OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident evaluations were updated within 30 days of move-in to the facility, and quarterly evaluations were completed timely or reflective of resident care needs for 2 of 2 sampled residents (#s 1 and 3) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 12/2024 with diagnoses including dementia and polyneuropathy. The initial evaluation, dated 12/18/24, was not updated as needed during the 30 days following the resident's move into the facility. The need to ensure new move-in evaluations were updated within 30 days following the resident's move into the facility was discussed with Staff 1 (Administrator) and Staff 20 (ALF ED) on 03/06/25. They acknowledged the findings. ?2. Resident 1 was admitted to the facility in 10/2024 with diagnoses including dementia, depression and congestive heart failure. Observations of the resident on 03/03/25 through 03/06/25, interviews with staff, and review of the resident’s current service plan and evaluation were conducted during the survey. a. The quarterly evaluation was completed 01/05/25, three days after the service plan was updated on 01/02/25. There was no documented evidence to indicate the evaluation, which was the foundation used to develop the service plan, was updated until after the service plan was completed. b. The quarterly evaluation was not reflective in the following areas: * Mental health; * Current skin conditions; * Significant weight gain; * Behaviors exhibited; * Fall risk; and * Sleeping location. The need to ensure quarterly evaluations were the basis of the quarterly service plan and accurate was discussed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional Director of Operations), Staff 20 (ED), and Staff 21 (Regional RN) on 03/06/25. They acknowledged the findings.

C 252 - Resident Move-in and Resident Evaluation 1. Level of Care evaluations were reviewed and updated to accurately reflect resident needs and service plans were updated, printed and reviewed by Health Services staff to accurately reflect resident needs for resident 1 and 3. 2. Audited and updated all current residents to verify their required evaluations, assessments and service plans are completed timely and accurately to reflect their needs. All health services staff received training on reporting changes in resident care needs and environmental concerns to health services timely so resident evaluations are updated appropriately. Training conducted with health services team about the requirements of timely evaluations and assessments. All new residents will have a timely evaluation per regulatory requirement. 3. Reviewed weekly during clinical meeting and weekly Regional Team review. 4. Arbor Administrator, Executive Director, Director of Health Services

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to complete a 30-day service plan, ensure service plans were reflective of residents' needs and provided clear direction for staff for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 12/2024 with diagnoses including dementia and polyneuropathy. Observations of the resident, interviews with staff, and review of the resident's service plan dated 12/28/24 and progress notes dated 12/18/24 to 03/03/25 were completed. Staff interviews indicated the resident was a full assist with all ADLs except eating. The resident often exhibited behaviors in the evenings and at nighttime when s/he would not sleep, attempt to leave building, and bang on exit doors. The resident required two staff assistance for transfers with a slide board. The resident's service plan was not reflective and was not followed by staff in the following areas: * Name preference; * Current activities; * Current pain medications; * Ability to use call system; * Side rails on bed, instructions for staff on what to look for; * Skin related to current heel wounds; * Cognition related to behaviors and interventions for staff; * Transfers – two person with slide board and gait belt; * Bathing – one person, full assist; * Toileting – one person, full assist; and * Assistive device – manual wheelchair. Resident 3’s service plan was not updated at 30 days from admission. The need to ensure resident service plans were updated at 30 days, were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional VP), Staff 20 (ALF ED) and Staff 21 (Regional RN) on 03/06/25. They acknowledged the findings. ?2. Resident 1 was admitted to the facility in 10/2024 with diagnoses including dementia, depression and congestive heart failure. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/02/25, and progress notes, dated 11/10/24 to 03/02/25, were completed. The resident's service plan was not reflective and did not provide clear instruction to staff in the following areas: * Behaviors including how exhibited and interventions for night terrors; * Wound care; * Skin conditions related to edema in the lower extremities; * Outside services including HH RN and PT; * Pain including location and how pain was exhibited; * Fall history and interventions including sitting up in the wheelchair or recliner; * Shower preferences; * Mobility including use of a wheelchair; * Environmental factors including noise, temperature and lighting; * Significant weight gain and elevation of lower legs; * Sleeping location; and * Toileting behaviors. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional Director of Operations), Staff 20 (ED), and Staff 21 (Regional RN) on 03/06/25. They acknowledged the findings.

C260 - Service Plan General 1. Service plans for resident #1 and 3 were reviewed and updated to reflect resident's current care needs and have clear directions to staff regarding the delivery of services. 2. To prevent recurrance, all current resident service plans will be audited for accuracy. Direct care staff were reeducated regarding the importance of implementing current service plans and reporting any discrepancies. Training with Health Services team completed to ensure service plans are updated for accuracy and they provide clear direction to care team. Monitored during Stand up/Clinical meeting to review upcoming evals/service plan reviews that need to be completed as well as to note when there are changes of condition that could require an update more frequent than the quarterly schedule. 3. Service plans will be evaluated and reviewed upon admission, at 30 days, quarterly and with significant change of condition. System monitored during Stand up/Clinical meeting. 4. Arbor Administartor, Executive Director and Director if Health Services

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 evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition, and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 2 of 2 sampled residents (#s 1 and 3) who experienced changes of condition. Resident 1 experienced a severe and ongoing significant weight gain followed by a hospital visit and an infection in his/her legs. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2024 with diagnoses including dementia, depression and congestive heart failure. The resident's clinical record was reviewed, including 10/09/24 through 02/26/24 weight records, 01/02/25 service plan, 11/01/24 through 02/28/25 MARs, 11/10/24 through 03/02/25 progress notes, interim service plans and outside provider notes. The resident was observed, and interviews with staff, the resident and family were conducted. a. Facility weight records noted the following: * 10/09/24 - 155 pounds; * 11/06/24 - 163 pounds; * 11/15/24 – 166 pounds; * 11/20/24 – 164 pounds; * 11/27/24 – 170 pounds; and * 12/02/24 - 170 pounds. Resident 1 gained 8 pounds which constituted a severe weight gain of 5.2% of his/her body weight in one month (10/09/24 through 11/06/24), resulting in a significant change of condition. From 11/06/24 through 11/27/24, the resident gained an additional 7 pounds which constituted an additional significant weight gain, or a gain of 4.5% in three weeks. Review of the progress notes and physician correspondence revealed the following: * 11/10/24 - Resident 1 had “swelling in hands, feet, calves…moaning in pain. has [sic] a bit short of breath;” * 11/11/24 – a Physician Progress/Information Record instructed the facility to “Pl. (please) avoid extra salts, pl. monitor closely for short of breath and worsening swellings and CALL PCP’s (primary care physician’s) office for these symptoms”; * 11/18/24 - “care staff discovered resident’s legs and calves are very swollen and red. and there is yellow-brownish drainage coming out of R (right) great toe underneath toenail.” * 11/22/24 - Resident 1 sent to the ER (emergency room) for a “change in baseline and looking yellowish in color and…blood sugar was 275”; and * 11/23/24 a visiting nurse “noticed resident having cellulitis (bacterial infection of the skin) in both legs. Both Left and right legs are swollen, red and warm to touch. Please make sure resident has legs elevated throughout the day when able.” Resident 1 started antibiotic treatment on 11/24/25. Observations of the resident during 03/03/25 through 03/06/25 revealed Resident 1’s legs were edematous and the right leg was wrapped with a compression dressing. Resident 1 spent time in the morning and afternoons in a recliner with legs elevated. Resident 1 was identified to have heart failure and at risk for “Increased swelling of legs and feet, Shortness of breath with activity,…sudden weight gain,” and experienced a significant weight gain on 11/06/24. There was no documented evidence the facility evaluated the resident’s significant weight gain, referred to the facility RN following a significant change of condition, determined and documented interventions regarding the weight gain, communicated the interventions to staff and monitored the resident according to his/her evaluated needs. The resident continued to gain weight and his/her condition worsened resulting in an emergency room visit and diagnosis of cellulitis. In an interview with Staff 1 (Administrator) on 03/05/25 at 10:20 am indicated there was no documented evidence the resident’s weight gain was referred to the facility RN until an RN assessment was completed on 12/01/24, which was 25 days from the significant change of condition. The facility failed to identify and evaluate the resident's significant weight gain, refer to the facility RN following a significant change of condition, determine and document interventions regarding the weight gain, communicate the interventions to staff and monitor the resident according to his/her evaluated needs. The resident’s condition worsened resulting in a hospital visit and cellulitis that required antibiotic treatment. Refer to C 280, example 1. b. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress through resolution for the following short-term changes of condition: * 11/23/24 – cellulitis in both legs; * 11/24/24 – new antibiotic for infection; * 12/05/24 – “1 in (inch) X.5 inch scab covered open blister” on “back of left calf near ankle”; * 12/19/24 – initiation of HH RN services; * 12/27/24 – return from ER for “over an hour resident screaming help it hurts….[his/her] foot was red, hot to touch and swollen; * 12/27/24 – elevated blood pressure; * 12/31/24 – non-injury fall; * 12/31/24 – bruising to both forearms; * 01/03/25 – HH PT note indicated “patient demonstrating difficulty maintaining O2 levels in 90%.” Instructed to “Monitor O2 levels.”; * 01/10/25 – elevated blood pressure; * 01/14/25 – new medications including Lasix (for fluid retention) and spironolactone (for high blood pressure); * 01/19/25 – respiratory illness; * 01/25/25 – HIF (head injury fall)/ER return; * 01/25/25 – “sutures on the L (left) eyelid, R thumb, and bruising around the L eye and nose; * 01/28/25 – loss of spouse; * 02/06/25 – new medication mirtazapine (for mood and agitation); * 02/12/25 – possible UTI (urinary tract infection); and * 02/27/14 – “rash under breast”. The need to ensure the facility evaluated the resident, referred to the facility nurse when necessary, documented the change, and updated the service plan as needed for a significant change of condition, and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional Director), Staff 20 (ED), and Staff 21 (Regional RN) on 03/06/25. They acknowledged the findings. No further information was provided. ?2. Resident 3 was admitted to the facility in 12/2024 with diagnoses including dementia and polyneuropathy. A review of the resident's clinical records,12/18/24 through 03/03/25, indicated the following changes of condition: * 01/03/25 Resident missed an AM dose of metoprolol 50mg; * 01/04/25 Right side facial swelling; * 01/04/24 Increased pain; * 01/04/25 Increased behaviors, anxiety/agitation; * 01/04/25 New medication, buspirone 10mg; * 01/16/25 Prescription changes of PRN trazadone changed to routinely scheduled; * 01/23/25 Resident had a non-injury fall; * 01/23/25 Resident had a new order for multiple medications including Lasix 20 mg, lisinopril 20 mg, potassium 20 MEQ and PRN quetiapine 25 mg; * 01/31/25 Resident had a new order for acetaminophen 500 mg PRN every 6 hours as needed for pain; * 01/31/25 Prescription order for wound care to pressure ulcer; * 02/15/24 Resident returned from ER with new diagnosis of flu and new medication Tamiflu; and * 02/25/25 Resident had a discontinue order for capsaicin and Voltaren creams for pain. There was no documented evidence the facility had evaluated these changes (to determine actions and interventions), provided written instructions to staff, and/or monitored the above documented changes of condition at least weekly to resolution. The need to ensure all changes of conditions were reviewed, resident-specific actions and interventions were developed and communicated to staff, and monitored until resolution was discussed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional Director), Staff 20 (ED), Staff 21 (Regional RN) and Staff 22 (ED) on 03/06/25.They acknowledged the findings.

C270 - Change of Condition and Monitoring 1. Residents 1 and 3 were reviewed, ISPs were updated and all assessments completed and staff direction and updated by RN. Service plans have been updated and interventions have been reviewed for effectiveness. Service plan includes clear direction to direct cares on current interventions. 2. To prevent recurrence, staff will be reeducated on our alert charting guidelines, when to notify the RN and providing resident-specific actions or interventions to staff when a change of condition has been identified. 24 hour summary will be reviewed five days a week as part of daily standup meeting. Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will then trigger a LN assessement which will include any changes to the care. The change of condition will be monitored until resolved or a new base is determined. When a change of condition is determined to be a significant change the RN will be notified to complete a significant change of condition assessment and resident will be monitored until resolve or until a new baseline is determined. Licensed nurses and Resident Care Coordinator reviewed regulations related to monitoring of change of condition, including effectiveness of interventions. 3. This system will be evaluated five days a week as part of stand up meeting and as needed when a change of condition occurs. 4. Arbor Administrator, Executive Director, Licensed Nurse and RN

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 observation, interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 2 of 2 sampled residents (#s 1 and 3) who experienced significant changes of condition for weight gain and a pressure ulcer. Resident 1 experienced ongoing, significant weight gain followed by a hospital visit and an infection in his/her legs. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2024 with diagnoses including dementia, depression and congestive heart failure. Observations of the resident during 03/03/25 through 03/06/25 revealed Resident 1’s legs were edematous and the right leg was wrapped with a compression dressing. Resident 1 would spend time in the morning and afternoons in a recliner with his/her legs elevated. The resident's clinical record was reviewed, including 10/09/24 through 03/05/24 weight records, 01/02/25 service plan, 11/01/24 through 02/28/25 MARs, 11/10/24 through 03/02/25 progress notes, and interim service plans. The resident was observed, and interviews with staff, the resident and family were conducted. Resident 1’s weight records noted the following: * 10/09/24 - 155 pounds; * 11/06/24 - 163 pounds; * 11/15/24 – 166 pounds; * 11/20/24 – 164 pounds; * 11/27/24 – 170 pounds; and * 12/02/24 - 170 pounds. Resident 1 gained 8 pounds which constituted a severe weight gain of 5.2% of his/her body weight in one month (10/09/24 through 11/06/24), which was considered severe and triggered a significant change of condition. Between 11/06/24 through 11/27/24, the resident gained an additional 7 pounds which constituted an additional significant weight gain, or a gain of 4.5% of his/her body weight in three weeks. There was no documented evidence an RN completed an assessment of the severe weight gain until 12/01/24. The significant, ongoing weight gain represented a serious risk to the health, safety, and welfare of the resident. The need to ensure all significant changes of condition were assessed by an RN, as well as ensuring they were completed in a timely manner, with documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional Director), Staff 20 (ED), and Staff 21 (Regional RN) on 03/06/25. They acknowledged the findings. No further information was provided. Refer to C 270, example 1a. ?Resident 3 was admitted to the facility in 12/2024 with diagnoses including dementia. On 01/31/25, progress notes stated new wound care orders were received along with recommendation to encourage resident to offload. A second 03/01/25 progress note stated “dressing still in place from HH. No changes observed to pressure wound. Resident has not yet begun medication changes.” On 03/05/25 at 2:52pm, in an interview with Staff 2 (Assistant Wellness Director), she stated she was unaware that Resident 3 had a pressure ulcer. Per the surveyor’s request, Staff 2 then went and looked at Resident 3’s coccyx. Staff 2 determined that Resident 3’s skin was healed. Staff 3 acknowledged that no RN assessment had been completed for this significant change of condition. The facility failed to ensure an RN assessment was completed for a significant change of condition which documented findings, resident status, and interventions made as a result of the assessment. The need for a timely RN assessment to be completed for a significant change of condition was discussed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional Director), Staff 20 (ED), Staff 21 (Regional RN) and Staff 22 (ED) on 03/06/25. They acknowledged the findings.

C280 - Resident Health Services 1. Significant change of condition assessments for resident #1 and #3 were completed and updated by RN. RN conducted audit for all residents to determine if any current change of conditions required an RN assessment. 2. To prevent reoccurence, staff will be reeducated on change of condition reporting and when to notify the RN. An RN has been hired for the Director of Health Services position to provide consistency of resident care. 24 Hour summary will be reviewed during daily stand up meeting. At the beginning of the week, the 72 hour summary will be reviewed to include documentation over the weekend. When a change of condition is identified, the resident will be placed on alert chartingwhich will then trigger a LN assessment, which will include any changes to the plan of care. The change of condition will be monitored until resolved or a new baseline is determiend. When a change of condition is determined to be a significant change, the RN will be notified to complete a change of condition assessment and resident will be monitored until resolved or a new baseline is determined. The health services team have been reeducated on the RN requirements related to change of condition. 3. This system will be evaluated five days a week as part of stand up meeting and as needed when a change of condition occurs. 4. Arbor Administrator, Executive Director and Licensed Nurses will be responsible for maintaining this system

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

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions from outside providers and that service plans were adjusted if necessary for 2 of 2 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2024 with diagnoses including dementia, depression and congestive heart failure. During the acuity interview on 03/03/25, the resident was identified to receive home health services. The resident’s 01/02/25 service plan, 12/01/24 through 03/02/25 charting notes, incident reports, interim service plans, and outside provider notes for HH RN and PT were reviewed. Observations were made of the resident, and staff were interviewed. * 12/9/24: "…will benefit from daily walking to improve…circulation and LE [lower extremity] swelling;" * 12/19/24: “…leg elevation;” * 12/30/24: “encourage resident to elevate legs on day and swing shift daily;” * 01/03/25: “Monitor O2 (oxygen) levels. Help patient with sitting leg exercises as able;” * 01/07/25: “…daily reminders to do ankle pumps to assist with venous return on both LE [lower extremity];” and * 01/27/25: “Please don’t put a slippery sock over the compression wrapped foot (right foot). It sticks to the outer wrap and causes it to move up the foot.” During an interview with Staff 1 (Administrator) on 03/06/25 at 10:55 am, she confirmed the facility did not have the instructions requested and would “instruct staff to put recommendations for outside providers in an ISP (interim service plan)”. There was no documented evidence staff were informed of new interventions and the service plan adjusted to ensure continuity of care. The need to ensure the facility coordinated care with outside service providers and communicated recommendations for staff to follow was discussed with Staff 1, Staff 14 (Regional RN), Staff 15 (Regional Director of Operations), Staff 20 (ED), and Staff 21 (Regional RN) on 03/06/25. They acknowledged the findings. ?2. Resident 3 was admitted to the facility in 12/2024 with diagnoses including dementia and osteoarthritis. During the survey, Resident 3's records were reviewed, and staff were interviewed about his/her care needs. The following was identified: Resident 3 received home health RN services for wound care. S/he started home health services prior to admission to the memory care. Home health RN made recommendations for staff to do the following: * 01/06/25: "Elevating BLE [Bi-lateral extremities] for circulation and wound care"; * 01/30/25: "Cover dressings when showering patient. Applying heel protectors at bedtime"; and * 02/13/25: "Continue to encourage /offer patient to wear bilateral heel protectors". In an interview with Staff 1 (Administrator) on 03/05/25 at 11:30 am, she agreed there was no follow up from the facility on information obtained from the outside service provider regarding care recommendations, if there were any new interventions or if the service plan required adjustment. There was no documented evidence the facility informed staff of new interventions and adjusted the service plan if necessary. The need to coordinate care with on and off-site health care providers, staff were informed of new interventions, and that the service plan was adjusted if necessary was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 7, and Staff 10 (Regional RN) on 12/04/24 at 1:30 pm. They acknowledged the findings.

C290 - On Site and Offsite Health Services 1. All outside provider summary notes for the past 90 days have been reviewed for resident #1 and #3 and service plan has been updated with all recommendations and appropriate interventions. Service plan has been printed for all direct care staff to review and sign. 2. To prevent recurrance all outside provider notes to be reviewed through facility triple check process, which includes initiation of ISP by med tech and reviewed by Licensed Nurse. Coordination of care will be performed by Licensed Nurse with all outside health services to ensure appropriate care and services are provided within the scope of the regulation and practice. 3. This system will be evaluated semi-annually as part of the facility’s CQI program. 4. Arbor Administrator, Executive Director, Licensed Nurse will be responsible for maintaining this system

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible for administering for 1 of 2 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2024 with diagnoses including dementia, depression and congestive heart failure. a. Review of physician orders, dated 11/12/24, indicated the resident was to start taking furosemide (for fluid retention) 20 mg, 2 tablets daily for 3 days and then 1 tablet daily until further notice. A follow up physician’s order, dated 11/14/24, had documented a conversation regarding Resident 1’s furosemide. The note indicated “Spoke with [Staff 1 (Administrator)] who confirmed…she just got a new fax for BID dose for 3 days. They (facility) will start BID dosing today…”. The November 2024 MAR revealed 2 tablets of furosemide was administered once daily between 11/15/24 through 11/18/24, not BID as ordered. During an interview on 03/06/25, Staff 1 acknowledged furosemide had not been administered twice a day as ordered and “it should have been.” No further documentation was provided. b. Resident 1’s quarterly physician orders were provided on 03/03/25 for review. The quarterly orders lacked a signed physician order and a date. During an interview on 03/06/25 at approximately 1:30 pm, Staff 1 acknowledged “we do not have those signed orders and they have been faxed over today to be signed.” No further documentation was provided. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed and the facility had written, signed physician orders documented in the resident's facility record was reviewed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional Director of Operations), Staff 20 (ED), and Staff 21 (Regional RN) on 03/06/25. They acknowledged the findings.

C303 - Systems: Treatment Orders 1. Received signed medication orders for Resident #1. Provided staff training regarding system to request quarterly physician orders and how to process and file new physician orders. 2. Resident Care Coordinator, Licensed Nurse and Medication technicians have received education about processing medication orders, the triple check process, filing new orders and the requirement to have signed physicians orders. 3. This system will be reviewed through weekly Resident Care Coordinator audits to ensure quarterly physician orders are requested and through daily triple check process to ensure new orders are received, processed and filed appropriately. 4. Executive Director and LNs will be responsible for maintaining this system.

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

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a RN, PT or OT was completed for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (# 3) who had a supportive device. Findings include, but are not limited to: Resident 3 was admitted to the facility in 12/2024 with diagnoses including dementia. During the entrance conference on 03/03/252, Resident 3 was identified as having siderails on his/her bed. Observations of the resident and the resident's room showed the siderails were on the bed in the down position and represented a device with restraining qualities. Review of Resident 3's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT. In an interview on 03/06/25 at 12:30 pm, Staff 1 (Administrator) stated no assessment had been completed for Resident 3's siderails. The lack of an assessment for the resident's siderails was discussed with Staff 1 (Administrator), Staff 14 (Regional RN), Staff 15 (Regional Director), Staff 20 (ED), and Staff 21 (Regional RN) on 03/06/25. They acknowledged the findings.

C340 - Restraints and Supportive Devices 1. Supportive Device assessment for resident #3 was completed by RN. 2. Staff re-educated on the importance of reporting to RN when a resident has, is requesting or wants a device with restraining qualities. RN received reeducation on the expectation of completing the Supportive Device assessment per regulation. 3. This process will be reviewed during stand-up/Clinical meeting to review progress notes to review new notes that may indicate a resident requesting or wanting to add a supportive device. During Stand up/Clinical meeting the LN will review Assistive Device assessment schedule to track who needs an assessment and will complete. 4. Arbor Administrator, Executive Director and Licensed Nurse will be responsible to maintain compliance.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 5, 7, and 8) demonstrated competency in first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 03/05/25 at 2:28 pm with Staff 15 (Regional Director of Operations). Staff 5 (MT), Staff 7 (CG), and Staff 8 (CG), hired 09/25/24, 12/26/24, and 12/26/24, respectively, lacked documented evidence they had completed abdominal thrust training within 30 days of hire. The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Administrator), Staff 15, and Staff 20 (ED) on 03/05/25. They acknowledged the findings.

C372 - Training within 30 days of hire 1. A complete audit was done of all training records. Staff who were missing components of training were removed from the floor until their training was completed. 2. To prevent recurrence, training grid will be utilized to ensure that all staff have required trainings completed. Staff will not be allowed to work on the floor unsupervised until all of their required trainings are completed. Monthly, as part of facility continuous quality improvement meetings, training grid will be reviewed to identify any staff members whose certifications/trainings are close to expiration and they will be scheduled to complete the required training. Incomplete trainings will be reviewed five days a week as part of the daily standup meeting to identify missing training components and to review the status of new hires and where they are at with their trainings. 3. This system will be evaluated monthly as part of the facility continuous quality improvement process and will include a review of the training grid. 4. The Arbor Administrator, Executive Director will be responsible for maintaining this system

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

OAR 411-054-0090 (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 ensure residents were instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, 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: In an interview on 03/05/24 with Staff 1 (Administrator), fire and life safety records were reviewed, and the following was identified: Survey requested documentation of fire and life safety instruction provided to residents within 24 hours of admission and the process for re-instruction, at least annually after admission. Staff 1 confirmed new residents were not instructed about the facility's fire and life safety procedures, residents were not reinstructed annually, and an annual written record of fire safety training, including content of the training sessions, was not being done. The need to ensure resident instruction in general safety procedures within 24 hours of move-in and at least annual reinstruction was discussed with Staff 1, Staff 15 (Regional Director of Operations), and Staff 20 (ED) on 03/05/25. They acknowledged the findings.

C422 - Fire and Life Safety Training for Residents 1. Fire and life safety training has been completed and documented for all current residents. 2. To prevent recurrance, Environmental evaluation will be completed at time of move-in and semi-annually and includes documentation of re-instruction on fire and life safety training, including specifics on what information is covered. 3. Fire drills and fire and life safety trainings for residents will be reviewed monthly as part of our CQI process to ensure compliance. 4. Arbor Administrator, Executive Director and Maintenance Director will be responsible for maintaining this system

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 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: ?Based on observation and interview, it was determined the facility failed to ensure a call system that connected resident units to the care staff center or staff pagers. Findings include, but are not limited to: Observations of resident units in the MCC were made on 03/04/25 and 03/05/25. The units lacked a call system that connected to the care staff center or staff pagers. At 10:40 am on 03/05/25, Staff 1 (Administrator) confirmed the lack of a call system. Staff 1 stated the facility policy was to complete frequent safety checks, encourage residents to be in common areas during the day, and for staff to use walkie talkies when they needed additional assistance in resident rooms. The need to ensure a call system that connected resident units to the care staff center or staff pagers was discussed with Staff 1, Staff 15 (Regional Director of Operations), and Staff 20 (ED) on 03/05/25. They acknowledged the findings.

C555 - Call System 1. Pagers were ordered for Memory Care and residents who were evaluated to be able to use the call system were given pendants. If unable to utilize call system, staff will follow service plan will be followed to anticipate needs. 2. All residents are evaluated for their ability to use the call system and if identified as being able to use call system, staff will provide residents with pendants. Residents all have pull cords in their apartment bathroom to use as well which will alert the paging system so the team can follow up. All residents who are unable to utilize call system, staff will follow their service plan to anticipate needs. 3. Call times reviewed during stand up and clinical meeting to make sure resident call lights are answered promptly. 4. Arbor Administrator, Executive Director, and Maintenance Director

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 372, C 422 and C 555.

Z142 - Administration Compliance Refer C372, C422 and C555.

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 3, 4, 5, and 6) completed all required pre-service orientation training topics and received a written job description; 3 of 3 newly-hired direct care staff (#s 4, 5, and 6) completed all required pre-service dementia training topics; 3 of 3 newly-hired direct care staff (#s 5, 7, and 8) demonstrated competency in all assigned job duties within 30 days of hire; 1 of 2 long-term direct care staff (#9) completed the required number of annual in-service training hours, including at least six hours of training on dementia care; and 3 of 3 long term non-care staff (#s 11, 12, and 13) completed annual home and community-based services (HCBS) training and/or LGBTQIA2S+ training. Findings include, but are not limited to: Staff training records were reviewed on 03/05/25 at 2:28 pm with Staff 15 (Regional Director of Operations). a. There was no documented evidence Staff 3 (Cook), Staff 4 (CG), Staff 5 (MT), and Staff 6 (Server), hired 02/21/25, 02/17/25, 09/25/24, and 02/11/25, respectively, had a written description of their job responsibilities and/or completed one or more of the following pre-service orientation topics before completing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * HCBS course; * LGBTQIA2S+ course; and * Infectious disease prevention. b. There was no documented evidence Staff 4, Staff 5 and Staff 6 completed one or more of the following pre-service dementia training topics: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach; * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 5, Staff 7 (CG), hired 12/26/24, and Staff 8 (CG), hired 12/26/24, demonstrated competency in one or more of the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Providing assistance with ADLs; * Identification, documenting and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Other duties, including medication pass and treatments. The facility completed Staff 5’s signed MT competencies and provided a copy to the survey team on 03/06/25. d. Documented annual in-service hours acquired between 04/28/23 and 04/28/24 were reviewed for Staff 9 (CG), hired 04/28/21. There was no documented evidence Staff 9 had completed the required number of annual in-service training hours, including at least six hours of training related to dementia care, HCBS training, and LGBTQIA2S+ training. e. There was no documented evidence Staff 11 (Cook), Staff 12 (Housekeeping), and Staff 13 (Housekeeping) hired 06/18/22, 08/01/22, and 12/20/23, respectively, completed the required HCBS and/or LGBTQIA2S+ training. The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules and staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator), Staff 15, and Staff 20 (ED) on 03/05/25. They acknowledged the findings.

Z155 - Staff Training Requirements 1. A complete audit was completed of all preservice, dementia and annual training records and job descriptions(including HCBS, LGBTQIA2S+). Staff who were missing components were removed from the floor until completed. 2. To prevent recurrence, training grid will be utilized to ensure that all staff have required trainings completed. Staff will not be allowed to work on the floor unsupervised until all of their required trainings are completed. Monthly, as part of facility continuous quality improvement meetings, training grid will be reviewed to identify any staff members whose certifications/trainings are close to expiration and they will be scheduled to complete the required training. 3. Incomplete trainings will be reviewed during standup meeting to identify missing training components and to review the status of new hires and where they are at with their trainings. This system will be evaluated monthly as part of the facility continuous quality improvement process and will include a review of the training grid. 4. The Arbor Administrator, Executive Director and Business Office Manager will be responsible for maintaining this system

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 270, C 280, C 290, C 303, and C 340. ?

Z162 - Compliance with Rules Health Care Refer to C252, C260, C270, C280, C290, C303 and C340.

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