OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors. Findings include but are not limited to: A tour of the facility was conducted on 06/09/25 and the following required postings were not observed to be posted: * The name of administrator or designee in charge; and LGBTQIA2S+ protections were not posted as required. The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Administrator) on 06/11/25. He acknowledged the findings.

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were taken to protect against any condition that could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#3) while performing ADL care and multiple unsampled residents during dining service. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2025 with diagnoses including dementia with behavioral disturbance and hypertension. On 06/09/25 at 2:07 pm, Witness 2 (Agency Staff) and Witness 3 (Agency Staff) provided ADL incontinence care for Resident 3. Witness 2 and Witness 3 donned gloves prior to providing incontinence care. Witness 3 removed the resident's soiled brief, performed perineal care without doffing soiled gloves. Witness 2 and Witness 3 then placed a clean brief on the resident and repositioned the resident all while wearing the same gloves. The need to ensure reasonable precautions were taken to protect against any condition that could threaten the health, safety, or welfare of residents while performing ADL care was discussed with Staff 1 (Administrator) on 06/11/25 at 10:25 am. He acknowledged the findings. 2. During an observation on 06/09/25 at 11:55 am, Witness 2 (Agency Staff) was assisting an unsampled resident with lunch. Witness 2 left the dining room to resident’s bedroom with gloves on, returned to the table with a pillow and placed it under resident’s right arm to assist in maintaining positioning. Witness 2 then proceeded to the kitchenette area, removed the gloves, placed the dirty gloves in his/her pocket and put on clean gloves prior to disinfecting hands then proceeded to serve dessert to residents. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed during exit interview on 06/11/25. They acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were taken to protect against any condition that could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#5) while performing ADL care, and 1 of 2 sampled residents (#5) and multiple unsampled residents during dining room service. This is a repeat citation. Findings include, but are not limited to: 1. On 10/21/25, observations during lunch service identified the following: At 11:24 am, a caregiver provided meal assistance to two unsampled residents. The caregiver sat between the two residents while she provided meal assistance to both residents with her right hand. She was observed holding each of the resident's spoons and/or forks as she alternated assisting each resident simultaneously, as well as wiping the mouth of one resident with a napkin, with no handwashing in between. At 11:31 am the caregiver no longer needed to assist one of the two unsampled residents. At 11:32 am the caregiver stood up, retrieved a straw, removed the wrapper and held the tip of the straw as she placed it in the water cup for the unsampled resident. No handwashing was observed prior to touching the unwrapped straw or resuming meal assistance. At 12:16 pm, the caregiver assisted the resident to drink water from the straw. At 11:34 am, the caregiver briefly stopped providing meal assistance to the resident while she left the table to assist another unsampled resident. The caregiver was observed pushing the resident’s wheelchair and moving his/her plate of food, cups, and silverware to a different table. Afterwards, the caregiver returned to provide meal assistance to the resident. No handwashing was observed prior to moving the resident’s food or resuming meal assistance. At 11:42 am, the caregiver left the table again to briefly provide meal assistance to Resident 5. She was observed picking up the resident’s fork, assisting with a bite of food, handing Resident 5 the fork, and then returning to finish providing meal assistance to the unsampled resident. No handwashing was observed prior to providing meal assistance to Resident 5 or when returning to the unsampled resident. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 21 (ED) and Staff 3 (Director of Health and Wellness) on 10/22/25 at 2:35 pm. They acknowledged the findings. 2. Resident 5 moved into the facility in 07/2025 with diagnoses including dementia, vascular heart disease, chronic diastolic heart failure, and atrial fibrillation. The resident was observed to require the assistance of two direct care staff to provide ADL incontinence care while the resident was in bed. On 10/20/25 at 1:20 pm, Staff 19 (CG) and Staff 24 (CG) provided incontinence care for Resident 5. Staff 19 and Staff 24 donned gloves prior to providing care. Staff 24 removed the resident’s soiled brief, and Staff 24 and Staff 19 provided perineal care with the same soiled gloves. Staff 19 and Staff 24 placed a clean brief on the resident, clothed and repositioned the resident in his/her bed, pulled the bedding over the resident, positioned two fall mats next to the bed, and touched the resident’s dresser, all without doffing the soiled gloves or completing hand hygiene. On 10/22/25 at 10:31 am, Staff 8 (CG) and Staff 17 (CG) provided incontinence care for Resident 5. Staff 8 and Staff 17 donned gloves prior to providing care. Staff 17 removed the resident's soiled brief and then performed perineal care. Staff 8 and Staff 17, without changing the soiled gloves or completing hand hygiene, then placed a clean brief and clean clothes on the resident, transferred them into his/her wheelchair, made the resident’s bed, and touched the resident’s dresser. The need to ensure reasonable precautions were taken to protect against any condition that could threaten the health, safety, or welfare of residents while performing ADL care was reviewed with Staff 3 (Director of Health and Wellness) and Staff 21 (ED) on 10/22/25 at 1:54 pm. They acknowledged the findings.

1. Staff educated on only assisting one resident at a time with meals. Staff training for hand washing/hand hygeine when going from dirty to clean done at all staff meeting in October. Elderwise Consultant in-serviced staff on hand hygeine and handwashing on 10/30/25. Staff were individually educated on correct inefection control practices. 2. Executive Director, nursing, and resident care director will continue to monitor meals regularly and intermittently observe care being preformed. Will continue hand hygeine and hand washing education both at all staff meetings and in the moment education. 3.Multiple times per day. 4. Executive Director and nursing.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents' rights to be treated with dignity and respect, and to be given informed choice and opportunity to select or refuse service for 1 of 1 sampled resident (#1) on hospice. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia and osteoporosis. During the survey, Resident 1 was unable to use the call light and was dependent on staff for ADL care. On 05/07/25 Resident 1 was admitted to a hospice program. OAR 411-054-0005 defines a "Hospice Program" as a coordinated program of inpatient care, available 24 hours a day”, with the intent of providing end of life services at home without having to be transported for care. A note dated 06/08/25 documented Resident 1 fell out of bed, and staff “notified physician via fax, management notified of resident fall, EMS called, and resident taken to hospital for evaluation”. In an interview on 06/09/25 at 12:30 pm, Witness 3 (Hospice RN) stated neither the family or hospice was notified of the fall, and if they had been, a hospice RN would have come on-site to evaluate Resident 1 to prevent unnecessary transportation to the emergency room. Witness 3 stated sending Resident 1 to the emergency room without notifying family or hospice was a mistake. During an interview on 06/10/25, Witness 5 (Family) stated they were the Power of Attorney, were not notified before Resident 1 was taken to the hospital. The hospital Resident 1 was taken to did not have the resident’s medical information or accept their insurance. Witness 5 stated some of the staff were not aware of what hospice meant in relation to Resident 1’s care. On 06/11/25, in an interview at 1:00 pm, Witness 6 (Family) stated they were not notified prior to the facility sending Resident 1 to the hospital. Witness 6 stated they should have had an opportunity to make a choice about care, and that agency staff did not always know Resident 1’s hospice status or care needs. The need to ensure residents received services in a manner that protected dignity and allowed for informed choice to select or refuse service was discussed with Staff 1 (Administrator) on 06/11/25 at 11:45 am. He acknowledged the findings.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to investigate incidents to rule out abuse, document all required areas of an investigation, and/or report to the local Seniors and People with Disabilities (SPD) office if abuse could not be ruled out for 1 of 1 sampled residents (#1) reviewed for injuries of unknown cause and unwitnessed falls. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia and osteoporosis. During the survey, Resident 1 was unable to use the call light and was dependent on staff for ADL care. Observations of the resident, interviews with staff, and review of the resident's progress notes, alert charting, and incident reports were reviewed. The following incidents were revealed: * Note dated 03/21/25 “bruise of unknown origin on right forearm in two sections, stripped like”; * Note date 03/25/25 “Caregiver notified med tech resident was on the floor”; * Note dated 4/1/25 “Resident skin tear appears to be scabbed over and has had no drainage during this shift”; and * Note dated 4/25/25 “I walked in, and Resident was on the floor in front of the closet”. There was no documented evidence the bruises, skin tear, or the unwitnessed falls had been investigated to rule out abuse or suspected abuse, nor evidence the local SPD was immediately notified of the incidents. During an interview on 06/11/25 at 11:45 am, Staff 1 (Administrator) confirmed the incidents were not promptly investigated to rule out abuse or neglect and were not reported to the SPD office. The facility was requested to notify the SPD office of the incidents. Confirmation of the reporting was received on 06/11/25 prior to survey's exit. The need to immediately investigate injuries of unknown cause and unwitnessed falls, when the resident was dependent on staff for care, to rule out abuse or neglect of care, and to notify the local SPD if abuse could not be ruled out was discussed with Staff 1 (Administrator) on 06/11/25 at 11:45 am. He acknowledged the findings.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluation was completed for 1 of 1 sampled Resident (# 4), whose move-in evaluation was reviewed, and evaluation updates were reflective of residents’ current status for 1 of 4 sampled Residents (# 2) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility on 05/2025 with diagnoses including Dementia, Alzheimer’s and hypothyroidism. Resident 4’s records were reviewed during the survey and revealed the following: * There was no documented evidence a move in evaluation was completed for Resident 4. In an interview on 06/10/25 at 1:55 pm, Witness 1 (Consultant, RN) acknowledged that the evaluation on record dated 05/12/25 was an update for significant change of condition related to hospice admission. The need to ensure move-in evaluations were completed prior to a resident moving in was discussed with Staff 1 (Administrator) and Staff 3 (Quality Improvement LPN) on 06/11/25 at 11:20 am. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2022 with diagnoses including vascular dementia and diabetes. Resident 2’s last quarterly evaluation dated 05/29/25 was reviewed. Observations were made of the resident and interviews of staff and resident were conducted. The resident’s most recent evaluation was not reflective of Resident 2’s current care needs including: *Toileting; *Dressing, grooming, bathing and personal hygiene; *Transfers and assistive devices for mobility; *Pain: pharmaceutical and non-pharmaceutical interventions; and *Complex medication regimen in relation to sliding scale insulin and prn psychoactive. The need to ensure evaluations were reflective of the residents’ current status and care needs was discussed with Staff 1 (Administrator) and Staff 3 (Quality Improvement LPN) on 06/11/25 at 11:20 am. They acknowledged the findings.

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 ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including vascular dementia and diabetes. Observations of the resident, interviews with staff and resident, review of service plan dated 05/28/25 and progress notes dated 03/21/25 through 06/09/25 were completed. The service plan was not reflective and did not provide direction for staff in the following areas: * Behaviors related to narcotic use; * Blood sugar check prior to meals; * Environmental factors related to loud noise; * ADL assistance related to bathing; * Assistive devices related to shower chair; and * Nutritional habits related to food preference and dislikes. 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) and Staff 3 (Quality Improvement LPN) on 06/11/25 at 11:20 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia and osteoporosis. During the survey, Resident 1 was unable to use the call light and was dependent on staff for ADL care. Observations of the resident, interviews with staff, and review of the resident's most recent service plan available to staff, dated 06/05/25 was completed. The following areas were not reflective of residents’ current care needs and/or failed to provide clear direction to staff regarding the delivery of services: * Hospice contact information; * Repositioning schedule and skin precautions; and * Low bed, fall mat, and fall precautions. On 06/11/25 at 11:30 am the need to ensure service plans were reflective of current needs and provided clear direction to staff was discussed with Staff 1 (Administrator). He acknowledged the findings. 3. Resident 3 was admitted to the facility in 03/2025 with diagnoses including dementia with behavioral disturbance and hypertension. Observations of the resident, interviews with staff, and review of the resident's most recent service plan available to staff, dated 05/27/25 was completed. The following areas were not reflective of residents’ current care needs and/or failed to provide clear direction to staff regarding the delivery of services: * “Orders” section regarding non-pharmacological interventions and refusals; and * Transfers. On 06/11/25 at 10:25 am the need to ensure service plans were reflective of current needs and provided clear direction to staff was discussed with Staff 1 (Administrator). He acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences and provided clear direction regarding the delivery of services for 2 of 2 sampled residents (#s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 moved into the community in 07/2025 with diagnoses including dementia, vascular heart disease, chronic diastolic heart failure, and atrial fibrillation. The resident was observed throughout the survey to require the assistance of two staff with transferring and incontinence care. The resident’s record was reviewed, including the current service plan, dated 09/03/25, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and/or did not provide clear direction regarding the delivery of services in the following areas: * Transfer assistance needs; * Incontinence care instructions; * Instructions related to the use of oxygen; * Instructions related to outside providing bathing the resident; * Instructions related to repositioning the resident in bed; * Instructions regarding the use of a hospital bed and fall mats; * Nutritional habits, including food likes and dislikes; * Skin care instructions for rashes; and * Information regarding the resident’s preferred language. The need to ensure service plans were reflective of the residents’ current care needs and provided clear direction to staff was reviewed with Staff 3 (Director of Health and Wellness) and Staff 21 (ED) on 10/22/25 at 1:54 pm. They acknowledged the findings. 2. Resident 6 moved into the community in 10/2018 with diagnoses including dementia. The resident’s clinical record was reviewed, including the current service plan, dated 10/10/25, observations were made, and interviews were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and/or lacked clear instructions in the following areas: * Mobility assistance required; * How often to perform safety checks and provide toileting assistance; * Cognitive status; and * Non-pharmaceutical interventions for pain. During an interview on 10/21/25 at 1:40 pm, Staff 24 (CG) indicated Resident 6 was confused “most of the time” and needed an escort to his/her room or to the activity area. The need to ensure residents’ service plans were reflective of their current status and care needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 21 (ED) and Staff 3 (Director of Health and Wellness) on 10/22/25 at 2:35 pm. They acknowledged the findings.

1. Surveyed resident 5 and resident 6 service plans have been updated to reflect residents current care needs and address all areas identified during survey. 2. Executive Director, nursing, and resident care director will all review service plan quarterly, 30 day, and significant change in conditions. 3. Daily, weekly, and quarterly. 4. Executive Director and nursing.

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

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident’s choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service planning team was reviewed. Findings include but are not limited to: Resident 1, 2, and 3’s most recent service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. On 06/11/25 at approximately 1:15 pm, the need to ensure service plans were developed by a Service Planning Team was discussed during the exit interview with Staff 1 (Administrator) and Staff 3 (Quality Improvement LPN). No additional information was provided.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored until resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including vascular dementia and type II diabetes. The resident's 05/28/25 service plan and 03/21/25 through 05/19/25 progress notes were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved in the following areas: *Medication changes surrounding insulin on 04/01/25 and 05/10/25. During an interview on 06/11/25 at 11:30 am, Staff 1 (Administrator) and Staff 3 (Quality Improvement LPN), reported there was no current process for identifying changes of conditions, identifying actions/interventions necessary and monitoring through resolution. This process was under review. No additional information was provided. The need to ensure short-term changes of condition had documentation of weekly progress until resolution was discussed with Staff 1 and Staff 3 on 06/11/25. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia and osteoporosis. A review of the resident’s progress notes, service plan updates, and alert charting from 03/13/25 through 06/08/25, indicated the following changes of condition were not monitored until the condition resolved: * 03/21/25 “bruise of unknown origin on right forearm in two sections, striped like”; * 04/1/25 “Resident skin tear appears to be scabbed over and has had no drainage during this shift”; and * 05/06/25 “Monitor surgical site and shoulder for changes”. An interview with Staff 1 (Administrator) on 06/11/25 at 11:45 am confirmed the facility did not have a process in place to discontinue monitoring when the condition resolved. The need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1 (Administrator) on 06/11/25 at 11:50 am. He acknowledged the findings. 3. Resident 3 was admitted to the facility in 03/2025 with diagnoses including dementia with behavioral disturbance and hypertension. A review of the resident’s progress notes from 03/13/25 through 06/08/25, indicated the following changes of condition were not monitored at least weekly until the condition resolved: * 03/13/25 – New move-in; and * 05/19/25 – Unwitnessed fall. An interview with Staff 1 (Administrator) on 06/11/25 at 10:25 am confirmed the facility did not have a process in place to discontinue monitoring at least weekly when the condition resolved. The need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1 on 06/11/25 at 10:25 am. The findings were acknowledged.

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 411-054-0055 (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 physician orders were carried out as prescribed or written and/or signed physician orders were documented in the resident's facility record for all medication and treatments the facility was responsible to administer for 2 of 3 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia and osteoporosis. Resident 2's MARs, dated 06/01/25 through 06/11/25, and physician orders dated 09/16/24 were reviewed and identified the following: Medications documented on the MAR with no signed physician’s order in the record: * Morphine sulfate PRN 20 mg (pain); * Lorazepam PRN 2mg (anxiety); * Lidocaine patch 4% (pain); * Hyoscyamine PRN .25 mg (secretions); * Acetaminophen PRN 325 mg (pain); * Acetaminophen PRN 650 mg suppository (pain); and * Bisacodyl PRN 10 mg suppository (pain). Medications with a signed physicians order that were not documented as discontinued or listed on the MAR: * Donepezil 10 mg (dementia); * Ensure supplement (nutrition); * Glycopyrrolate 1 mg (secretions); * Polyethylene glycol (laxative); * Remedy PRT Z-Guard 17% (skin barrier cream); * Antacid plus simethicone PRN (stomach antacid); and * Loperamide PRN (anti-diarrheal). The requirement to maintain current physician’s orders for all medication and treatments the facility was responsible to administer was discussed with Staff 1 (Administrator) at 10:45 am on 6/11/25. Staff 1 acknowledged the findings and stated he would contact the prescriber to request a copy of the current signed orders. 2. Resident 2 was admitted to the facility in 06/2022 with diagnoses including vascular dementia and diabetes. Resident 2's current physician's orders, MAR/TAR dated 06/01/25 through 06/09/25, and progress notes dated 03/21/25 through 06/09/25 were reviewed. The following was identified: a. Resident’s order for Metformin 500mg twice daily with meals had an evening dose scheduled on the MAR for 7 pm- 9 pm. Interview with staff and observation during survey, dinner was served approximately 4:30 pm. b. Resident had blood sugar check order twice daily, AM fasting and as needed. MAR had several blood sugar readings 7 am – 9 am, 8 am, 12 pm and 4 pm. Based on MAR readings, unable to determine if AM blood sugar was fasting as ordered. The need to ensure all medication and treatments were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 3 (Quality Improvement LPN) on 06/11/25 at 11:20 am. They acknowledged the findings.

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 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including vascular dementia and diabetes. Resident 2's current physician's orders, MAR/TAR dated 06/01/25 through 06/09/25, and progress notes dated 03/21/25 through 06/09/25 were reviewed. The following was identified: There were multiple blanks (dashes) on the MAR for routine blood sugar checks and scheduled Humalog 100-u/ml on 06/06/25 at 4pm, where the facility failed to document whether the medication was administered. In an interview with Staff 13 (MA) on 06/10/25 at 1:30 pm, she stated the dash on MAR indicated it was not administered and may have been a refusal or a hold. The need to ensure prescription medications were documented as administered or not was discussed with Staff 1 (Administrator) and Staff 3 (Quality Improvement LPN) on 06/11/25 at 11:20 am. The findings were acknowledged. 2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia and osteoporosis. Residents 1's MARs were reviewed from 06/01/25 through 06/09/25 and revealed the following: The following medications/dates had scheduled administration times left blank (dashes), failing to document if the medications were administered as ordered: * Acetaminophen (for pain); * Lidocaine patch (for pain); * Levothyroxine (hormonal supplement); and * Olanzapine (for psychosis). The need to ensure prescription medications were documented as administered or not was discussed with Staff 1 (Administrator) on 06/11/25 at 11:25 am. The findings were acknowledged. 3. Resident 3 was admitted to the facility in 03/2025 with diagnoses including dementia with behavioral disturbance and hypertension. Residents 3's MARs were reviewed from 06/01/25 through 06/09/25 and revealed the following: The following medications/dates had scheduled administration times left blank (dashes), failing to document if the medications were administered as ordered: * Calcium carbonate oral tablet (for gastroesophageal reflux disease); * Oxycodone (for pain); * Cephalexin (Antibiotic); * Sodium fluoride (for oral health); * Calcium antacid (for gastroesophageal reflux disease); * Acetaminophen (for pain); * Famotidine (for gastroesophageal reflux disease); * Calmoseptine ointment (for rash); * Donepezil (for dementia); * Eliquis (for stroke); * Nystatin (for rash); and * Quetiapine (for dementia). In an interview with Staff 13 on 06/10/25 at 3:20 pm the MAR dated 06/01/25 through 06/09/25 was reviewed and she could not confirm the above medications had been administered. The need to ensure prescription medications were documented as administered or not was discussed with Staff 1 (Administrator) on 06/11/25 at 10:25 am. The findings were acknowledged.

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure direct care staff were scheduled and maintained staff according to their staffing plan to meet the 24-hour scheduled and unscheduled needs of the residents. Findings include, but are not limited to: During the ABST review on 06/10/25, the following was identified: * The memory care facility was home to 28 residents at the time of survey; * Four residents who required two- staff members assistance with transfers; * Five residents who required assistance in the dining room including cueing or physical assistance with eating; and * Four residents who exhibited behaviors that required supervision and redirection. The current facility staffing plan was reviewed and indicated the following: * Day shift: Four direct caregiving staff and one Medication Technician; * Evening shift: Four direct caregiving staff and one Medication Technician; and * Night shift: Three direct caregiving staff and one Medication Technician. A review of the facility’s scheduled staffing and timecards for the period of 06/01/25 through 06/07/25 revealed discrepancies in staffing levels. On 06/02/25 and 06/06/25, both the day and evening shift did not meet the posted staffing levels. Additionally, on 06/03/25 and 06/07/25 all shifts were identified as being short by one or two direct care staff. Additional documentation was requested during the survey and no documentation was provided prior to the survey team exit. The need to ensure direct care staff were scheduled and maintained the staffing according to their staffing plan to meet the 24-hour scheduled and unscheduled needs was reviewed with Staff 1 (Administrator) on 06/10/25 and 06/11/25. He acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to accurately capture care time and care elements that staff were providing for 1 of 3 sampled residents (#1) as outlined in the individual service plan. Findings include but are not limited to: Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia and osteoporosis. During the survey, Resident 1 was unable to use the call light and was dependent on staff for ADL care and required assistance to eat or drink. The service plan, dated 06/05/25, Interim Service Plans, and the resident's corresponding ABST individual minutes were reviewed. Resident 1 was observed, and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas: * Safety check and fall prevention; * Monitoring physical conditions or symptoms; * Supervising, cueing, and supporting while eating; * Repositioning in bed or chair; and * Escorting to and from meals. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator) at 11:30 am on 06/11/25. He acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident had an ABST evaluation completed prior to admission for 1 of 1 sampled resident (# 4) whose move in evaluation was reviewed. Findings include but are not limited to: Resident 4 was admitted to the facility in 05/12/2025 with diagnoses including Dementia, Alzheimer’s and hypothyroidism. The facility’s ABST data was reviewed during the survey 06/09/25 through 06/11/25. Resident 4's ABST evaluation was entered on 05/25/25; therefore, the resident's ABST evaluation was not completed prior to moving into the facility. The need to ensure residents’ ABST evaluations were completed prior to move-in was discussed with Staff 1 (Administrator) and Staff 3 (Quality Improvement LPN) on 06/11/25 at 11:20 am. They acknowledged the findings.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 7, 9, and 19) completed first aid and abdominal thrust training within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 2 (Assistant Executive Director/Business Office Manager) on 06/10/25 and showed the following: * Training records for Staff 7 (CG) hired 03/27/25, Staff 9 (CG) hired 04/15/25 and Staff 19 (CG) hired 04/29/25 lacked documented evidence either first aid or abdominal thrust training was completed within 30 days of hire. The need to ensure staff completed first aid and abdominal thrust training within 30 days of hire was reviewed with Staff 1 (Administrator) and Staff 2 on 06/11/25. They acknowledged the findings.

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Six months of fire and life safety records were requested on 06/09/25 and reviewed on 06/10/25. The following was identified: a. Fire drills were not conducted every other month in accordance with OFC. b. The documented fire drills conducted on 03/30/25 and 06/06/25 lacked the following required components: * Escape route used; and * Evidence of alternate routes used. c. Staff were interviewed, and they did not know the designated point of safety area. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 1 (Administrator) and Staff 4 (Director of Maintenance) on 06/11/25. They acknowledged the findings.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed, at least annually. Findings include, but are not limited to: Documentation of fire and life safety training provided to residents within 24 hours of admission and annually was requested multiple times during the survey, 06/09/25 through 06/11/25. However, the facility did not provide any documentation prior to the survey exit. The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Administrator) and Staff 3 (Quality Improvement LPN) on 06/11/25. They acknowledged the findings.

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 160, C 260, Z 142 and Z 162.

1. Refer to c160, c260, z142, and z162

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

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and outside areas were maintained in good repair. Findings include, but are not limited to: The inner courtyard was toured on 06/09/25 and the following was identified: * The cement pathway had several areas of cracks, uneven surfaces; * Drop offs exceeding 1 inch; and * The dumpster located outside of the building was not covered which could allow entry of rodents and other pests. The dumpster was full at the time of the survey. The environment was toured with Staff 4 (Director of Maintenance) on 06/10/25 and the need to ensure all exterior pathways and outside areas were maintained in good repair was discussed with Staff 1 (Administrator) on 06/11/25. They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior was kept clean and in good repair. Findings include, but are not limited to: The interior of the building was toured on 06/09/25. The following areas were identified as needing cleaning and repairs: * The carpet next to the activity room, near the kitchenette and dining area, and hallway near Room 411 had multiple stains; * The baseboards surrounding the activity room, adjacent hallway and in the dining room area had chips and gouges; * The baseboard at the kitchenette entrance was detached and coming off; * The door frame of Room 407 and Health Service room had chips and gouges; * The ceiling vent at the entrance to the unit, near the laundry room and Room 413 had a layer of dust; * The wall at the entrance to the kitchenette had wallpaper that was coming off; * There was a strong urine odor throughout the facility; * Right outside of Room 423, there was an uncovered light fixture with exposed wires; and * Room 414 was missing a bathroom door. The environment was toured with Staff 4 (Director of Maintenance) on 06/10/25 and the need to maintain the interior of the facility free from unpleasant odor, clean and in good repair was discussed with Staff 1 (Administrator) on 06/11/25. They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to locks on bathroom doors for residents who had shared bathrooms. Findings include, but are not limited to: a. The facility had four double-occupancy rooms, with two residents residing in each room during the survey. During an observation on 06/09/25, it was noted the shared bathrooms had no locking mechanism on the door to ensure resident privacy. b. The double - occupancy room did not have a curtain, screen or divider to provide privacy when one of the residents was receiving incontinent care or personal care. The inability to lock the bathroom door for residents who shared the bathroom and used it for their toileting needs raised residents’ rights to privacy and dignity concerns. The observations were reviewed with Staff 1 (Administrator) and Staff 4 (Director of Maintenance) on 06/10/25 and 06/11/25. They acknowledged the findings.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: Review of records for Residents 1, 2 and 3 showed no documented evidence the residents had been provided a key to their rooms or had been evaluated for the ability to manage keys to their rooms. During the survey on 06/09/25 through 06/11/25, observation and interviews with staff confirmed residents did not have keys to their units. The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Administrator) and Staff 4 (Director of Maintenance) on 06/10/25 and 06/11/25. They acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to ensure Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections were posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. Findings include, but are not limited to: Refer to: C 152.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by:

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (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. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure the move-in evaluation addressed all required elements, including pronouns and gender identity, for 1 of 1 resident (# 4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (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. 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 C152, C160, C200, C231, C360, C362, C363, C372, C420, C422, C510 and C513.

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. This is a repeat citation. Findings include, but are not limited to: Refer to C 160.

Refer to c160

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 4, 7, 9 and 19) completed all required pre-service orientation, 2 of 3 staff (#s 7 and 9) completed pre-service dementia training, 3 of 3 staff (#s 7, 9 and 19) completed competency training within 30 days of hire, 3 of 3 sampled direct care staff (#s 6, 10 and 14) had the required annual infection disease training, and 2 of 3 sampled direct care staff (#s 6 and 10) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to: The facility’s training records were reviewed on 06/10/25 and 06/11/25 with Staff 2 (Assistant Executive Director/Business Office Manager). The following was identified: a. Staff 4 (Director of Maintenance), hired 01/07/25, Staff 7 (CG), hired 03/27/25), Staff 9 (CG) hired 04/15/25 and Staff 19 (CG) hired 04/29/25. There was no documented evidence the staff had completed orientation and the pre-service training on one or more of the following required topics: * Resident rights and values and CBC care; * Abuse reporting requirements; * Fires safety and emergency procedures; * Infectious Disease Preventions; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. Staff 7 (CG), hired 03/27/25 and Staff 9 (CG) hired 04/15/25. There was no documented evidence the staff had completed the pre-service dementia training on one or more of the following required topics: * Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging person with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety f residents with dementia including addressing pain, providing food/fluids, preventing wandering, sue of 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, including an orientation to the resident’s service plan; and * Use of supportive deices with restraining qualities in memory care communities. c. Staff 7 (CG), hired 03/27/25, Staff 9 (CG) hired 04/15/25 and Staff 19 (CG) hired 04/29/25. There was no documented evidence staff had demonstrated competency in one or more of the following required topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. d. Staff 6 (MA) hired 12/20/16, Staff 10 (MA) hired 03/13/25 and Staff 14 (CG) hired 07/11/19. There was no documented evidence staff had completed the required annual infection disease training. e. Staff 6 (MA) hired 12/20/16 and Staff 10 (MA) hired 03/13/23. There was no documented evidence staff had completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training, within their anniversary date of hire. The facility failed to ensure all required training was completed and staff demonstrated competency was discussed with Staff 1 (Administrator) and Staff 2 on 06/11/25. They acknowledged the findings.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C262, C270, C303 and C310.

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

Refer to c260

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

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service plan for 1 of 3 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2022 with diagnoses including dementia and osteoporosis. During the survey Resident 1 required assistance to eat and drink and could not initiate requesting food or fluids. Resident 1’s service plan dated 06/05/25 noted Resident 1 was at risk for aspiration and required pureed food and nectar thick liquids for safety. The service plan lacked any other information or individualized instructions related to preferences, snacks, or hydration. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) on 06/11/25. He acknowledged the findings.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to individually identify resident’s rooms to assist residents in recognizing their room. Findings include, but are not limited to: The memory care facility was toured on 06/09/25. Residents’ rooms 405, 408, 410, 418 and 424 lacked any means of identifying the room for the resident. All of these rooms were occupied at the time of survey. The need to ensure each resident room was identified for the resident was reviewed with Staff 1 (Administrator) on 06/11/25. He acknowledged the rooms lacked identification.

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: