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 immediately report abuse relating to resident to resident altercations, ensure incidents were immediately investigated to rule out abuse or suspected abuse, and report to the local SPD (Seniors and People with Disabilities) office when abuse could not be reasonably ruled out for 3 of 5 sampled residents (#s 2, 5, and 7) who had documented incidents. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 03/2023 with diagnoses including Type 2 diabetes. The resident’s service plan dated 03/27/25; progress notes and Customer Compliment/Grievance Form dated 03/25/25 to 06/23/25 were reviewed. Progress notes indicated Resident 2 experienced the following incidents: * 05/19/25: Left index finger was red, "skin was broken", and "tender" with the resident having no recollection as to what occurred; * 05/21/25: Verbal resident to resident altercation in which an unsampled resident "was crying and has reported that [s/he] lives in this building in fear [of Resident 2]"; * 06/12/25: Verbal resident to resident altercation with threats to "punch" another resident; and * 06/13/25: Verbal resident to resident in which another resident attempted to spin Resident 2's wheelchair around and made "fist gestures" at him/her. There was no documented evidence the incident on 05/19/25 was immediately investigated to rule out abuse nor was there documented evidence the three verbal resident to resident altercations were immediately reported to the local SPD office. Documentation that the facility reported the three resident to resident verbal altercations was provided to the survey team on 06/24/25 at 3:01 pm. The need to ensure incidents of abuse or suspected abuse were immediately investigated and resident to resident altercations were immediately reported to the local SPD office was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 2:45 pm on 06/25/25. They acknowledged the findings. 2. Resident 5 moved into the facility in 03/2023 with diagnoses including pain and tremors. The resident’s service plan dated 03/27/25; and progress notes, dated 03/27/25 through 06/16/25, were reviewed. Progress notes indicated Resident 5 experienced the following incident: * 06/13/25: Verbal resident to resident in which the resident attempted to spin another resident's wheelchair around and made "fist gestures" at the other resident. There was no documented evidence the resident to resident altercation was immediately reported to the local SPD office. Documentation that the facility reported the resident to resident verbal altercation was provided to the survey team on 06/24/25 at 3:01 pm. The need to ensure resident to resident altercations were immediately reported to the local SPD office was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 2:45 pm on 06/25/25. They acknowledged the findings. 3. Resident 7 moved into the facility in 07/2021 with diagnoses including mild neurocognitive disorder, scoliosis, and degenerative disc disease. The resident’s service plan dated 03/12/25; progress notes, incident reports, investigations, and ADL logs dated 02/25/25 to 06/23/25 were reviewed. The resident’s service plan indicated staff were responsible for administering his/her medications. The resident was identified as a high fall risk and had a history of falls. Progress notes indicated the resident experienced the following incidents: * 03/31/25 – medication error; and * 05/22/25 – unwitnessed injury fall. There was no documented evidence the above incidents were promptly investigated to rule out abuse. The need to ensure incidents of abuse or suspected abuse were promptly investigated was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 1:40 pm on 06/25/25. They acknowledged the findings, and no further information was provided.

1. The Administrator reviewed each event for Resident's #2, 5 and 7 and another Unsampled resident that had the Potential to be abuse/neglect and reported it to the APS while state survey was being conducted . 2.Administrator or Designee will review each event that has the potential to be abuse/neglect. That person will complete the investigation in a timely manner and sign it off as complete or report it out to APS. The administrator or designee will use the Abuse decision tree from DHS when reviewing incidents to determine tif they need to be reported. 3. This process will be used on all events that have the potential for abuse or Neglect. Daily at stand up and through incident reports management reviews all incidents. In addition, staff will call the manager in charge on off hours and the weekends to report any incidents. 4. The Administrator or Designee. Incident reports will be reviewed by the Quality Assurance committee to ensure compliance.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) who was newly admitted into the facility. Findings include, but are not limited to: Resident 3 moved into the facility in 05/2025 with diagnoses including rheumatoid arthritis. The resident’s Initial Screen and Service Plan document was reviewed, and the following elements were not addressed: * List of medications and PRN use; * Visits to health practitioners, emergency department, hospital or nursing facility in the past year; * Vital signs if indicated by diagnosis, health problems, or medications; * Cognition including memory and decision making abilities; * Personality including how the person copes with change or challenging situations; * Ability to understand and be understood; * Pain including pharmaceutical interventions and how the person expresses pain or discomfort; * Nutrition habits, fluid preferences, and weight if indicated; * List of treatments including the type, frequency, and level of assistance needed; * Complex medication regimen; * Smoking and the ability to smoke safely; * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, and room temperature; * Preferred name; * Preferred pronouns, and * Gender identity. The need to ensure all required elements were addressed on the move-in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 2:45 pm on 06/25/25. They acknowledged the findings.

1. The administrator has reviewed all the components as listed that were missing in the facilities Move in Evaluation Form and updated them to reflect the components are received and reviewed prior to move in. In Addition to this additional sections to reflect Gender indentity, preferred name and preferred pronouns are reflected. 2. The administrator will be using the updated Move in Evaluation form that has been cross referenced by the DHS CBC Resident Review Form for Every Potential new Residents. 3.Administrator will review the form atleast every 6 months and cross check for any changes per departments requirements. In addition, the Administrator will double check the answers to ensure all elements have been addressed prior to the new resident moving in. 4. The Administrator is responsible to make sure the Form is updated and Completed.

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 provided clear direction to staff regarding the delivery of services, were reflective of residents' current status, care needs and preferences and/or were implemented for 4 of 7 sampled residents (#s 2, 5, 6 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 09/2023 with diagnoses including chronic depression and chronic knee pain with arthritis of the knee. The resident’s service plan dated 03/13/25 and ADL logs dated 06/01/25 to 06/24/25 were reviewed, interviews with staff and the resident were conducted, and observations of the resident were made. The resident’s service plan was not reflective of current needs and preferences and/or did not provide clear direction to staff in the following areas: * Behavioral-Cognitive (irritability) related to what caused the behavior and interventions for staff; * Intentional weight loss; * Mobility related to use of transfer pole; * Personal care (bathing) related to refusals; * Preference related to gender of care provider for personal care; and * Skin. On 06/25/25 at 1:15 pm, the need to ensure service plans were reflective of current needs and preferences and/or provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor). They acknowledged the findings. 2. Resident 7 moved into the facility in 07/2021 with diagnoses including schizophrenia, bipolar disorder, scoliosis and degenerative disc disease. The resident’s service plan dated 03/12/25 and ADL logs dated 02/25/25 to 06/23/25 were reviewed, interviews with staff and the resident were conducted, and observations of the resident were made. The resident’s service plan was not reflective of current needs and preferences and/or did not provide clear direction to staff in the following areas: * Fall interventions; * Skin condition, including susceptibility for infections; * Surgical status; and * Hallucinations and delusions. The need to ensure the service plan was reflective of the resident’s needs and preferences and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 1:40 pm on 06/25/25. They acknowledged the findings. 3. Resident 2 moved into the facility in 03/2023 with diagnoses including Type 2 diabetes. The resident’s service plan dated 03/27/25, and progress notes dated 03/25/25 to 06/19/25, were reviewed. Interviews with staff and Resident 2 were conducted. The resident’s service plan was not reflective of current needs and preferences and/or did not provide clear direction to staff in the following areas: * Preference of staff not asking him/her questions in the dining room; * Staff are not to enter the resident's room if s/he does not verbally consent; * Direction to staff relating to the monitoring of siderails; * Specifics on when to empty Resident 2's garbage; * Instruction to staff relating to how to assist the resident if s/he falls and is on the floor; * Location of the epinephrine auto-injector pen (epi-pen); * What staff should monitor for relating to a blood thinner medication; * Person centered signs and symptoms of how Resident 2 exhibits hypoglycemia and hyperglycemia; * Conflicting information relating to the use of a Continuous Positive Airway Pressure (CPAP) or a Bilevel Positive Airway Pressure (BiPAP) machine; * Resident 2 will call staff when s/he needs assistance with his/her shoes, socks, and application of lotion; and * Interventions for staff to use when the resident becomes agitated with other residents. The need to ensure the service plan was reflective of the resident’s needs and preferences and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 2:45 pm on 06/25/25. They acknowledged the findings. 2. Resident 5 moved into the facility in 03/2023 with diagnoses including pain and tremors. The resident’s service plan dated 03/27/25; and progress notes, dated 03/27/25 through 06/16/25, were reviewed. Interviews with staff and Resident 5 were conducted. The resident’s service plan was not reflective of current needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: * Assistance needed to care for his/her personal items; * Provide assistance making phone calls; * What triggers his/her behaviors and how staff try to negate the behaviors; * High stimulus areas and how it effects Resident 5; * The resident's routine relating to meals; and * Toileting assistance. The need to ensure the service plan was reflective of the resident’s needs and preferences, provided clear direction to staff regarding the delivery of services, and was being implemented was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 2:45 pm on 06/25/25. They acknowledged the findings.

1.The Administrator and RN's reviewed Service plans for sampled residents # 2,5,6 and 7 and updated them to reflect current care needs. 2.Administrator or designee will conduct a training with staff members who are completing service plans with an emphasis on specific interventions that are current and reflective of each residents care needs. Housing leadership will review the resident Roster and determine which service plans need an immediate review due to complex nature of the resident and clear direction for Staff regarding delivery of services. Those Service plans will be reviewed in the next 45 Days. All service plans will be reviewed by the management team and make any necessary changes prior to the AOC date of 08/24/25. All others will be reviewed at next regular scheduled Service plan review date and or Change of condition which ever comes first. 3.Administrator or designee will review service Plans for accuracy and to ensure they are reflective and specific to each resident. 4.Administrator or designee will Audit 5% of service Plans each Month to ensure compliance is maintained.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition had actions or interventions determined, documented, and communicated to staff on each shift with weekly progress noted to resolution for 3 of 6 sampled residents (#s 2, 5, and 7) who had short-term changes of condition. Resident 7 continued to experience falls and sustained a right knee injury. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 07/2021 with diagnoses including mild neurocognitive disorder, scoliosis, and degenerative disc disease. The resident’s care plan dated 03/12/25, and incident reports, progress notes and ADL logs dated 02/28/25 to 06/23/25 were reviewed. The following was identified: The resident’s care plan indicated s/he was at increased risk for falls and listed the following interventions: * CG to encourage Resident 7 to wear panic button at all times; * CG to assist resident in keeping pathways clear and uncluttered; * CG to encourage resident to change positions slowly; and * CG to encourage nightlight in bathroom at night for safety. Progress notes indicated the resident experienced the following falls: * 02/28/25: Unwitnessed non-injury fall. Staff documented Resident 7 reported s/he was sleepwalking while rolling cigarettes and fell over backwards; * 03/29/25: Unwitnessed non-injury fall. Staff documented the resident reported s/he fell but there was no description of the fall documented in the resident’s record; and * 05/22/25: Unwitnessed injury fall with right knee wound. Staff documented the resident reported s/he slid across the carpet and ran into the trash can in his/her room. There was no documented evidence the above falls had actions or interventions determined, documented, and communicated to staff on each shift. There was no documented evidence prior fall interventions were reviewed for effectiveness and new interventions developed as needed. There was no documented evidence the 05/22/25 fall was monitored with weekly progress noted to resolution. In an interview at 1:40 pm at 06/25/25, Staff 1 (Administrator) confirmed the lack of documentation. Observations of Resident 7’s room made on 06/24/25 revealed a clear pathway from the resident’s front door to the back sliding glass door; however, small items such as tissue boxes were observed to be placed on the floor near the resident’s side table. The resident was observed running into them while ambulating about the room. During an interview at the same time, the resident noted s/he “had balance problems” and confirmed the history of falls; however, Resident 7 could not provide details regarding the most recent fall on 05/22/25 when asked. In an interview at 11:36 am on 06/25/25, Staff 10 (CG) stated she was aware the resident was a fall risk but was not able to identify any fall interventions. In an interview at 12:02 pm on 06/25/25, Staff 7 (CG) stated she was not aware the resident had a history of falls or that she was a fall risk. The facility's failure to evaluate the resident after each fall, determine actions or interventions, communicate the interventions to staff, and monitor the effectiveness of previously established fall interventions put the resident at risk for repeated falls, resulting in a fall with a right knee wound. The need to ensure actions and interventions were determined, documented, communicated to staff on each shift with weekly progress noted to resolution for short-term changes of condition was discussed with Staff 1 and Staff 2 (Resident Care Supervisor) at 1:44 pm on 06/25/25. They acknowledged the findings, and no further information was provided. 2. Resident 2 moved into the facility in 03/2023 with diagnoses including Type 2 diabetes. The resident’s service plan dated 03/27/25, and progress notes dated 03/25/25 to 06/19/25, were reviewed. Interviews with staff and Resident 2 were conducted. The following changes of condition lacked documented evidence actions or interventions were determined, documented, and communicated to staff on each shift, and/or monitored through resolution: * 05/19/25: Left index finger was red, "skin was broken", and "tender"; * 05/21/25: Verbal resident to resident altercation; * 06/12/25: Verbal resident to resident altercation with threats to "punch" another resident; and * 06/13/25: Verbal resident to resident in which another resident attempted to spin Resident 2's wheelchair around and made "fist gestures" at him/her. On 06/23/25 at 2:12 pm, the resident confirmed that his/her left index finger was almost healed. Resident 2 had an upcoming appointment during the first part of July, 2025 at the on-site clinic and planned to “have it looked at” if s/he had any concerns. The need to ensure changes of condition had documented evidence actions or interventions were determined, documented, and communicated to staff on each shift as well as monitored with progress noted through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 2:45 pm on 06/25/25. They acknowledged the findings. 3. Resident 5 moved into the facility in 03/2023 with diagnoses including pain and tremors. The resident’s service plan dated 03/27/25; and progress notes, dated 03/27/25 through 06/16/25, were reviewed. Interviews with staff and Resident 5 were conducted. The following changes of condition lacked documented evidence actions or interventions were determined, documented, and communicated to staff on each shift, and/or monitored through resolution: * 04/08/25: Left eye pain; and * 06/13/25: Resident to resident altercation. On 06/25/25 at approximately 10:00 am, Staff 13 (MT/CG) stated she had not been made aware to monitor the resident’s eye pain and verified Resident 5 had “many medications” for his/her eyes. She was aware of the resident’s behaviors but there was “nothing specific” relating to the incident with another resident. The need to ensure changes of condition had documented evidence actions or interventions were determined, documented, and communicated to staff on each shift as well as monitored with progress noted through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 2:45 pm on 06/25/25. They acknowledged the findings.

1. Administrator and RN's reviewed changes of conditions for sampled Residents #2,5 and 7 and determined if a change of condition was still current and if so placed new interventions in place after determining effectiveness of prior interventions. 2. Housing Leadership will Review the change of condition practices at Housing all direct care staff meeting on 07/9 and 07/16 respectively as well and all staff meeting on 07/30 to ensure that changes of condition and monitoring are communicated and documented Timely. RN manager will review the facility policy in regards to Temporary and significant change in conditions and training to include Identification, reporting, monitoring, documentation and communication about changes and Housing leadership will review residents with potential changes in condition or need for increased monitoring atleast 2X per week with housing RN. Housing RN will be responsible for documentation. Administrator will Audit. 3. Management will review weights, service plans, ADLs, skin, falls, etc., prior to the AOC date. After that is completed, the Administrator will Audit 5% of the charts Monthly. 4. Please see above #3.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services. Findings include, but are not limited to: Observations of meal service were conducted from 06/23/25 through 06/25/25 and the following was identified: a. Staff were observed serving meals and beverages, entering and exiting resident apartments, touching residents, and removing dirty dishes without changing their gloves and/or performing hand hygiene between dirty and clean tasks. b. Direct care staff were observed serving food to residents without donning a protective barrier over potentially contaminated clothing. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene and the use of protective barriers over potentially contaminated clothing while serving meals to residents, was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) on 06/25/25 at 2:03 pm. The findings were acknowledged.

1. The Administrator has Met with all Staff including Dietary and Direct care staff and reviewed infection prevention practices.Staff have been educated about proper donning and doffing of gloves , hand hygiene high risk surface areas. Staff have been referred to Oregon care partners training for Infection control and Food safety. Administrator has purchased and implemented Aprons while direct care staff are handling food and meal delivery to rooms. 2. The administrator or designee ( food service lead) will ensure that at all meal times these hygienic practices and aparatus are used and followed in the dining room as well as food and beverage delivery to residents rooms. 3.Administrator and designee will evaluate to ensure this practice is followed at all meal times for the next 14 days, then random days and meal times thereafter. 4. Please see above #3.

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

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the staff person who administered the medication visually observed the resident take the medication unless the prescriber's order for that specific medication stated otherwise for 2 of 6 sampled residents (#s 4 and 7) whose medications were administered by the facility. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 08/2024 with diagnoses including hypothyroidism and developmental disability. The resident’s 06/01/25 to 06/23/25 MAR and current physician orders were reviewed, the resident and staff were interviewed, and observations of the resident were made. The following was identified: During an interview with Resident 4 at 11:02 am on 06/25/25, a medication cup with brown liquid was observed on the resident’s bedside table. The resident stated the medication was “my iron” and staff assisted him/her in mixing it with tea. S/he further confirmed staff left the medication with him/her “often” and did not observe the resident taking the medication. In an interview at 11:27 am on 06/25/25, Staff 9 (MT) stated Resident 4 received levothyroxine (for hypothyroidism) mixed with tea in the morning and confirmed that staff “sometimes” left the medication without observing the resident take the medication. Review of the resident’s current signed physician orders indicated there were no signed orders to leave medications without observing the resident take them. The need to ensure the staff person who administered the medication visually observed the resident take the medication unless the prescriber's order for that specific medication stated otherwise was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 1:40 pm on 06/25/25. They acknowledged the findings, and no additional information was provided. 2. Resident 7 moved into the facility in 07/2021 with diagnoses including schizophrenia. The resident’s 06/01/25 to 06/23/25 MAR and current physician orders were reviewed, the resident and staff were interviewed, and observations of the resident were made. The following was identified: During an interview with Resident 7 at 10:02 am on 06/24/25, a medication cup with a pill in a foil packet was observed on his/her side table. The resident stated the medication was asenapine (for schizophrenia) and confirmed staff left the medication without observing him/her take it “all the time.” In an interview at 10:46 am on 06/24/25, Staff 9 confirmed staff left the asenapine medication for Resident 7 without observing him/her take it. Review of the resident’s current signed physician orders indicated there was no order for staff to leave the asenapine without observing the resident take the medication. The need to ensure the staff person who administered the medication visually observed the resident take the medication unless the prescriber's order for that specific medication stated otherwise was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 1:40 pm on 06/25/25. They acknowledged the findings, and no additional information was provided.

1.The Administrator has reviewed the medication for residents # 4 and 6. Medical team have been notified about prt preferences for self med and Physicians orders have been obtained.The administrator and Resident care supervisor will review the medication policy with all staff administering medications on 07/16/2025. 2. The administrator or RCS will provide medication training via Oregon care partners and conducting annual audits for the staff administering medications. 3. The RCS and RN to review medication orders as received and quartely. RCS will meet with med administering staff on monthly basis to review administration and medication policies and procedures 4. Please see Above #4.

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. 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 the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in and no less than quarterly at the same time of service plan update for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6, and 7) and multiple unsampled residents. Findings include, but are not limited to: The facility’s ABST was reviewed on 06/23/25 at 11:15 am and the following was identified: a. One unsampled resident who was identified on the facility’s resident roster was not reflected in the facility’s ABST. b. Six unsampled residents as well as Resident 3 did not have their information in the ABST prior to moving into the facility. c. Twenty-six residents, including Resident 1, 2, 4, and 6, had their ABSTs updated on 03/03/25, which was not quarterly at the same time as their service plans. d. Twelve residents, including Resident 5, had their ABSTs updated on 03/04/25, which was not quarterly at the same time as their service plans. The need to ensure residents’ ABST evaluations were updated before move-in and no less than quarterly with the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Supervisor) at 2:45 pm on 06/25/25. They acknowledged the findings.

1. The Administrator has reviewed Findings on all the 7 of 7 residents. Abst tracking tool in conjuction with service Plan tracking has been implemented so that both of the items mentioned are updated at the same time quartely or at change of condition to meet the departments rule. Abst tracking has been added to the move in check in list so that abst is update prior to resident move in.Resident that was not tracked in the ABST has been identified and added to the ABST . 2.The Administrator and RN will work together to discuss residents potentially needing change of condition and completed service plans Quartely and update ABST at the same time service plan has been completed. 3. The Administrator will be evaluating and updating for any new move ins at a minimum of 1 week prior to any new move in. Administrator will update ABST quartely or at every significant change of condition. 4. The Administrator is responsible for updating staffing tool.

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics had been completed prior to staff providing direct care to residents for 1 of 1 newly hired staff (# 20) whose training records were reviewed. Findings include, but are not limited to: Training records were reviewed on 06/23/25 and revealed the following: Staff 20 (MT), hired on 12/16/24, lacked documented evidence of having completed the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; and * Fire safety and emergency. The need to ensure newly hired staff completed all required pre-service orientation training was discussed with Staff 1 (Administrator) on 06/23/25. He acknowledged the findings.

1. The Administrator has reviewed findings about preservice education and training . Administrator has implemented a checklist and tracker to ensure all Department required training is implemented in timely manner within the timeline as specified.Administrator has conducted an Audit and all staff identified as not in compliance have been provided with Links to regon care partners for training material to be completed no later than 7/31/2025. 2. Administrator or designee will use the check list for every new hire upon hire and annually for existing staff. 3. Please see #2 above. This will be reviewed upon hire and during the orientation time period, prior to newly hired staff working with residents independently. 4. Administrator will review all required training materials and its completion at orientation.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (# 20) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 06/23/25 and revealed the following: There was no documented evidence Staff 20 (MT), hired 12/16/24 demonstrated competency in all assigned job duties within 30 days of hire in the following areas: * 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 which require assessment, treatment, observation, and reporting; and * General food safety, serving and sanitation. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) on 06/23/25. He acknowledged the findings.

1. Staff 20 has completed all required annual training. 2. Administrator will perform and audit of all competency requirements and will ensure that all competencies are completed.Administrator wil utilize a competency checklist and sign off on completion prior to caregiver starting work on the floor. 3. Administrator will review together with RCS prior to work start date. Newly hired employees will print out their checklist so that the Administrator will put it in their file. After the training is received, the new employee will be added to the schedule. 4.Administrator will review for completion of competencies.

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

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure and document 3 of 3 long-term staff (#s 12, 6, and 11) completed 12 hours of annual in-service training, including at least six hours of dementia care and one hour of infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 06/23/25 and revealed the following: There was no documented evidence Staff 12 (CG), Staff 6 (CG), and Staff 11 (MT), hired 12/13/21, 03/29/21, and 07/12/21, respectively, completed at least 12 hours of training related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics and at last one hour of infectious disease training within their anniversary date of hire. The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training and annual infectious disease training was discussed with Staff 1 (Administrator) on 06/23/25. He acknowledged the findings.

1.Staff 12,6 and 11 Have completed all required 30 day competencies. 2. Administrator will perform an audit of all annual training requirements and will ensure that all training is completed. Administrator will develop an annual training checklist and sign off on completion. 3. Administrator will review monthly based on date of Hire by using a tracking system. 4. Administrator will review monthly.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements and provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to: Fire and life safety records, dated 10/04/24 through 05/08/25, were reviewed on 06/24/25. The following was identified: a. Fire and life safety instruction was not provided to staff on alternating months of the fire drills. b. Fire and life safety records lacked documentation of the following components: * Fire and life safety training for staff did not include topics related to fire drills or responses to other common emergencies; * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. On 06/24/25 an interview with Staff 1 (Administrator) revealed the facility was not relocating or evacuating residents as part of the fire drill process. The need to ensure the facility conducted and documented fire drills according to the Oregon Fire Code (OFC) and the requirements for fire and life safety training for staff on alternating months were reviewed with Staff 1 on 06/24/25. He acknowledged the findings.

1. Administrator will ensure that all components required in OAR 411-054-0090 (1)(a-d) are included in each fire drill or life safety training and in the documentation of those drills and trainings. Administrator will ensure that residents are Physically evacuated and or documented for those resisting.Signatures will be obtained for record purposes for those residents participating in the drills Annually. 2. Please see #1 above. 3.Administrator will conduct Fire drills every other month and then safety trainings opposite months from fire drills. This will be reviewed monthly either after the fire drill or after the fire and life safety training. 4. Administrator and or Admin assist.

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 411-054-0200 (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 the grounds were orderly and free of litter and refuse, garbage was stored in covered refuse containers, chemicals and toxic materials were secured in locked storage. Findings include but are not limited to: The facility grounds and interior of the Residential Care Facility (RCF) was toured on 06/23/25 and 06/24/25, and observations were made throughout the survey. The following was identified: a. Building interior: * Cleaning chemicals were stored in an unlocked room next to the medication room on the sunflower court hallway. b. Building exterior: * An uncovered garbage dumpster containing bagged garbage; * Surrounding the dumpster were two mattresses, broken furniture, a bedside commode, wood pallets, cardboard boxes and wood planks; * Litter and refuse throughout the grounds; * Multiple cigarette butts were on the ground in front of the smoking area; * A covered patio area of the interior courtyard had a worn stained wood storage closet, a mop and broom were propped against the wall, and a grey plastic storage bin was full of empty boxes; * The patio walkway area was covered with fallen cherries and pits; * On the west side of the interior courtyard, under a flower box were pieces of a sprinkler; * On the west side of the interior courtyard, tangled cable wires were hanging below the gutter; * The brick trim on the west side of the interior courtyard was covered with clumps of moss; * On the west side garden area of the zone nine building, an open metal stand had four bottles of chemicals/toxins, and a shredded silver tarp; * On the west side garden area of the zone eleven building, several garden tools including a hoe, pitchfork and shovels were propped against the building; * The pathway of the zone ten and eleven buildings had debris which included: - an inoperable motorized scooter; - dirty and worn plastic chairs and lounge chair; - a worn and rough wood chair; - a tangled garden hose; - exposed, loose cable wires; and - a worn and rough wood post with an attached broken birdhouse. The findings were reviewed in a tour of the facility on 06/24/25 at 10:20 am with Staff 1 (Administrator). The need to ensure all chemicals, and other toxic materials were stored in locked storage, and to ensure the grounds were free of litter and refuse and refuse containers were covered, was discussed with Staff 1 on 06/24/25. He acknowledged the findings.

1. Administrator will ensure that items listed in the survey are removed or repaired. Administrator will educate residents about how to get rid of unwanted items and identify a designated area to store before Junk removal is done monthly.Administrator has reached out to the property manager and scheduled for the building exterior to be power washed. Administrator has provided education about cleaning chemicals and the importance of making sure houskeeping closets to remain closed and not accessible by residents for their safety. 2. Administrator will perform monthly checks of the building Exterior to ensure grounds are clear of litter, refuse and ensure pathways are accessible.Administrator will Conduct weekly checks to ensure all chemicals remain locked and stored safely and only used when a staff member is present. 3.Monthly by the Administrator or Designee. 4. Administrator.

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 and exterior of the facility environment was clean and maintained in good repair. Findings include, but are not limited to: The facility was toured on 06/23/25 and 06/24/25 and the following was observed: a. Interior of the building: * The visitor bathroom near the dining room had black scuff marks on the wall and the inside of the door had multiple gouges and scrapes. b. Exterior of the building: * The siding of the zone ten and eleven buildings facing the pathway was dirty; and * The roof of the zone ten and eleven buildings had clumps of moss, sticks, and clogged gutters. On 06/24/25 at 10:20 am, an environment tour was conducted with Staff 1 (Administrator). The need to ensure the interior and exterior of the building was clean and maintained in good repair was discussed with Staff 1 (Administrator) on 06/24/25. He acknowledged the findings.

1. Administrator will work with maintenance Team to repair issues listed in the survey document. 2.Administrator will conduct an internal and external building review monthly and work with maintenance team on any needed repairs. 3. Monthly. 4.Administrator or designee.

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:

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 preferred name, pronouns, and gender identity, for 1 of 1 sampled resident (# 3) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

Please refer to C252. This information has been corrected in the resident Move in evaluation form.

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: