OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure incidents and injuries of unknown cause were promptly investigated to rule out abuse and reported to the local Seniors and People with Disabilities Office (SPD) if abuse or suspected abuse could not be ruled out for 3 of 3 sampled resident (#s 1, 2, and 5) who had reportable incidents. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2021 with diagnoses including Parkinson’s disease. Interviews with staff and review of Resident 5's clinical record including interdisciplinary notes, dated 09/03/24 through 11/27/24, service plan dated 11/26/24 and Interim Service Plans (ISPs) revealed the following: a. The following incidents were identified: * 09/07/24 – Found on floor; * 09/15/24 – Found on floor; and * 09/26/24 – Found on floor. Resident 5’s service plan noted s/he was a fall risk, required one person to assist with transfers, and used a wheelchair with escort for mobility. Staff were instructed to walk with the resident to destinations for safety as s/he was able. The following fall precautions were included in the service plan: * Floor is free from clutter and trip hazards; * Bed in low position when s/he was in bed; * Proper fitting shoes and if not wearing shoes, ensure nonskid socks were on; and * Safety and toileting check every hour. The facility lacked documented evidence the incidents were investigated to determine if the resident’s service plan was being followed at the time of the incidents and to rule out neglect of care as the cause for the incidents. b. The following injuries of unknown cause were identified: * 09/28/24 - Skin tear to the right elbow. “…unclear when/how skin tear occurred.”; *10/04/24 – Skin tear to right outer forearm. “CG came and reported to this licensed nurse that member has another skin tear of unknown cause, however member’s spouse has multiple times assisted or attempted to assist member [out of bed] or into bathroom without calling for help until s/he is done.”; and *10/20/24 – Laceration of right hand with possible arterial injury and skin avulsion. The facility was required to immediately investigate the incidents and injuries of unknown cause to rule out abuse or reported to the local SPD office as suspected abuse if abuse could not be ruled out. On 12/05/24 Staff 3 (Director of Nursing) confirmed there was no documented evidence the facility immediately investigated Resident 5’s incidents and injuries of unknown cause to rule out abuse or reported to the local SPD office as suspected abuse if abuse could not be ruled out. Abuse reporting requirements were discussed with Staff 1 (Director of Assisted Living Services) and Staff 3 on 12/05/24. They acknowledged the findings. Per request of the survey team, the facility reported the required incidents to the local SPD office. Confirmation was provided on 12/05/24 at 11:54 am. ?2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including edema and unspecified dementia. The resident’s 09/25/24 to 11/26/24 interdisciplinary notes were reviewed, and the following was identified: * A 10/31/24 interdisciplinary note stated, “CG called this LN [licensed nurse] to report a new open area to LLE [left lower extremity]. This LN went to assess, member was sitting in recliner chair. Noted open area (skin tear) to Lt. outer calf.”; and * An 11/15/24 interdisciplinary note stated, “Member on alert skin tear on the right lower extremity below [his/her] knee.” The above incidents constituted injuries of unknown cause, which required an immediate facility investigation to rule out abuse or suspected abuse. An interview with Staff 1 (Director of Assisted Living Services) on 12/04/24 at 11:10 am confirmed there was no documented evidence the facility completed an immediate investigation that ruled out abuse and suspected abuse for the above injuries of unknown cause. Surveyor requested the facility report the two incidents to the local SPD office and confirmation was received on 12/04/24 at 4:10 pm. The need to ensure injuries of unknown cause were immediately investigated to rule out abuse and suspected abuse and/or reported to the local SPD office if necessary was discussed with Staff 1 on 12/05/24 at 5:00 pm. The findings were acknowledged. 3. Resident 2 was admitted into the facility in 09/2023 with diagnoses including Alzheimer’s disease. The resident’s 09/03/24 to 12/03/24 interdisciplinary notes were reviewed. The following was identified: * 10/09/24 – “member has new skin tear to [right] hand…it was not there the day before”; and * 10/18/24 – “new bruise to [left] elbow.” The above incidents constituted injuries of unknown cause, which required an immediate facility investigation to rule out abuse. At 1:00 pm on 12/04/24 Staff 1 (Director of Assisted Living Services) stated no investigations had been completed. Survey requested the facility report the two incidents to the local SPD office, and confirmation was received at 4:10 pm on 12/04/24. The need to ensure injuries of unknown cause were immediately investigated to rule out abuse and suspected abuse and/or to report to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 at 3:54 pm on 12/05/24. She acknowledged the findings.

1. Residents 1, 2 and 5 incidents were reported to APS by 12/05/24. 2. All incident reports to be reviewed in the clinical meeting several times per week. Staff training will be completed on incident reporting and investigation and how to report to the department on nights and at weekends. All incident reports to be reviewed by the administrator to ensure completeness of investigations. The consultant team is providing training on abuse and neglect investigations to the investigative team and will review the 2024 Abuse and Reporting Guide with all staff. 3. Incident reports to be reviewed several times per week in the clinical meeting and monthly in the quality improvement meeting. 4. Administrator and nurses.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4). Findings include, but are not limited to: Resident 4 was admitted to the facility in 11/2024 with diagnoses including atrial fibrillation and hypertension. The 11/15/24 move-in evaluation failed to address the following required elements: * Personality: including how the person copes with change or challenging situations; * Dental status; and * To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: name, pronouns and gender identity. The failure to address all required areas in the move-in evaluation was discussed with Staff 1 (Director of Assisted Living Services) and Staff 3 (Director of Nursing) on 12/05/24. They acknowledged the findings.

1. Resident 4 evaluation was updated with the missing elements of personality and how the resident copes with challenging situations, dental status, and added pronouns and gender information. 2. The evaluation tool is being reworked to include missing elements and there will be more room for personalization in the updated tool. The consultant team is providing an evaluation checklist to ensure that all items are fully addressed. The checklist is to be used for all updated and new evaluations. Consultant team will provide training to staff involved in completing the evaluations to ensure thoroughness in the evaluation process. Upcoming evaluations due will be discussed in the clinical meeting as a team. All evaluations and service plans to be reviewed by nursing to ensure complete. 3. New evaluations due to be reviewed weekly by the team in the clinical meeting and tracked utilizing MatrixCare, monthly review in the quality improvement meeting. 4. Administrator and nursing.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding delivery of services for 4 of 4 sampled residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2021 with diagnoses including edema and unspecified dementia. The resident's service plan, dated 06/19/24, and interim service plans (ISP’s), dated 10/10/24 to 11/16/24, were reviewed, interviews and observations of the resident were made, and interviews with staff were conducted. The service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Sleep regarding where resident sleeps; * Pain management and how resident demonstrates pain; * Behaviors and interventions regarding refusals; * Life enrichment activities; and * Communication and call system regarding resident’s ability to use call pendant. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Director of Assisted Living Services) on 12/05/24 at 5:00 pm. The findings were acknowledged. ?2. Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as having experienced weight loss. The resident’s 09/18/24 service plan and 09/03/24 to 12/03/24 interim service plans were reviewed, interviews with staff were conducted, and observations of the resident were made. The service plan was not reflective of the resident’s needs and/or did not provide clear direction to staff in the following areas: * Weight loss; * How to assist with communication; * Ability to verbalize pain; * Sleep patterns; * What signs of depression to watch for; and * Level of assistance with activities. The need to ensure service plans were reflective of residents’ needs and provided clear instructions to staff was discussed with Staff 1 (Director of Assisted Living Services) at 3:54 pm on 12/05/24. She acknowledged the findings. 3. Resident 3 was admitted to the facility in 05/2023 with diagnoses including rheumatoid arthritis, muscle wasting, difficulty walking, and weakness. The resident’s 09/17/24 service plan and 09/03/24 to 12/03/24 interim service plans were reviewed, interviews with staff and the resident were conducted, and observations were made. The service plan was not reflective of his/her needs and did not provide clear direction to staff in the following areas: * Use of siderails, including instructions to staff on correct use and precautions; and * Level of assistance needed for evacuations. The need to ensure service plans were reflective of residents’ needs and provided clear instructions to staff was discussed with Staff 1 (Director of Assisted Living Services) at 3:54 pm on 12/05/24. She acknowledged the findings. 4. Resident 5 was admitted to the facility in 07/2021 with diagnoses including Parkinson’s disease. The resident's 11/26/24 service plan was reviewed, observations were made of the resident, and interviews with the resident and staff occurred throughout the survey. The service plan was not reflective of the resident's needs and preferences and did not give clear instruction to the staff in the following areas: * Language, including reverting to first language; and * Bathing, including preference for bed baths. The need to ensure Resident 5’s service plan was reflective and gave clear instruction to staff was discussed with Staff 1 (Director of Assisted Living Services) and Staff 3 (Director of Nursing) on 12/05/24. They acknowledged the findings.

1. Residents 1, 2, 3 and 5 service plans updated for missing information in relation to activities, life enrichment and assistance needed, bathing, behaviors, communication and call system, depression signs, emergency evacuation, language, pain, sleep and sleep patterns, side rail use and weight loss. 2. The service plan template is being expanded to include missing elements and allowing for more room for personalization. All service plans to be updated utilizing service plan checklist provided by the consultant team to ensure service plans are complete and information is resident specific. All persons assisting with service plan updates to take the NurseLearn course on Creating Individualized Service Plans. Service plan completion will be tracked in MatrixCare and consultants to review and provide feedback to the team on updated service plans. 3. Weekly in the clinical meeting, monthly in the quality improvement meeting. 4. Administrator and nursing.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure actions and interventions were determined, documented, and communicated to staff on each shift and weekly progress was noted to resolution for short-term changes of condition for 2 of 4 residents (#s 2 and 5) who had changes of condition. Resident 2 experienced severe, ongoing weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease, chronic diarrhea, and chronic pancreatitis. During the acuity interview at 9:58 am on 12/03/24, the resident was identified as having experienced weight loss, as well as being provided a daily nutritional shake. The resident’s 07/01/24 to 12/03/24 interdisciplinary notes and interim service plans (ISPs), 09/18/24 service plan, 11/01/24 to 12/03/24 TARs, current signed physician orders, and 06/07/24 to 12/03/24 weight logs were reviewed. Interviews with staff were conducted, and observations of the resident were made. Review of the resident’s service plan indicated s/he was on meal monitoring. Staff were instructed to “document meal percentage eaten.” The resident’s history of weight loss was not addressed on the service plan. Review of the TAR indicated the resident had an order for and was receiving Ensure “three times daily with meals,” staff were to remind the resident of meals, and staff were to obtain weights weekly and “notify [resident’s doctor] if gains 2 pounds in 2 days or 5+ pounds in a week.” The following weights were documented in the resident record: * 06/07/24 – 114 pounds; * 07/04/24 – 104.6 pounds; * 08/06/24 – 102.5 pounds; * 08/13/24 – 98 pounds; * 09/10/24 – 100 pounds; * 10/08/24 – 98 pounds; * 11/12/24 – 94.5 pounds; and * 12/04/24 – 87 pounds (requested by survey). Between 06/07/24 to 07/04/24, the resident experienced a severe weight loss of 9.4 pounds, or 8.2% of his/her body weight. Between 06/07/24 to 09/12/24, the resident experienced a severe weight loss of 14 pounds, or 12.2% of his/her body weight. Resident 2 continued to lose weight and experienced a severe weight loss of 7.5 pounds or 7.9% of his/her body weight between 11/12/24 and 12/04/24. Interviews with staff and observations of the resident from 12/03/24 to 12/05/24 indicated the resident was not able to verbalize his/her wants and needs, including food and liquid preferences. Staff reported s/he had a poor appetite, and s/he would often eat less than 50% of his/her meals. They reported s/he “never” finished his/her nutritional supplement. Staff reported his/her favorite foods were cereal and ice cream. Staff reported the resident ate all meals in the facility dining room. The resident was observed eating lunch on 12/03/24 and breakfast and lunch on 12/04/24. Foods offered included cereal in milk, half of a cut up banana, chicken salad, split pea soup, vegetable soup, pasta, and ice cream. A nutritional shake was not observed to be offered at lunch on 12/03/24. The resident ate 100% of cereal at breakfast and 100% of the soup offered on both lunch occasions. S/he was otherwise observed taking one to three bites of the rest of the food offered and taking one to two drinks of the nutritional supplement. S/he was not observed eating the ice cream offered. S/he was observed leaving the table abruptly at both lunch observations. Staff were not observed to redirect him/her to the rest of the meal. One staff was observed encouraging the resident to eat on one occasion. Staff were not observed to offer the resident an alternative meal if s/he did not eat the one offered. There was no documented evidence the facility monitored current interventions for effectiveness and/or developed new interventions. There was no documented evidence the weight loss was monitored at least weekly with progress noted. At 1:00 pm on 12/04/24, Staff 1 (Director of Assisted Living Services) confirmed the lack of monitoring current interventions, developing new interventions, and monitoring the weight loss with weekly progress noted. The failure to monitor current interventions for effectiveness, develop new interventions, and monitor the weight loss with weekly progress noted put Resident 2 at risk and constituted an immediate threat to his/her health and safety. An immediate plan of correction to address the severe ongoing weight loss was requested from Staff 1 on 12/04/24 at 3:50 pm. The plan of correction was received and accepted by the survey team on 12/04/24 at 6:20 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure actions or interventions for changes of condition were determined, documented, and communicated to staff on each shift with weekly progress noted to resolution was discussed with Staff 1 (Director of Assisted Living Services) at 3:54 pm on 12/05/24. She acknowledged the findings. 2. Resident 5 was admitted to the facility in 07/2021 with diagnoses including Parkinson’s disease. The resident's 09/03/24 through 11/27/24 interdisciplinary notes, 11/26/24 service plan, and Interim Service Plans (ISPs) were reviewed and revealed the resident experienced the following short-term changes of condition: * 09/08/24 - Skin tear to right elbow; * 10/04/24 - Skin tear to right outer forearm; and * 10/19/24 – Skin tear to posterior right hand with arterial bleed. The facility lacked documented evidence the skin conditions were monitored with progress noted at least weekly through resolution. The need to ensure short-term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Director of Assisted Living Services) and Staff 3 (Director of Nursing) on 12/05/24. They acknowledged the findings.

1. Resident 2 has been assessed for weight loss and interventions developed, and ongoing monitoring initiated to monitor effectiveness of interventions. Resident 5’s skin issues have resolved. 2. Weights are collected monthly and reviewed by the RN. Weekly and daily weights have been initiated as required and weights reviewed by the nursing team for changes. Residents at risk for weight changes have been added to the whiteboard for ongoing monitoring. Progress to be noted weekly and interventions revised as necessary. All residents with skin concerns have been added to the whiteboard which will be used to track weekly monitoring until resolution. All nurses to take the NurseLearn modules on change of condition. All change of condition will be monitored until resolution noted by the nurse. Interim Service Plans and alert charting to be reviewed in the clinical meeting. 3. Several times per week in the clinical meeting. 4. Administrator and nurse.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed including resident status, RN findings, and interventions made as a result of the assessment for 1 of 2 residents (#2) who experienced a significant change of condition. Resident 2 experienced severe, ongoing weight loss. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease, chronic diarrhea, and chronic pancreatitis. During the acuity interview at 9:57 am on 12/03/24, the resident was identified as having experienced weight loss. The resident’s 07/01/24 to 12/03/24 interdisciplinary notes and interim service plans (ISPs), 09/18/24 service plan, 11/01/24 to 12/03/24 TARs and current signed physician orders, and 06/07/24 to 12/03/24 weight logs were reviewed. Interviews with staff were conducted, and observations of the resident were made. The following weights were documented in the resident record: * 06/07/24 – 114 pounds; * 07/04/24 – 104.6 pounds; * 08/06/24 – 102.5 pounds; * 08/13/24 – 98 pounds; * 09/10/24 – 100 pounds; * 10/08/24 – 98 pounds; * 11/12/24 – 94.5 pounds; and * 12/04/24 – 87 pounds (requested by survey). Between 06/07/24 to 07/04/24, the resident experienced a severe weight loss of 9.4 pounds, or 8.2% of his/her body weight. Between 06/07/24 to 09/12/24, the resident experienced a severe weight loss of 14 pounds, or 12.2% of his/her body weight. Resident 2 continued to lose weight and experienced a severe weight loss of 7.5 pounds or 7.9% of his/her body weight between 11/12/24 and 12/04/24. The severe weight losses constituted significant changes of condition and required a timely RN assessment that documented resident status, RN findings, and interventions made as a result of the assessment. At 1:08 pm on 12/04/24 Staff 3 (Director of Nursing) stated no RN assessments had been completed for the severe weight losses. The failure to complete timely RN assessments for the severe ongoing weight losses put Resident 2 at risk and constituted an immediate threat to his/her health and safety. An immediate plan of correction to address the severe ongoing weight loss was requested from Staff 1 (Director of Assisted Living Services) on 12/04/24 at 3:50 pm. The plan of correction, including an RN assessment, was received and accepted by the survey team on 12/04/24 at 6:20 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure a timely RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 at 3:54 pm on 12/05/24. She acknowledged the findings. Refer to C270, Example 1.

1. Resident 2 has been assessed by the RN for weight change and interventions added to the service plan based on the RN assessment and plan. 2. Residents at risk for weight loss have been added to the whiteboard for ongoing monitoring, and weekly progress will be noted in the chart using the whiteboard to track. Staff will be trained on reporting weight changes to the RN. Training to be conducted to all staff by consultant team on what conditions are significant changes to ensure prompt reporting to the RN. The RN will take the NurseLearn courses on significant changes of condition. The consultant team will help review RN documentation and plan and provide feedback and training. 3. Several times per week in the clinical meeting, monthly in quality assurance meeting. 4. Administrator and RN.

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

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to treatment orders for 1 of 1 sampled resident (#1) who had documented treatment refusals. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2021 with diagnoses including edema and unspecified dementia. The resident's 11/01/24 through 12/03/24 MARs, current physician orders, and “Vital Stats” data dated 11/01/24 through 12/03/24 were reviewed and revealed there was no documented evidence the prescriber was notified of the following refusals: * 11/2024 - daily weights 11 times; and * 11/2024 – weekly weights three times. The provider was notified on 11/11/24 of Resident 1’s refusals of daily weights, and the facility requested weights be changed to weekly. On 11/12/24 the provider agreed to change the weights to weekly. Staff 3 (Director of Nursing) confirmed in an interview on 12/04/24 at 1:55 pm there was no documented evidence the provider had been notified of refusals prior to 11/11/24 or after 11/12/24. The need to ensure the facility contacted the physician each time the resident refused to consent to treatment orders was discussed with Staff 3 on 12/04/24 at 1:55 pm and Staff 1 (Director of Assisted Living Services) on 12/05/24 at 5:00 pm. They acknowledged the findings.

1. Refusals of Resident 1 were reported to the PCP and plan to increase compliance with daily weights addressed by nursing. 2. Residents with daily weights are being tracked on the whiteboard. Medication exceptions and variance reports will be reviewed several times per week in the clinical meeting to ensure PCP notifications are occurring and to develop plan to increase compliance with refused medications and treatments. 3. Several times per week in the clinical meeting. 4. Administrator and nursing.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a physician or other legally recognized practitioner provided a written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#4) who self-administered medications. Findings include, but are not limited to: Resident 4 was admitted to the facility in 11/2024 with diagnoses including atrial fibrillation and hypertension. Observations, interviews, and record review were completed during the survey. During the acuity interview on 12/03/24, Resident 4 was noted to self-administer medications. The facility lacked documentation of a physician or other legally recognized practitioner’s written order of approval for self-administration of prescription medications. The need to ensure a physician or other legally recognized practitioner provided a written order of approval for self-administration of prescription medications was discussed with Staff 1 (Director of Assisted Living Services) and Staff 3 on 12/05/24. They acknowledged the findings.

1. Resident 4 was assessed for ability to manage medications. Medication staff are now assisting with medication management. 2. Self-administered medications have been added to the whiteboard for ongoing tracking of self-medication assessments and ensuring physician orders approving self-administration are in place. All self-medication assessments to be completed prior to admission and evaluated again with each service plan update including with significant change of condition. 3. Monthly in the quality assurance meeting, and with service plan updates. 4. Administrator and nursing.

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

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to submit the acuity-based staffing tool (ABST) Proprietary Department Review Request (PDRR) form to the Department for approval no later than 08/31/2024 and to include all care elements as required. Findings include, but are not limited to: The facility’s proprietary ABST was requested and reviewed with Staff 2 (Vice President of Health and Wellness) at 9:30 am on 12/04/24. 1. Documentation of department approval of the ABST was requested at the same time. Staff 2 stated she had engaged in conversations with the Department regarding the proprietary ABST but did not have documentation that it was approved. 2. Review of the facility’s proprietary service plan revealed it did not address the following required care elements: * Assistance with communication; and * Additional care services. The need to ensure the facility submitted a PDRR form to the Department for approval of their proprietary ABST and to include all required care elements on the ABST was discussed with Staff 1 (Director of Assisted Living Services) on 12/05/24 at 3:54 pm. She acknowledged the findings.

1. Proprietary ABST has been updated to include missing care elements in relation to assistance with communication and additional care services. ABST will be submitted to the department for approval. State ABST to be used while awaiting approval. 2. ABST update schedule is in place to coincide with each admission and discharge, service plan update and with significant change of condition. Consultant team will provide training on ABST updates and provide feedback. State ABST to be used to determine staffing levels. ABST is to be updated to meet scheduled and unscheduled needs. 3. Weekly in the clinical meeting, monthly in the quality assurance meeting. 4. Administrator, Resident Care Coordinator and Staffing Manager.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 4 sampled residents (#1) and multiple unsampled residents had an acuity-based staffing tool (ABST) evaluation that was updated whenever there was a significant change of condition and/or no less than quarterly to correspond with the quarterly service plan update, and to use the results of an ABST to develop and routinely update the facility’s posted staffing plan. Findings include, but are not limited to: The facility’s proprietary ABST was requested and reviewed with Staff 2 (Vice President of Health and Wellness) at 9:30 am on 12/04/24. The following was identified: 1. There was no documented evidence that an updated ABST evaluation for Resident 1’s 10/2024 significant change of condition had been completed, and that an updated quarterly ABST evaluation had been completed for four unsampled residents. 2. During the above interview, Staff 2 was asked how the ABST was used to develop and update the facility’s posted staffing plan. She stated the facility used an “Acuity FTE calculator” to determine staffing levels. She confirmed the minutes generated by the ABST were not used to determine the facility’s posted staffing plan. The need to ensure all resident ABST evaluations were updated whenever there was a significant change of condition and/or no less than quarterly to correspond with the quarterly service plan update and to use the results of an ABST to develop and routinely update the facility’s posted staffing plan was discussed with Staff 1 (Director of Assisted Living Services) on 12/05/24 at 3:54 pm. She acknowledged the findings.

1. Resident 1 ABST was updated for significant change of condition and has been added to tracking system to be updated quarterly. 2. ABST has been scheduled to coincide with quarterly service plan updates and as needed for significant change of condition. Consultants will provide training on calculating ABST minutes to determine appropriate staffing plan. 3. Weekly and monthly in the quality improvement meeting. 4. Administrator and Resident Care Coordinator with nursing.

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 2 of 3 newly-hired staff (#s 18 and 20) completed all required pre-service orientation training and 2 of 2 newly- hired direct care staff (#s 17 and 18) completed required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed on 12/04/24 with Staff 25 (HR Recruiter), and the following was identified: a. There was no documented evidence Staff 18 (CG) or Staff 20 (Life Enrichment Manager), hired 08/29/24 and 04/01/24, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; * Infectious disease prevention training; and * Home and Community-Based Services training. b. There was no documented evidence Staff 17 (CG) and Staff 18, hired 05/02/24 and 08/29/24, respectively, had completed one or more of the following pre-service dementia care training topics: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was discussed with Staff 1 (Director of Assisted Living Services) on 12/04/24 at 5:11 pm. She acknowledged the findings, and no additional documentation was provided.

1. Staff members 17, 18 and 20 have been assigned their pre-service training. A full training audit conducted by consultant team on 12/19. Staff who have not completed their pre-service training will be assigned training so that these can be assigned and completed. 2. A training tracker has been implemented to track training completed. All training files audited using the training tracking tool and updated with all new hires and changes in staffing. A new communication system is being implemented to ensure that pre-service training is completed prior to staff being scheduled on the floor. Staffing Manager and clinical team to ensure all pre-service training is completed before scheduling on the floor training. 3. New hire training progress to be reviewed several times per week in stand-up meetings and reviewed monthly in quality improvement meetings. 4. Administrator, HR and Staffing Manager

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 2 of 2 newly-hired direct care staff (#s 17 and 18) demonstrated satisfactory performance in assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 12/04/24 with Staff 26 (Staffing Manager). There was no documented evidence Staff 17 (CG) and Staff 18 (CG), hired 05/02/24 and 08/29/24, respectively, had demonstrated satisfactory performance within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition; * Conditions that require assessment, treatment, observation, and reporting; and * First Aid / abdominal thrust. The need to ensure the facility verified that direct care staff demonstrated satisfactory performance in any duty they were assigned within 30 days of hire was discussed with Staff 1 (Director of Assisted Living Services) on 12/04/24 at 5:11 pm. She acknowledged the findings, and no additional documentation was provided.

1. Staff members 17 and 18 have been assigned their training and completion is being tracked. A comprehensive training audit has been conducted to identify training areas needed for completion. 2. A training tracker has been implemented to track completion of training assignments. All new hires will be added to the training tracker to monitor completion of progress. 3. Training will be audited weekly in stand-up meetings and monthly in quality improvement meetings. 4. Administrator and Staffing Manager.

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 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (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. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 long-term direct care staff (#s 22, 23, and 24) completed annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 12/04/24 with Staff 26 (Staffing Manager). Staff 22 (CG), Staff 23 (CG), and Staff 24 (CG), hired 04/16/08, 08/03/17, and 09/04/19, respectively, lacked documented evidence of the completion of annual infectious disease training based on anniversary date of hire. The need to ensure all staff completed the required annual infectious disease training was discussed with Staff 1 (Director of Assisted Living Services) on 12/04/24 at 5:11 pm. She acknowledged the findings, and no additional documentation was provided.

1. Staff members 22, 23 and 24 have been assigned infectious disease training. All employee files are being audited to ensure completion of training. 2. A training tracker has been implemented to track training upon hire and annually. Annual trainings have been assigned to staff members for completion. The administrator is implementing a training schedule. 3. Annual training completion will be audited monthly in the quality improvement meeting. 4.Administrator and Staffing Manager.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (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. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct and record unannounced fire drills every other month in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were requested for the months of 06/2024 through 11/2024. Review of facility records on 12/03/24 and 12/04/24 revealed documentation from fire drills completed in 07/2024 and 11/2024; however, there was no documentation of a fire drill for 09/2024. In an interview on 12/03/24 at 2:45 pm, Staff 1 (Director of Assisted Living Services) confirmed the facility did not have documentation from the fire drill completed in 09/2024. Therefore, the facility failed to conduct and record unannounced fire drills every other month. The need to conduct and record unannounced fire drills every other month in accordance with the OFC was discussed with Staff 1 on 12/04/24 at 12:30 pm. She acknowledged the findings.

1. An unannounced fire drill was completed on NOC shift in December. 2. Fire drill schedule has been reviewed with Campus Safety Manager and fire drill form provided by consultants. 3. Monthly in the quality improvement meeting. 4. Administrator and Campus Safety Manager.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: On 12/03/24 and 12/04/24, the facility fire and life safety records were reviewed. The facility lacked documented evidence residents were instructed within 24 hours of admission and re-instructed, at least annually, on general safety procedures, evacuation methods, and responsibilities. On 12/04/24 at 11:58 am, Staff 1 (Director of Assisted Living Services) confirmed the current system did not include resident instruction of fire and life safety procedures at move-in or annually. The need to ensure that residents received instruction in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area within 24 hours of admission, and were re-instructed at least annually, was reviewed with Staff 1 on 12/04/24 at 12:30 pm. She acknowledged the findings.

1. A training plan for Fire and Life Safety training requirements for residents has been developed and training tracker initiated to track progress of training completed. 2. All new residents will receive Fire and Life Safety training upon admission and then annually thereafter. Training audit tool will be used to track completion of training. Consultant team provided resources on information to include in the resident training. 3. New residents will be discussed weekly in stand-up meetings, training completion will be monitored monthly in the quality improvement meeting. 4. Administrator and Campus Safety Manager.

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

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 12/03/24 at 9:45 am and the following was identified: * The reception desks on floors one through four had scrapes and gouges with bare wood exposed; * The residential laundry rooms on the first and second floor had lint build-up on the walls and the equipment behind the washers and dryers; * The residential laundry room on the second floor had a gouge in the drywall near the washing machine; * The fourth floor residential washing machine was out of order; and * The handrails near resident room 453 and Staff 1’s (Director of Assisted Living Services) office were rough, unsanded, and unsealed. The interior of the facility was toured with Staff 1, Staff 27 (Facility Manager), and Staff 28 (Lead Maintenance) on 12/04/24 at 11:30 am. They acknowledged the areas that required cleaning and/or repair.

1. Areas by the reception desk have been repaired, wall gouges have been repaired, a regular cleaning schedule of the laundry room has been implemented , the laundry machine on the fourth floor has been added to repair list, and sanding of handrails has been started. 2. Administrator and maintenance crew will tour the building weekly to ensure identification and completion of projects. Staff training has been scheduled to ensure staff know how to report any maintenance concerns. 3. Monthly environmental walk-throughs to be reviewed in the monthly the quality improvement meeting. 4. Administrator and Facilities designee.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0300 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. An ALF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) An ALF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (C) Each unit must have individual thermostatic heating controls. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Effective 01/15/2015 wall heaters are not acceptable in new construction or remodeling. (d) VENTILATION. Ventilation in each unit must occur via an open window to the outside, or with a mechanical venting system capable of providing two air changes per hour with one-fifth of the air supply taken from the outside. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: On 12/04/24 at 9:45 am, the interior of the facility was toured, and each floor was observed to have an operational fireplace in the common area near the unit’s entrance. The temperature of the metal vent for each fireplace was measured with the surveyor’s probe thermometer. The vent fr the fireplace on the second floor reached a temperature of 133.3 degrees F, the vent for the fireplace on the third floor reached 120.9 degrees F, and the vent for the fireplace on the fourth floor reached 153 degrees F. On 12/03/24 at 2:32 pm, Staff 1 (Director of Assisted Living Services) was informed and acknowledged that the temperatures of the venting units on the fireplaces exceeded 120 degrees F. The facility was toured with Staff 1, Staff 27 (Facility Manager), and Staff 28 (Lead Maintenance) on 12/04/24 at 11:30 am. The fireplaces had been turned off, signs were posted to instruct staff to keep the fireplaces off, and Staff 27 acknowledged work orders were in place to identify a solution to the fireplaces exceeding 120 degrees F. The need to ensure residents did not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1, Staff 27, and Staff 28 on 12/04/24 at 11:30 am. They acknowledged the findings.

1. The fireplaces have been marked as out of order and disabled to prevent use while the community seeks to convert all fireplaces to electric. 2. Routine walk-throughs by Facilities staff to temp fireplaces to ensure within acceptable range. 3. Monthly environmental walk-throughs and reviewed monthly in quality improvement meeting. 4. Administrator and Facilities designee.

OAR 411-054-0300 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. An ALF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) An ALF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (C) Each unit must have individual thermostatic heating controls. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Effective 01/15/2015 wall heaters are not acceptable in new construction or remodeling. (d) VENTILATION. Ventilation in each unit must occur via an open window to the outside, or with a mechanical venting system capable of providing two air changes per hour with one-fifth of the air supply taken from the outside. This Rule is not met as evidenced by:

OAR 411-054-0300 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction. (a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit. (b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules). (c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to: On 12/04/24, resident apartments were toured, and water temperatures were taken throughout the building. Water temperatures were higher than 120 degrees F in the following apartments: * Room 156 – 136.0 degrees F in the bathroom and 135.5 degrees F in the kitchen; * Room 250 – 125.6 degrees F in the bathroom; * Room 353 – 129.0 degrees F in the kitchen; and * Room 454 – 125.5 degrees F in the kitchen. The need to maintain the water temperatures between 110 degrees and 120 degrees Fahrenheit was discussed with Staff 1 (Director of Assisted Living Services) on 12/03/24 at 2:32 pm. The water temperature for the fourth floor common use bathroom was re-measured on 12/04/24 with Staff 1, Staff 27 (Facility Manager), and Staff 28 (Lead Maintenance). The reading was 113 degrees F and was within the required range. According to Staff 27, water temperatures were taken every Sunday; and the forms for auditing the facility’s water temperatures had been updated with the accurate range of 110 degrees to 120 degrees F. The need to ensure water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1, Staff 27, and Staff 28 on 12/04/24 at 12:30 pm. They acknowledged the findings.

1. At time of survey water temperature was reduced to acceptable range of 110 to 120 degrees. 2. Routine water temperatures to be taken. 3. Monthly routine water temperature testing. 4. Administrator and Facilities designee.

OAR 411-054-0300 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction. (a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit. (b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules). (c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure health and other personal information was kept private for 4 of 5 sampled residents (#s 2, 3, 4, and 5) and multiple unsampled residents. Findings include, but are not limited to: Observations made throughout the survey identified three-ring binders which stored resident Interim Service Plans (ISPs), including private health and other personal information for Residents 2, 3, 4, and 5 and multiple unsampled residents. The binders were located in charting areas on the second, third, and fourth floors of the facility and were accessible to residents and visitors to the facility. During an interview on 12/04/24 Staff 1 (Director of Assisted Living Services) confirmed storage of resident ISPs in the common area infringed on the residents’ right to privacy. The need to ensure individuals’ right to privacy was discussed with Staff 1 and Staff 3 (Director of Nursing) on 12/05/24. They acknowledged the findings.

1. At the time of survey, it was agreed upon to keep the resident binders with resident information secure in the nurse’s station. 2. Resident Privacy and Resident Rights training to be completed with staff upon hire and reinforced in monthly all-staff meetings. Clinical management team to conduct ongoing walk-throughs to ensure binders are not accessible to the public and laptops are closed when not in use. 3. Daily walk-throughs, and monthly in quality improvement meetings. 4. Administrator and RN.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the freedom and support to control his or her own schedule and activities for 1 of 1 sampled resident (#2) and two unsampled residents. Findings include, but are not limited to: A tour of the facility on 12/05/24 at 11:30 am identified the assisted living consisted of four floors within a larger high-rise building. During the acuity interview on 12/03/24 at 9:57 am, three residents were identified as at risk for elopement and having WanderGuards (a device worn on the resident’s person or mobility device that alerted staff when a resident attempted to leave a predetermined area of the facility). Interviews with direct care staff conducted on 12/03/24 indicated an alarm sounded when a resident with a WanderGuard attempted to exit any floor of the facility, and staff were to redirect the resident back to the facility. The residents’ HCBS right to freedom to control one’s own schedule and activities was being limited by the use of a WanderGuard device. During an interview on 12/05/24 at 12:56 pm, Staff 1 (Director of Assisted Living Services) and Staff 2 (Vice President of Health and Wellness) confirmed the use of the WanderGuards to protect residents who might become lost or injured if they left the facility. They further confirmed the facility had not completed the approved form to implement the limitation and had not documented the unsampled and sampled residents’ consent to the limitation. The need to ensure the facility allowed individuals the freedom and support to control his or her own schedule and activities was discussed with Staff 1 and Staff 2 on 12/05/24 at 12:56 pm. They acknowledged the findings.

1. The use of WanderGuards has been reviewed, and residents who continue to use these will have an Individual Based Limitation (IBL) completed for this. 2. Individual Based Limitations will be implemented for residents requiring WanderGuards for safety. IBL process has been reviewed with the clinical team by the consultant team. Documentation of the IBL process will be reviewed by the consultant team. 3. Monthly in the quality improvement meeting. 4. Administrator.

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by:

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. This Rule is not met as evidenced by: Based on interview and record review it was determined the facility failed to ensure an Individually-Based Limitation (IBL) was based on specific assessed needs by completing and signing a program approved form documenting the consent to limiting 1 of 1 sampled resident (#2) and two unsampled residents’ right to freedom to control one’s own schedule and activities, was only implemented with the informed consent of the individual or, as applicable, the legal representative of the individual. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 06/2023 with diagnoses including Alzheimer’s disease and had been identified in the acuity interview on 12/03/24 as posing an elopement risk. Review of Resident 2’s clinical record including the current service plan dated 09/18/24 identified the following: * Resident 2’s HCBS right to freedom to control one’s own schedule and activities was being limited by the use of a WanderGuard device. 2. During the acuity interview on 12/03/24 two unsampled residents were reported to also use a WanderGuard device. During an interview on 12/05/24 at 12:56 pm, Staff 1 (Director of Assisted Living) and Staff 2 (Vice President of Health and Wellness) confirmed the facility had not completed the approved form to implement the limitation and had not documented the sampled and unsampled residents’ consent to the limitation. There was no documented evidence the facility completed a program approved form that justified and documented at minimum all the following requirements: • The specific and individualized assessed need justifying the IBL; • The positive interventions and supports used prior to any IBL; • Less intrusive methods that have been tried but did not work; • A clear description of the limitation that is directly proportionate to the specific assessed need; • Regular collection and review of data to measure the ongoing effectiveness of the IBL; • Established time limits for periodic reviews of the IBL to determine if the limitation should be terminated or remains necessary; • The informed consent of the individual or, as applicable, the legal representative of the individual, including any discrepancy between the wishes of the individual and the consent of the legal representative; and • An assurance that the interventions and support do not cause harm to the individual. The need to ensure the facility completed and maintained a signed, program approved form which documented the consent to limit a resident’s freedom to control one’s own schedule and activities and ensured the form was signed by the individual, or, if applicable, the legal representative of the individual was discussed with Staff 1 and Staff 2 on 12/05/24 at 12:56 pm. They acknowledged the findings and provided verification that the IBL process was started prior to survey exit. Refer to H 1522.

1. The use of WanderGuards has been reviewed, and residents who continue to use these will have an Individual Based Limitation (IBL) completed for this. 2. Individual Based Limitations will be implemented for residents using WanderGuards. IBL process has been reviewed with the clinical team by the consultant team. Documentation of the IBL process will be reviewed by the consultant team. 3. Monthly in the quality improvement meeting. 4. Administrator.

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. This Rule is not met as evidenced by: