On 02/24/26, a weekly follow-up RN assessment was completed with documented interventions, however, there was no documented evidence the determined interventions were documented on and communicated to staff on each shift, and were implemented. On 03/04/26 at 10:35 am, the above was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) and no other documentation was provided. The need to ensure the facility communicated the determined action or interventions to staff on each shift for changes of condition was reviewed with Staff 1 on 03/06/256 at 11:30 am. She acknowledged the findings.

1.Residents # 1, 2, and 5 will be updated by the HSD by 4/10/26 to ensure appropriate interventions were included on the service plan. 2. The RDHS will educate the ED and the HSD by 4/10/2026 on the change of condition process and requirements for monitoring. The ED and HSD will educate all staff on reviewing/signing of temporary service plans in the binder at the start of their shifts by 4/20/2026. 3. Temporary service plans and documentation will be reviewed at least 4 times/week during clinical huddle and as needed to ensure they reflect current interventions and to determine if ongoing needs should be incorporated into the permanent service plan. Information from temporary service plans will be transferred to the permanent service plan when appropriate, by the HSD or designee . 4. HSD/ED/Designee

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 5) whose ADL care was observed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). The resident was identified in the acuity interview as requiring assistance for toileting. a. On 03/03/25 at 10:46 am, the surveyor observed one staff provide incontinence care for Resident 1 by the table in front of his/her recliner. Resident 1 stood up from the recliner and held onto the table for support. Staff placed a trash bag on the floor, donned gloves, set aside a clean brief and began assisting the resident remove his/her pants and brief. The caregiver removed the soiled brief, placed it in the trash bag and used wipes to clean the resident’s peri-area following a bowel movement. Once clean, the resident sat down on the recliner chair and with the same dirty gloves the caregiver touched the resident’s slippers, pants, clean brief, a clean chucks pad, the controller for the recliner, and the wheelchair. b. On 03/04/25 at 12:55 pm, the surveyor observed one staff assist the resident with incontinence care in his/her bathroom. The staff donned gloves and after the resident stood up using the grab bar, the caregiver removed his/her soiled briefs and pants and assisted the resident onto the toilet. With the same soiled gloves, the caregiver touched the resident’s clean clothes in the laundry basket and brought a clean pair of pants, a brief and wipes into the bathroom. She removed the soiled pants and set them on the bathroom floor, used wipes to clean the peri-area following a bowel movement, and with the same dirty gloves touched the clean pants, briefs, wheelchair handles and brakes, a pillow, jacket, a clean chucks pad, blanket, and the controller for the recliner. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 10/2023 with diagnoses including diabetes and hypertension. On 03/04/26 at 1:10 pm, during observations, Staff 21 (Resident Assistant) donned gloves and did not perform hand hygiene prior. Staff 21 picked up a used urinal and stated she needed to wait for a MT to bring cleaning supplies to perform the resident’s catheter care. After touching the used urinal, Staff 21 touched her radio located in her pocket, without performing hand hygiene. Staff 21 stated will proceed to empty catheter then return to clean the catheter opening later. Placed the urinal on the bare carpet without a protective barrier and proceeded to empty the resident’s catheter bag. Staff 21 emptied the urinal into the toilet, rinsed the urinal in the sink and was not observed to complete hand hygiene after doffing gloves. The need to maintain effective infection prevention and control protocols was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 9:31am. They acknowledged the findings.

1. On 3/26/2026, the HSD educated all Staff on infection control practices, including proper hand hygiene, appropriate glove use, and the separation of clean and dirty tasks during resident care. Education included when to perform hand hygiene, when to change gloves, and proper handling of contaminated items and equipment to prevent cross-contamination. 2. The HSD/Designee will perform an infection control audit of at least 10% staff weekly x 4 weeks, to include watching handwashing and incontinence care, and identify any deficient practices and provide education as needed. The results of these audits will be reported monthly to the Continuous Quality Improvement Committee. 3. The ED/HSD will perform spot audits on Infection control practices during resident care on an ongoing basis to ensure staff are following proper hand hygiene, glove use, and clean versus dirty task practices. 4. The Executive Director or designee is responsible for oversight of the process.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (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 and provided resident-specific parameters and instructions for PRN medications for 4 of 4 sampled residents (#s 1, 2, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the assisted living facility in 10/2023 with diagnoses including diabetes and hypertension. The resident’s 02/01/26 through 03/02/26 MAR and current physician’s orders were reviewed. The following was identified: The resident’s MAR lacked a reason for use for the following medications: * Finasteride 5mg tablet; and * Haloperidol 1mg tablet. The need to ensure the MAR included the reason for use for all medications was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 9:31 am. They acknowledged the findings. No further documentation was provided. 2. Resident 2 moved into the assisted living facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s clinical record was reviewed, including the 02/01/26 through 03/02/26 MAR, and physician’s orders. The following was identified: a. The MAR lacked a reason for use for the following orders: * Polyvinyl alcohol 1.4%; * Trelegy ellipta; * Continuous oxygen; * Furosemide 20 mg; * Albuterol inhaler; * Bisacodyl 5 mg; and * Diclofenac sodium 1%. b. The MAR indicated a range for administration for the following orders: * Diclofenac sodium 1% gel; and * Albuterol inhalation aerosol inhaler. c. The resident had the following PRN bowel medications that lacked clear instruction to staff for the order of administration: * Polyethylene glycol powder – three times daily as needed for “no [bowel movement] in [two] days”; * Bisacodyl suppository – daily as needed; * Bisacodyl tablet – daily as needed; and * Senna/Docusate tablet – daily as needed. On 03/04/26 at 9:18 am, Staff 11 (Medication Assistant) reported the PRN bowel medication instruction for the order of administration was unclear for this resident. The need to ensure MARs included the reason for use and dose for each medication and provided clear instruction for the order of administration when multiple PRN medications were used, was reviewed with reviewed with Staff 1 (ED) on 03/06/26 at 11:30 am. She acknowledged the findings. 3. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). The resident’s 02/01/26 through 03/02/26 MAR and physician’s orders were reviewed. The following was identified: The MAR lacked a reason for use for the following orders:: * Carvedilol 6.25 mg; * Citalopram 10mg; * Haloperidol 0.5mg; and * Nitrofurantoin macro 100mg. The need to ensure the MAR included the reason for use for all medications was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 12:15 pm. They acknowledged the findings. 4. Resident 4 moved into the assisted living facility in 09/2025 with diagnoses including asthma, hypothyroidism and pain. The resident’s physician’s orders and 01/01/26 through 01/26/26 MARs were reviewed. The following was noted: a. The following medications had no reason for use: * Eliquis 2.5 mg; * Fluticasone; * Isosorbide 30 mg; * Levothyroxine 12.5 mcg; * Montelukast 10 mg; * Omeprazole 40 mg; * Pregabalin 75 mg; * Spironolactone 50 mg; * Guaifen 400 mg; and * Ondansetron 4 mg. b. The MAR lacked parameters regarding the sequential order for use for the following PRN medications prescribed for the same diagnosis: * Morphine sulfate 20 mg/ml solution and acetaminophen 500 mg (for pain); and * Hydroxyzine 20 mg and Benadryl itch cream (for itchiness). The need to ensure the medication record contained a reason for use and the sequential order for use of PRN medications prescribed for the same diagnosis was discussed with Staff 1 (ED) on 03/06/26 at 11:45 am. She acknowledged the findings.

1The HSD/RN reviewed the MARS for residents # 1, 2, 4, and 5 on 3/9/2026, and updated them to ensure there were resident specific parameters on the PRN medication orders. 2. On 4/1/2026, the RDHS will educate the HSD and the ED regarding appropriate medication parameters, clear direction for administration and sequencing if multiple PRNs are noted for the same diagnosis. The HSD has reviewed All current medication administration records to ensure medications include a documented reason for use and appropriate instructions for administration. Identified medications lacking sufficient direction, including PRN medications without clear parameters or sequencing, were clarified with the prescribing provider and updated to reflect complete and accurate information. 3. Medication orders will be reviewed during the third check by the HSD/ED to ensure they have all of these items. 4. The HSD/ED are responsible. .

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 observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 2 of 2 sampled residents (#s 2 and 4) who were reviewed for self-administration of medications. Findings include, but are not limited to: 1. Resident 2 moved into the assisted living facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s 02/02/26 through 03/06/26 clinical record, including current signed physician orders, dated 02/26/26, were reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The following was identified: On 03/04/26 at 2:07 pm, the resident reported to self-administer an albuterol inhaler, as needed. The medication was observed in the resident’s apartment during the interview. On 03/06/26 at 9:54 am, Staff 11 (Medication Assistant) reported the resident kept a PRN albuterol inhaler in his/her apartment to self-administer as needed. There was no documented evidence of a physician or other legally recognized prescriber’s written order for the resident to self-administer a PRN albuterol inhaler. On 03/04/26 at 8:24 am, the resident’s self-administration evaluation was requested from Staff 1 (ED) and Staff 2 (Director of Nursing/LPN). At 11:27 am, Staff 1 confirmed there was no documented evidence of a self-administration evaluation. The need to ensure residents who chose to self-administer their medications were evaluated and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medication, was reviewed with Staff 1 on 03/06/26 at 11:30 am. She acknowledged the findings. 2. Resident 4 moved into the assisted living facility in 09/2025 with diagnoses including shortness of breath Review of Resident 4’s physician’s orders and MAR dated 02/01/26 through 03/02/26, and progress notes dated 12/02/25 through 03/02/26 revealed the resident was prescribed albuterol inhaler PRN for shortness of breath. During an interview on 03/03/26 at 9:30 am, Resident 4 stated s/he self-administered the albuterol inhaler. The medication was observed in the resident’s apartment during the interview. An order for the prescription medication to be self-administered and the resident's quarterly self-administration evaluation was requested on the same day at 11:15 am and on 03/04/26 at 9:35 am. The facility was unable to provide the requested physician's order prior to survey exit. The need to ensure residents who chose to self-administer medications were evaluated for safety and had a physician's written order of approval for the self-administration of prescription medications was discussed with Staff 1 (ED) on 03/06/26 at 11:45 am. She acknowledged the findings.

1.The HSD completed a self medication evaluation on Residents #2 and 4 on 3/5/2026. 2. The RDHS will educate the HSD and the ED on the policy for self medication evaluations by 4/10/2026. The HSD will audit and complete any out of date self-medication evaluations by 4/15/2026 and obtain any missing physician orders, if resident continues to be safe to self administer medications. Self medication evaluations will be completed by the HSD per policy monthly. 3. The ED/HSD will audit monthly self medication evaluations and report the results of the audit to the Continuous Quality Improvement Committee. 4. HSD/ED.

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 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions were attempted with ineffective results prior to administering PRN psychotropic medications and/or ensure staff administering medications knew the common side effects of the medications and when to contact a health professional regarding side effects for 2 of 3 sampled residents (#s 1 and 5) who had documented administrations of PRN psychotropics. Findings include, but are not limited to: 1. Resident 5 moved into the assisted living facility in 10/2023 with diagnoses including diabetes and hypertension. Review of Resident 5’s current physician orders and MAR, dated 02/01/26 through 03/02/26, revealed the resident was prescribed the following PRN psychotropic medication: * Haloperidol 0.5mg every four hours as needed for agitation. The MAR revealed administration of PRN haloperidol on 02/04/26. There was no documented evidence that non-pharmacological interventions were attempted with ineffective results prior to administering the psychotropic. In an interview on 03/04/26 at 11:40 am, Staff 8 (RCC) and Staff 10 (Medication Assistant) reviewed the electronic record and observation notes of the PRN psychotropic administration for Resident 5. Staff 8 and Staff 10 confirmed the lack of documentation of non-drug interventions attempted. The need to document non-pharmacological interventions attempted without effective results prior to administration of a PRN psychotropic medication of a PRN psychotropic medication was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 9:31 am. They acknowledged the findings. 2. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). A review of Resident 1’s current physician orders and MAR, dated 02/01/26 through 03/02/26 and progress notes identified the following: Resident 1 had a signed physician order for haloperidol 1 mg, 0.5 tablet two times daily as needed for restlessness and agitation. There were no non-pharmacological interventions documented in the resident's chart as having been attempted and ineffective prior to the PRN haloperidol being administered once on 02/14/26 and 02/15/26, and the MAR lacked common side effects of the medication and instructions for when to contact a health professional regarding side effects. During an interview on 03/04/26 at 2:44 pm, Staff 16 (Medication Assistant) confirmed the MAR did not indicate the side effects of the PRN haloperidol and when to contact a health care professional. She believed documentation regarding non-pharmacological interventions were attempted and found ineffective prior to use would be completed in the observation notes but was not sure since she had not administered this medication to Resident 1. Observation notes from 02/14/26 and 02/15/26 noted the PRN medication was given but lacked documented evidence non-pharmacological interventions were attempted and found ineffective prior to the medication being administered. The need to document non-pharmacological interventions attempted and ineffective prior to administration of a PRN psychotropic and to ensure all staff administering the medication knew common side effects and when to contact a health professional regarding side effects was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings.

1. The HSD/RN updated residents #1 and 5 MAR on 3/5/26 with non-pharmacological interventions. 2. The HSD reviewed all PRN psychotropic medications orders to ensure non-pharmacological interventions and potential side effects are identified and documented on the MAR. The ED/HSD educated Staff on the requirement to attempt and document at least 3 non-pharmacological interventions prior to administering PRN psychotropic medications on 3/5/2026. 3. Use of PRN psychotropic medications and associated documentation will be reviewed at least 4 days/week during clinical huddle. 4. ED/HSD.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions were attempted with ineffective results prior to administering PRN psychotropic medications and ensure staff administering medications knew the common side effects of the medications and when to contact a health professional regarding side effects for 1 of 1 sampled resident (# 8) who had documented administrations of PRN psychotropics. This is a repeat citation. Findings include, but are not limited to: Resident 8 moved into the facility in 04/2025 with diagnoses including hypertension. Review of Resident 8’s current physician orders and MAR, dated 06/05/26 through 07/08/26, revealed the resident was prescribed the following PRN psychotropic medication: * Trazadone 50 mg take 1 tab at bedtime as needed for sleep. The MAR revealed administration of PRN trazadone on five occasions. There was no documented evidence that non-pharmacological interventions were attempted with ineffective results prior to administering the psychotropic medication. Additionally, the MAR lacked common side effects of the medication and instructions for when to contact a health care professional regarding side effects. During an interview on 07/09/26 at 2:50 pm, Staff 31 (Medication Assistant/Resident Assistant) confirmed the MAR did not indicate the side effects of the PRN trazadone and when to contact a health care professional. She indicated the resident would ask for the medication and would be provided without the need to perform non-pharmacological interventions prior to use. The need to document non-pharmacological interventions attempted without effective results prior to administration of a PRN psychotropic medication was discussed with Staff 24 (ED), Staff 2 (Health and Wellness Director/LPN), and Staff 4 (Business Office Director) on 07/09/26 at 3:15 pm. They acknowledged the findings.

1. Resident #8 MAR was updated to reflect appropriate non pharmacological interventions for PRN psychotropic use by the Community Oversight RN on 7/21/2026. 2. Health Services Director to provide in-service to authorized medication technicians on documentation of interventions with use of PRN psychotropic medications in addition to monitoring/documentation of follow up/effectiveness by 8/4/2026. 3. Health Services Director/designee to audit any new and administered psychotropic medications daily during clinical meeting along with clinical leadership team and coordinate with Community Oversight RN on the following: (1) Rationale for the use of psychotropic medication (2) Common side effects of the medication (3) When and who to contact in the event of side effects (4) Community notification to primary care provider of psychotropic medications within 72 hours, including holidays and weekends if order was prescribed by provider other than primary care provider via phone or electronic submission and documented accordingly in electronic health record. (5) PRN medications that are given that affect resident behavior to have resident-specific parameters/interventions prior to administration. 4. The Health Services Director/designee is responsible to implement and audit corrections.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions were attempted with ineffective results prior to administering PRN psychotropic medications and ensure staff administering medications knew the common side effects of the medications and when to contact a health professional regarding side effects for 1 of 1 sampled resident (# 8) who had documented administrations of PRN psychotropics. This is a repeat citation. Findings include, but are not limited to: Resident 8 moved into the facility in 04/2025 with diagnoses including hypertension. Review of Resident 8’s current physician orders and MAR, dated 06/05/26 through 07/08/26, revealed the resident was prescribed the following PRN psychotropic medication: * Trazadone 50 mg take 1 tab at bedtime as needed for sleep. The MAR revealed administration of PRN trazadone on five occasions. There was no documented evidence that non-pharmacological interventions were attempted with ineffective results prior to administering the psychotropic medication. Additionally, the MAR lacked common side effects of the medication and instructions for when to contact a health care professional regarding side effects. During an interview on 07/09/26 at 2:50 pm, Staff 31 (Medication Assistant/Resident Assistant) confirmed the MAR did not indicate the side effects of the PRN trazadone and when to contact a health care professional. She indicated the resident would ask for the medication and would be provided without the need to perform non-pharmacological interventions prior to use. The need to document non-pharmacological interventions attempted without effective results prior to administration of a PRN psychotropic medication was discussed with Staff 24 (ED), Staff 2 (Health and Wellness Director/LPN), and Staff 4 (Business Office Director) on 07/09/26 at 3:15 pm. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure the facility RN, a PT, or an OT conducted a thorough assessment of a device with restraining qualities, the use of the device was included in the resident’s service plan, and the facility instructed caregivers on the correct use and precautions related to the use of the device, for 1 of 1 sampled resident (#1) with devices with restraining qualities. Findings include, but are not limited to: Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). During the acuity interview on 03/02/26, Resident 1 was identified as using a recliner. The resident’s clinical record from 12/03/25 through 03/02/26 was reviewed, observations and interviews with Resident 1 were made, and staff were interviewed. The following was identified: The resident’s 12/08/25 service plan indicated Resident 1 needed stand-by assist for transfers, was a high fall risk, and needed assistance with ADL care including toileting. A change of condition evaluation on 01/14/26 noted Resident 1’s cognition was moderately impaired, s/he was impulsive and had a poor short-term memory. Observations and interviews with Resident 1 identified s/he preferred to spend his/her awake time in the recliner with staff reclining the resident at a variety of angles. Staff were observed providing the chair controller to the resident after the legs were elevated. On 03/04/26, at 1:10 pm the surveyor asked the resident to demonstrate how to lower the legs of the chair to prepare to stand up. The resident pushed the chair controller buttons but acknowledged s/he was not sure how to operate the chair and was not successful in lowering the legs. In this latter instance, the resident’s ability to move freely was limited. Interviews with staff on 03/04/26 and 03/05/26 indicated the resident could “usually” use the chair controller to raise or lower the footrest of the chair and did not recall instances of the resident getting out of the chair when the footrest were still in the up position. Review of the resident's record showed no documented assessment of the recliner as a device with restraining qualities by a facility RN, a PT, or an OT. The resident’s 01/14/26 service plan did not provide information to staff related to the recliner including how to use the device with the resident and safety/maintenance items to watch for. During an interview on 03/04/26 at 1:45 pm, Staff 1 (ED) acknowledged no assessment had been completed for Resident 1’s recliner chair. On 03/04/26 at 3:30 pm, Staff 1 provided an assessment for a “Supportive Devices Assessment” dated 03/04/26, completed by Staff 3 (RN Consultant). The need for a RN, PT or OT to complete an assessment of any device with restraining qualities was discussed Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings.

1. Resident # 1 supportive device assessment was completed by the RN on 3/5/26. 2. The HSD/designee will audit for supportive device use and ensure that these are either referred to the RN for the initial assessment, or update them by 4/30/2026 for all residents that have these. The HSD will also ensure that these are on the service plans 3. The supportive device evaluation will be reviewed and updated by the HSD/designee at least quarterly. The ED will audit the supportive device evaluations at least quarterly for completion. 4. ED/HSD

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was documented in the resident’s service plan and evaluated at least quarterly for 1 of 1 sampled resident (# 1) who used a device with restraining qualities. This is a repeat citation. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). During the acuity interview on 07/08/26, the resident was identified as requiring staff assistance to operate the remote to his/her recliner. The resident’s clinical record from 06/09/26 to 07/08/26 and a Supportive Devices Assessment, dated 03/27/26 were reviewed, observations and interviews with Resident 1 were made, and staff were interviewed. The following was identified: * Interviews with staff on 07/08/26 indicated the resident was unable to operate the recliner remote independently. * Throughout the survey period, the resident was observed lying in the recliner with legs elevated to reduce edema. * The Supportive Devices Assessment for the recliner, completed by Witness 3 (Consultant RN) documented, “[Resident 1] is no longer able to independently use the remote correctly to lower the legs to get up out of the recliner.” On 07/09/26 at 1:00 pm, a quarterly evaluation for the recliner was requested of Staff 2 (Health and Wellness Director/ LPN). * The resident’s 04/05/26 service plan indicated s/he had moderate cognitive impairment and at times had difficulties expressing himself/herself. A temporary service plan had been created on 07/08/26 (prior to survey entry) changing the frequency of safety checks to every 30 minutes. Resident 1’s service plan did not include information on his/her inability to use the recliner remote, how staff should assist the resident with it, and safety/ maintenance items to watch for. On 07/09/26 at 1:05 pm, Staff 2 confirmed the facility had not included information on the service plan regarding the resident’s inability to operate the recliner remote, how staff should assist him/her with it, and potential safety issues with the device. She also confirmed the device had not been evaluated at least quarterly. The need to ensure a supportive device with restraining qualities was documented in the resident’s service plan and evaluated at least quarterly was reviewed with Staff 24 (ED), Staff 4 (Business Office Director), and Staff 2 on 07/09/26 at 2:30 pm. They acknowledged the findings.

C0340 – Restraints and Supportive Devices 1. The quarterly device assessment for Resident #1 was completed by the RN on 7/14/2026. Resident 1 Service Plan to be reviewed and updated to reflect use of supportive device with restraining quality, electric lift recliner by Health Services Director by 7/31/2026 with interventions and directives to staff. 2. The HSD/Designee will audit all supportive devices for appropriate orders, assessment by the RN, and service plan placement by 8/15/2026. 3. Ongoing quarterly supportive device assessments to be conducted/completed by Health Services Director or Designee in accordance with 90-day renewal intervals after initial RN assessment. Initial supportive device review to be completed, coordinated with and communicated to with Community Oversight RN upon acknowledgement of incoming supportive device for resident. Service plan will additionally be updated upon receipt of any new supportive devices after initial RN assessment has been completed with directives/interventions for staff to follow accordingly for resident safety and reviewed for completion by Health Services Director. Health Services Director will verify provider prescribed order for use of device and coordinate with outside provider/physical and/or occupational therapy as needed. 4. The Health Services Director/ED/RN are responsible for implementing correction and monitoring corrections.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: 1. On 03/02/26, the facility’s Acuity-Based Staffing Tool (ABST) information was downloaded for review. The total ABST time indicated the following minimum number of staff required: * Day shift: 8.001 or over eight direct-care staff; * Evening shift: 7.177 or over seven direct-care staff; and * Night shift: 2.215 or over two total direct-care staff. On 03/03/26, the “ABST Facility Entrance Questionnaire” noted the following staffing levels: * Day shift: 8 direct-care staff; * Evening shift: 5.5 direct-care staff; and * Night shift: 4 direct-care staff. A review of the staffing schedule and staff timecards, from 02/02/26 through 02/08/26, revealed seven of 21 shifts, or 33.33% of the shifts reviewed, were not staffed to meet the total ABST generated time. On 03/06/26 at 8:29 am, the above discrepancies were reviewed with Staff 1 (ED) and Staff 2 (Nursing Director/LPN). Staff 1 confirmed they were not staffing to the ABST generated time and did not have a system in place to capture the unscheduled needs of each resident. The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 1 on 03/06/26 at 11:30 am. She acknowledged the findings. 2. During the survey, the facility’s call system was observed to include manually operated call boxes in resident units and common area bathrooms and call pendants worn by multiple residents. When a resident engaged the system, an alert was sent to a computer in a staff area near the front entrance to the facility. Staff who were aware of the alert would alert other staff of calls for assistance via two-way radio. Throughout the survey from 03/02/06 through 03/06/26, observations and interviews with staff and residents revealed the following: * Call system response times were "way too long, often over 20 minutes”; * “I don’t even really call for help anymore, they answer too late”; * Staff were not able to respond to call lights in a "timely manner"; and * When there were no staff present at the workstation near the call system computer, staff were not made aware of resident calls for assistance. Resident 5 was admitted to the facility in 10/2023 with diagnoses including diabetes and hypertension. The resident was interviewed on 03/02/26 at 12:10 pm and reported it typically took about 20 minutes for staff to respond when s/he pressed the call light. Then, suggested to initiate the call light to check how long it would take for staff to respond. Resident 5’s call light was initiated at 12:16 pm and not answered until 12:52 pm. At 12:52 pm Staff 20 (Resident Assistant) answered the call light. Surveyor asked how she knew the resident needed assistance, and Staff 20 stated she saw the call light notification at the front desk. On 03/02/26 at 1:30 pm, Staff 1(ED) stated normally the receptionist would notify staff of call lights, and in the evening and during the night a staff member was assigned to check. She acknowledged the system was outdated. Call system logs from 02/05/26 through 03/05/26 for Residents 1, 2, 4 and 5 were requested and reviewed on 03/05/26 at 1:25 pm. The review revealed call system response times were greater than 20 minutes on 57 occasions. On 03/06/26 at 11:45 am, the need to meet residents’ 24-hour unscheduled needs including ADL care and lengthy response time to call for assistance were discussed with Staff 1. She acknowledged the findings and stated she had placed an order for staff pagers during the survey.

1. The ED and HSD will be educated by the RDHS by 4/10/2026 on how to staff per the ABST and account for unscheduled resident needs. 2. The ED/HSD/RDHS will conduct an audit of the ABST and Staffing levels to ensure sufficient staff are available to meet resident scheduled and unscheduled care needs in accordance with the ABST by 4/10/2026. The call system is being addressed and is scheduled for a new system install (Date TBD). A person will continue to be staffed at the reception desk 24/7 to alert staff to call lights until the system is repaired/replaced. 3. The ED will complete an audit of the ABST tool and update it accurately per resident needs by 4/20/2026. The ED will update and post a corrected staffing plan by 4/20/2026. The ABST will be updated by the ED/HSD/Designee prior to move in, quarterly and with any change of condition. The ED will update the posted staffing plan with changes in the ABST. 4. The Executive Director

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident. This is a repeat citation. Findings include, but are not limited to: On 07/08/26 at 9:30 am, the acuity interview identified the following: * The facility was home to 52 residents; * The facility consisted of a three-story building; * Three residents required two staff members for transfer or care at all times; and * One resident required supervision with eating. During the survey, Resident 1 was identified as an additional resident who required two staff members for transfer and ADL care. Refer to C260. On 07/08/26 at 10:41 am, the facility’s posted staffing plan, dated 06/09/26, reflected the following: * Day shift: Three MTs and five CGs; * Evening shift: Two MTs and five CGs; and * Night shift: One MT and three CGs. Review of the staffing schedule and records, dated 06/29/26 through 07/05/26, showed the facility failed to staff according to its posted staffing plan on 11 of 21 caregiver shifts reviewed. On 07/09/26 at 1:30 pm, Staff 8 (RCC) reported she was just starting to learn about the Acuity-Based Staffing Tool and was not always aware of the changes to staffing needs regarding the posted staffing plan. She also indicated when there were call outs, staff who managed the on-call phone were not consistently ensuring the shifts were covered. The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 24 (ED), Staff 2 (Health and Wellness Director/LPN), and Staff 4 (Business Office Director) on 07/09/26 at 3:15 pm. They acknowledged the findings.

C0360 – Staffing Requirements and Training: Staffing 1. The Health Services Director will provide ABST and staffing training/in-service to Resident Care Coordinator(s) by 7/27/2026 which will discuss appropriate staff/resident ratios in accordance with facility used acuity-based staffing tool on ODHS long-term care facility site. Service plans will additionally be audited by this date in order to provide fulfillment and accuracy to meet facility scheduled and unscheduled needs. 2. An audit of the Acuity Based Staffing Tool/schedule and posted staffing plan will be completed by the HSD/ED/RCC by 8/15/2026. The ABST will be updated prior to move in, at least quarterly and with any change of condition by the HSD/RCC/ED. The schedule will be updated in real time with any changes (call offs/agency persons/shift replacements by the RCC/HSD/Designee. 3. The HSD/ED/RCC will review the ABST tool/schedule weekly x 4 weeks, bi-weekly x 4 weeks and then at least monthly ongoing. 4. The Executive Director/Designee is responsible for implementing corrections and monitoring ongoing compliance.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident. This is a repeat citation. Findings include, but are not limited to: On 07/08/26 at 9:30 am, the acuity interview identified the following: * The facility was home to 52 residents; * The facility consisted of a three-story building; * Three residents required two staff members for transfer or care at all times; and * One resident required supervision with eating. During the survey, Resident 1 was identified as an additional resident who required two staff members for transfer and ADL care. Refer to C260. On 07/08/26 at 10:41 am, the facility’s posted staffing plan, dated 06/09/26, reflected the following: * Day shift: Three MTs and five CGs; * Evening shift: Two MTs and five CGs; and * Night shift: One MT and three CGs. Review of the staffing schedule and records, dated 06/29/26 through 07/05/26, showed the facility failed to staff according to its posted staffing plan on 11 of 21 caregiver shifts reviewed. On 07/09/26 at 1:30 pm, Staff 8 (RCC) reported she was just starting to learn about the Acuity-Based Staffing Tool and was not always aware of the changes to staffing needs regarding the posted staffing plan. She also indicated when there were call outs, staff who managed the on-call phone were not consistently ensuring the shifts were covered. The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 24 (ED), Staff 2 (Health and Wellness Director/LPN), and Staff 4 (Business Office Director) on 07/09/26 at 3:15 pm. They acknowledged the findings.

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 observation, interview, and record review, it was determined the facility failed to use the results of the Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's posted staffing plan. Findings include, but are not limited to: On 03/02/26 at 9:26 am, when survey entered the facility, the posted staffing plan was observed at the reception desk and noted “Starting February 17, 2025”: * “Day: 6am-2pm” – noted a total of seven direct-care staff; * “Eve: 2pm-10pm” – noted a total of six direct-care staff; and * “NOC: 10pm-6am” – noted a total of three direct-care staff. On 03/02/26, the results of the facility ABST, including all three floors on each shift, indicated the following staffing levels: * Day shift – 60.02 hours, totaling 8.001 direct-care staff; * Eve shift – 53.83 hours, totaling 7.177 direct-care staff; and * NOC shift – 16.14 hours, totaling 2.215 direct-care staff. The facility failed to use the results of the ABST to routinely update the posted staffing plan. On 03/06/26 at 8:29 am, the above information, including the posted staffing plan last updated on 02/17/25, and the staffing level discrepancies between the posting staffing plan and the ABST-generated staffing level, was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN). Staff 1 confirmed the last update to the posted staffing plan was in February 2025 and acknowledged the discrepancies between the posted staffing plan and the ABST-generated staffing levels. The need to ensure the facility used the results of the ABST to develop and routinely update the posted staffing plan was reviewed with Staff 1 on 03/06/26 at 11:30 am. She acknowledged the findings.

1.The posted staffing plan was reviewed and updated to ensure it reflects current staffing levels based on the state ABST tool. A current staffing plan has been generated, printed, and posted to accurately reflect staffing requirements by the ED on 4/1/2026. 2. The ED and HSD will be educated by the RDHS by 4/10/2026 on how to staff per the ABST and account for unscheduled resident needs, and how to update the staffing plan with the most current date, and keep historical postings. 3. The ED/Designee will review the ABST weekly x 4 weeks, bi-weekly x 4 weeks and then each time an update is made to the ABST to review/update the staffing plan posting as needed. The results of the ABST/staffing plan review will be reported to the monthly Continuous Quality Improvement committee. 4. The Executive Director

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 4 of 4 newly-hired staff (#s 12, 16, 17, and 18) completed all required pre-service orientation training and 3 of 3 newly-hired direct care staff (#s 12, 17, and 18) completed required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed on 03/05/26 at 11:30 am with Staff 4 (Business Office Director), and the following was identified: a. There was no documented evidence Staff 12 (Medication Assistant), Staff 16 (Dining Staff), Staff 17 (Medication Assistant), or Staff 18 (Resident Assistant), hired 12/15/25, 12/29/25, 01/19/26, and 12/08/25, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Written job description; * Infectious disease prevention training; * Home and Community-Based Services training; and * LGBTQIA2S+ training. b. There was no documented evidence Staff 12, Staff 17, and Staff 18 had completed one or more of the following pre-service dementia care training topics prior to beginning their job responsibilities: * 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 orientation training and for direct care staff to complete required pre-service dementia training was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings.

1. Staff #’s 12, 16, 17, and 18 will complete the required pre-service training by 4/20/2026. Staff #’s 12, 17, and 18 will complete their pre-service dementia training by 4/20/2026. 2. The ED/BOM audited training records of all current staff. Any identified missing training will be completed by 5/5/2026. Any staff that have not completed the training by then will be removed from the schedule by the ED until it is completed. 3. The BOM/ED/designee will audit all new hires training prior to them working on the floor. 1 staff file will be audited at least 4 days per week at the daily stand up by the BOM. The ED will audit 10% of employee files/training records each month and report to the monthly Continuous Quality Improvement Committee the results of the audits. 4. The Executive Director /BOM

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 sampled newly-hired staff (#s 12, 17 and 18) demonstrated competency in all assigned job duties within 30 days of hire and 2 of 3 sampled newly-hired staff (#s 17 and 18) lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 03/05/26 at 11:30 am with Staff 4 (Business Office Director) and revealed the following: a. Staff 12 (Medication Assistant), Staff 17 (Medication Assistant), and Staff 18 (Resident Assistant), hired 12/15/25, 01/19/26, and 12/08/25, respectively, lacked demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; * Conditions which require assessment, treatment, observation, and reporting; and * Other duties as applicable (med pass, treatments). b. There was no documented evidence Staff 17 and Staff 18 completed first aid and abdominal thrust training within 30 days of hire. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings.

1. Staff #s 12, 17, and 18 competency records were completed on 4/10/2026 by the HSD. 2. The ED/HSD audited all staff records for competencies. Any identified missing competencies will be completed by 4/30/2026. 3. The BOM/Designee will track return of the staff competency checklists after 3 days of training on the floor. An audit of 10% of employee files will be conducted by the ED monthly and results will be reported to the monthly Continuous Quality Improvement Committee. 4. The ED/HSD

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded every other month, a written record documented all required components of the fire drill, and fire and life safety instruction was provided to staff on alternate months of fire drills and in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records from 10/2025 through 02/2026 were reviewed on 03/03/26. The following deficiencies were identified: a. Fire drills lacked the following required components: * Fire drills were not conducted every other month; and * Fire drills that were completed lacked documentation related to the escape route used and problems encountered with residents who declined to participate in the drill and what changes were made to ensure the facility could meet the evacuation standard. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills. In an interview on 03/04/26 at 11:50 am, Staff 6 (Environmental Services Director) reported the facility had not conducted fire drills and recorded each required component at least every other month and did not provide fire and life safety instruction to staff on alternate months of fire drills. The need to ensure fire drills were conducted at least every other month and included a record of each required component and fire and life safety instruction was provided to staff on alternate months of fire drills was discussed with Staff 1 (ED) on 03/06/26 at 11:45 am. She acknowledged the findings.

1.The RDHS will educate the ED/HSD on fire drill requirements and components related to documentation and training requirements by 4/10/2026. 2. By 4/13/2026 the Maintenance Director will be educated by the Executive Director on the requirements of fire drills and the associated components required for documenation. Drills will be held monthly on alternating shifts, and every other month will include a training on fire safety. 3. The ED/designee will audit the monthly fire drill form for completeness. This will be reported on the monthly Continuous Quality Improvement minutes. 4. Maintenance Director/ED

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to: C260, C330, C340, and C360.

Refer to C260, C330, C340 and C360 to C455.

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 4 newly hired staff (#s 12, 16, 17 and 18) whose training records were reviewed. Findings include, but are not limited to: Refer to C370.

1.Staff #s 12, 16, 17 and 18 will complete their LGBTQIA2AS+ training by 4/20/2026. 2. The ED/BOM audited training records of all current staff. Any identified missing LGBTQIA2S+ will be completed by 5/5/2026. Any staff that have not completed the training by then will be removed from the schedule by the ED until it is completed. 3. The BOM/Designee will track the initial and bi-annual requirement of this training. An audit of 10% of employee files will be conducted by the ED monthly and results will be reported to the monthly Continuous Quality Improvement Committee 4. ED/BOM

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: