OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure incidents or injuries of unknown cause were immediately investigated to rule out abuse or suspected abuse, and report to the local Seniors and People with Disabilities (SPD) office when abuse could not be ruled out for 1 of 3 sampled residents (# 3) whose records were reviewed. Findings include, but are not limited to: Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance. The resident’s record was reviewed, including the current service plan, dated 03/12/25, Progress Notes, dated 03/12/25 through 06/17/25, outside provider visit documentation, dated 05/25/25 through 06/23/25, 24-hour reports, dated 04/28/25 through 06/22/25, and Incident Reports dated 04/15/25 through 05/18/25. Interviews with staff were conducted, and the following was identified: a. On 05/16/25, a “large bruise” was identified on Resident 3’s “right side of thigh.” An incident report dated 05/18/25 was initiated; however, the report lacked documented evidence abuse and neglect was ruled out. b. On 06/16/25, an outside provider documented the resident had “toe sores on both feet.” Staff 1 (Administrator) and Staff 5 (Registered Nurse) reported they were unaware how the resident acquired the toe sores. There was no documented evidence the facility investigated the injury of unknown cause or reported the injury to local SPD. c. On 06/25/25 at 12:30 pm, Staff 5 evaluated Resident 3’s feet and lower legs. At that time, she identified multiple small scabs on the resident’s right shin and one scab, approximately one inch in length, on the resident’s outer left leg beside the knee. Staff 1 and Staff 5 reported they were unaware how the resident acquired the injuries. There was no documented evidence the above injuries of unknown cause were immediately investigated to rule out abuse or suspected abuse or were reported to the local SPD if abuse could not be ruled out. On 06/25/25 at 3:28 pm, the above injuries of unknown cause were reviewed with Staff 1. She confirmed the incidents were not reported to the local SPD. Survey requested the facility report the injuries of unknown cause to the local SPD. Confirmation of the report was provided at 4:08 pm. The need to ensure incidents or injuries of unknown cause were immediately investigated to rule out abuse or suspected abuse and reported to the local SPD office when abuse or neglect could not be ruled out, was reviewed with Staff 1 and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action 1. An incident report and investigation was created for resident #3 regarding toe sores (6/16/25), scabs on right shin and left outer leg beside knee (6/25/25). Both incidents for resident #3 including bruise dated 5/16/25 were reported to SPD office on 6/25/25 2. The administrator/designee will be provided with training on accident and incident investigations and reporting; All accidents/incidents will be comprehensively investigated in a timely manor. When abuse and neglect cannot be ruled out, or for injuries of unknow origin, DHS abuse Neglect Reporting requirements will be followed. 3.All incidents will be reviewed daily, at weekly clinical meetings, and monthly using the Administrator Quality Assurance audit. All incidents will be verified to confirm: a) Investigation is comprehensive, b)Notifications are made, c) Self-reporting ruled out or self-report is completed, d) Interventions or remedies are implemented to reduce reoccurrence or severity of injury. The Administrator on record will review and confirm all components of the investigatory process have occurred and the investigation was documented timely. 4.The Administrator and/or designee will be responsible to ensure the corrections are completed/monitored with over sight from the Regional Director of Operations.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large. Findings include, but are not limited to: During the survey the facility was home to 27 residents living in three houses of 9 residents each. Resident observations were made in each house from 06/23/25 to 06/26/25, the activity calendar was reviewed, and staff and residents were interviewed. The following was revealed: 1. The June 2025 Activity Program calendar provided to the survey team indicated the following activities would occur on 06/23/25: * Morning Motivation; * Pledge of allegiance; * Storyline; * This day in history; * Chair exercises; and * Sing-a-long. Observations of all three houses and interviews with staff confirmed none of the scheduled activities occurred on 06/23/25. 2. On 06/24/25 the activity calendar noted the following activities would occur in the morning: * Morning Motivation; * Pledge of allegiance; * Storyline; * This day in history; * Sit and sip; and * Poetry. Observations of all three houses and interviews with staff confirmed none of the scheduled activities occurred on 06/24/25. During an interview on 06/25/25 at 1:00 pm, Staff 7 (Universal Worker) reported she would try to provide activities if she had time and if there were enough staff. Staff 7 confirmed they had not been able to provide any activities over the weekend, Monday 06/23/25, Tuesday 06/24/25, or on Wednesday 06/25/25. The requirement to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 2:00 pm. They acknowledged the findings.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities 1)Activity Coordinator left during survey for a pregnancy related concern. An interim Activity Coordinator was appointed to this position until Activity Coordinator returns from maternity leave. 2)Training is being completed with Interim Activity Coordinator for this position. Training will include individual and group interests,physical, mental and psychosocial needs and creating opportunities for active participation in the community. Training and Review of processes and documentation of the activities program will be completed with Administrator /Designee and Interim Activity Coordinator. 3) Activity program will be reviewed monthly using the Administrator Quality Assurance audit, as well as at resident council meetings with resident input. 4)The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs, provided clear direction regarding the delivery of services, and were implemented for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2021 with diagnoses including neoplasm of the brain and hemiplegia. The resident's service plan, dated 06/19/25, was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 06/23/25 and 06/27/25. a. Resident 1's service plan was not reflective and/or did not provide clear direction to staff in the following areas: Smoking assistance; and Fall prevention. The need to ensure service plans were current and provided instructions for staff was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 2 pm. They acknowledged the findings. ?2. Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance and insomnia. During the survey the resident was observed to receive assistance from two direct care staff with transfers, repositioning after transferring into bed, and bowel and bladder management. Resident 3 also was observed to receive as-needed assistance from one direct-care staff during meals with verbal cuing and/or hand-over-hand assistance. The resident’s record was reviewed, including the current service plan, dated 03/12/25, and outside provider visit documentation. Interviews with staff were conducted and observations were made. The following was identified: The service plan was not reflective of the resident’s current status, lacked clear instruction regarding the delivery of services, and/or was not implemented in the following areas: * Nutrition and weight loss instruction that included how staff prepared the resident’s meals, assistance required during meals, use of daily nutritional shakes, and high calorie snacks between meals; * Fall prevention instruction and use of assistive devices including a hospital bed, fall mat, and gait belt; * Transfer assistance instruction that included number of staff needed and use of a gait belt; * Incontinence care and toileting instruction that included frequency of checks, number of staff needed, as-needed incontinence care while resident was in bed, and use of assistive devices including a gait belt, large reusable bed pad, and commode; * Repositioning instruction when the resident was in bed and his/her wheelchair that included frequency of repositioning, number of staff needed, and assistive devices used, including pillows, a foam cushion for wheelchair, large reusable bed pad, bed cane, and gait belt; * Skin conditions and instruction for care; * Nighttime needs that included behavioral interventions for when the resident was experiencing insomnia; * Shower assistance instruction, including as-needed bed baths; and * Emergency response instruction, including number of staff needed. The need to ensure the service plan was reflective of the resident’s current status, provided clear instruction regarding the delivery of services, and was implemented was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1) Resident #1's service plan will be updated to reflect;smoking assistance and fall prevention, including clear direction on providing services. Resident #3 has passed away on hospice services. 2)The Administrator/Designee will be provided training on resident service plans and all required components; including training to ensure the service plan is reflective of residents needs and provides clear direction regarding the delivery of services. 3) All resident service plans will be completed at least quarterly or with a change of condition to reflect the residents current needs with clear direction regarding the delivery of services. This will be monitored monthly with the Administrator Quality Assurance auit. 4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

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 residents who experienced changes of condition had resident-specific interventions developed and communicated to staff on each shift, with weekly progress noted until resolution, for 1 of 3 sampled residents (# 3) who experienced changes of condition. Findings include but are not limited to: Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance, glaucoma, and insomnia. The resident was observed to require assistance from two direct-care staff with transfers, repositioning after transferring into bed, and bowel and bladder management and assistance from one direct-care staff, as needed, during meals, including verbal cuing and/or hand over hand assistance. The resident’s record was reviewed, including the current service plan, dated 03/12/25, Progress Notes dated 03/12/25 through 06/17/25, outside provider visit documentation, 24-hour reports dated 04/28/25 through 06/22/25, and Incident Reports, dated 04/15/25 through 05/18/25. Interviews with staff were conducted and observations were made. The following changes of condition lacked documented evidence resident-specific interventions were developed, the determined interventions were communicated to staff on each shift, and were monitored through resolution: a. On 06/23/25 during an interview, Resident 3 was identified to have had weight loss and to receive hospice services. The resident received weekly weights and was noted to receive a regular diet. The residents record noted the following weights: * 05/13/25: 133.8 pounds; * 06/10/25: 125.0 pounds; and * 06/17/25: 123.5 pounds. From 05/13/25 through 06/17/25, Resident 3 experienced a total body weight loss of 10.3 pounds, or 7.69% of his/her total body weight, in one month. This constituted a severe weight loss and a change of condition. There was no documented evidence resident-specific interventions were developed and communicated to staff on each shift, with weekly progress noted until resolution. b. Documentation revealed the resident experienced the following additional changes of condition, and there was no documented evidence resident-specific interventions were developed, communicated to staff on each shift, and changes were monitored through resolution: * 04/27/25: unwitnessed fall; * 04/28/25: “pressure sore found on [resident’s] left butt cheek”; * 04/29/25: unwitnessed fall; * 05/16/25: “Large bruise on right side of thigh”; and * 06/16/25: “Open areas noted on the toes on right foot and great toe on left foot.” The need to ensure when a resident experienced a change of condition that resident-specific interventions were developed and documented, the determined interventions were communicated to staff on each shift, and changes of condition were monitored weekly through resolution was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1) RN completed Change of condition assessment of resident #3. Resident #3 passed away on hospice services. 2)Administrator/designee and Community RN will be provided training regarding resident changes of condition. Training will include, what a short term and Significant change of condition is, the process of addressing changes including; implementing a Temporary service plan, weekly monitoring notes, and resolution for the change of condition. 3)The system will be reviewed daily to ensure compliance is maintained through review of daily notes, EMR reports, monitoring reports, as well as weekly in clinical meetings, and monthly using Administrator Quality Assurance Audit. 4)The Administrator and/or designee and Registered Nurse will be respsonsible to ensure the corrections are completed and monitored, with oversight from the Regional Director of Operations.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and/or completed in a timely manner for 2 of 3 sampled resident (#s 2 and 3) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2020 with diagnoses including kidney disease stage 4 (severe) and type 2 diabetes mellitus. A review of the resident's clinical record dated between 03/23/25 and 06/22/25 identified the following: A progress note dated 06/17/25 stated Resident 2 “…returned from Urology appointment yesterday and [s/he] had a new indwelling catheter placed. Returned with no instructions.” The indwelling catheter placement constituted a significant change in condition requiring an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure the facility RN assessed all significant changes of condition in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:00 am. They acknowledged the findings. EX #2? BW? 2. Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance and insomnia. The resident’s record was reviewed, including Progress Notes, dated 03/12/25 through 06/17/25, and outside provider visit documentation. Interviews with staff were conducted, and observations were made. The following was identified: a. On 06/23/25 during the acuity interview, Resident 3 was identified to have recent weight loss. Throughout the survey, Resident 3 was observed to receive as-needed cuing and hand-over-hand assistance while eating meals. The resident’s record noted the following weights: * 05/13/25: 133.8 pounds; * 06/10/25: 125.0 pounds; and * 06/17/25: 123.5 pounds. From 05/13/25 through 06/17/25, Resident 3 experienced a total body weight loss of 10.3 pounds, or 7.69% of his/her total body weight, in one month. This severe weight loss constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. b. On 04/28/25 an outside provider noted “pressure sore found on [resident’s] left butt cheek” and documentation on 06/19/25 revealed the pressure sore was “stage 2,” which constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. On 06/25/25 at 11:52 am, Staff 5 (Registered Nurse) confirmed an RN assessment had not been completed for Resident 3’s severe weight loss or stage two pressure ulcer. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings. ? HEADER? &? EX #1? EB? Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and/or completed in a timely manner for 2 of 3 sampled resident (#s 2 and 3) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2020 with diagnoses including kidney disease stage 4 (severe) and type 2 diabetes mellitus. A review of the resident's clinical record dated between 03/23/25 and 06/22/25 identified the following: A progress note dated 06/17/25 stated Resident 2 “…returned from Urology appointment yesterday and [s/he] had a new indwelling catheter placed. Returned with no instructions.” The indwelling catheter placement constituted a significant change in condition requiring an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure the facility RN assessed all significant changes of condition in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:00 am. They acknowledged the findings. EX #2? BW? 2. Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance and insomnia. The resident’s record was reviewed, including Progress Notes, dated 03/12/25 through 06/17/25, and outside provider visit documentation. Interviews with staff were conducted, and observations were made. The following was identified: a. On 06/23/25 during the acuity interview, Resident 3 was identified to have recent weight loss. Throughout the survey, Resident 3 was observed to receive as-needed cuing and hand-over-hand assistance while eating meals. The resident’s record noted the following weights: * 05/13/25: 133.8 pounds; * 06/10/25: 125.0 pounds; and * 06/17/25: 123.5 pounds. From 05/13/25 through 06/17/25, Resident 3 experienced a total body weight loss of 10.3 pounds, or 7.69% of his/her total body weight, in one month. This severe weight loss constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. b. On 04/28/25 an outside provider noted “pressure sore found on [resident’s] left butt cheek” and documentation on 06/19/25 revealed the pressure sore was “stage 2,” which constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. On 06/25/25 at 11:52 am, Staff 5 (Registered Nurse) confirmed an RN assessment had not been completed for Resident 3’s severe weight loss or stage two pressure ulcer. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings. ? HEADER? &? EX #1? EB? Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and/or completed in a timely manner for 2 of 3 sampled resident (#s 2 and 3) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2020 with diagnoses including kidney disease stage 4 (severe) and type 2 diabetes mellitus. A review of the resident's clinical record dated between 03/23/25 and 06/22/25 identified the following: A progress note dated 06/17/25 stated Resident 2 “…returned from Urology appointment yesterday and [s/he] had a new indwelling catheter placed. Returned with no instructions.” The indwelling catheter placement constituted a significant change in condition requiring an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure the facility RN assessed all significant changes of condition in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:00 am. They acknowledged the findings. EX #2? BW? 2. Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance and insomnia. The resident’s record was reviewed, including Progress Notes, dated 03/12/25 through 06/17/25, and outside provider visit documentation. Interviews with staff were conducted, and observations were made. The following was identified: a. On 06/23/25 during the acuity interview, Resident 3 was identified to have recent weight loss. Throughout the survey, Resident 3 was observed to receive as-needed cuing and hand-over-hand assistance while eating meals. The resident’s record noted the following weights: * 05/13/25: 133.8 pounds; * 06/10/25: 125.0 pounds; and * 06/17/25: 123.5 pounds. From 05/13/25 through 06/17/25, Resident 3 experienced a total body weight loss of 10.3 pounds, or 7.69% of his/her total body weight, in one month. This severe weight loss constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. b. On 04/28/25 an outside provider noted “pressure sore found on [resident’s] left butt cheek” and documentation on 06/19/25 revealed the pressure sore was “stage 2,” which constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. On 06/25/25 at 11:52 am, Staff 5 (Registered Nurse) confirmed an RN assessment had not been completed for Resident 3’s severe weight loss or stage two pressure ulcer. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings. ? HEADER? &? EX #1? EB? Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and/or completed in a timely manner for 2 of 3 sampled resident (#s 2 and 3) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2020 with diagnoses including kidney disease stage 4 (severe) and type 2 diabetes mellitus. A review of the resident's clinical record dated between 03/23/25 and 06/22/25 identified the following: A progress note dated 06/17/25 stated Resident 2 “…returned from Urology appointment yesterday and [s/he] had a new indwelling catheter placed. Returned with no instructions.” The indwelling catheter placement constituted a significant change in condition requiring an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure the facility RN assessed all significant changes of condition in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:00 am. They acknowledged the findings. EX #2? BW? 2. Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance and insomnia. The resident’s record was reviewed, including Progress Notes, dated 03/12/25 through 06/17/25, and outside provider visit documentation. Interviews with staff were conducted, and observations were made. The following was identified: a. On 06/23/25 during the acuity interview, Resident 3 was identified to have recent weight loss. Throughout the survey, Resident 3 was observed to receive as-needed cuing and hand-over-hand assistance while eating meals. The resident’s record noted the following weights: * 05/13/25: 133.8 pounds; * 06/10/25: 125.0 pounds; and * 06/17/25: 123.5 pounds. From 05/13/25 through 06/17/25, Resident 3 experienced a total body weight loss of 10.3 pounds, or 7.69% of his/her total body weight, in one month. This severe weight loss constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. b. On 04/28/25 an outside provider noted “pressure sore found on [resident’s] left butt cheek” and documentation on 06/19/25 revealed the pressure sore was “stage 2,” which constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. On 06/25/25 at 11:52 am, Staff 5 (Registered Nurse) confirmed an RN assessment had not been completed for Resident 3’s severe weight loss or stage two pressure ulcer. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings. ? Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and/or completed in a timely manner for 2 of 3 sampled resident (#s 2 and 3) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2020 with diagnoses including kidney disease stage 4 (severe) and type 2 diabetes mellitus. A review of the resident's clinical record dated between 03/23/25 and 06/22/25 identified the following: A progress note dated 06/17/25 stated Resident 2 “…returned from Urology appointment yesterday and [s/he] had a new indwelling catheter placed. Returned with no instructions.” The indwelling catheter placement constituted a significant change in condition requiring an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure the facility RN assessed all significant changes of condition in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:00 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance and insomnia. The resident’s record was reviewed, including Progress Notes, dated 03/12/25 through 06/17/25, and outside provider visit documentation. Interviews with staff were conducted, and observations were made. The following was identified: a. On 06/23/25 during the acuity interview, Resident 3 was identified to have recent weight loss. Throughout the survey, Resident 3 was observed to receive as-needed cuing and hand-over-hand assistance while eating meals. The resident’s record noted the following weights: * 05/13/25: 133.8 pounds; * 06/10/25: 125.0 pounds; and * 06/17/25: 123.5 pounds. From 05/13/25 through 06/17/25, Resident 3 experienced a total body weight loss of 10.3 pounds, or 7.69% of his/her total body weight, in one month. This severe weight loss constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. b. On 04/28/25 an outside provider noted “pressure sore found on [resident’s] left butt cheek” and documentation on 06/19/25 revealed the pressure sore was “stage 2,” which constituted a significant change of condition and required an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. On 06/25/25 at 11:52 am, Staff 5 (Registered Nurse) confirmed an RN assessment had not been completed for Resident 3’s severe weight loss or stage two pressure ulcer. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services 1) RN completed Significant change of condition assessment on 6/26/25 for resident #2, including a new Temporary service plan, taught task training completed for catheter by RN. RN completed a significant change of condition assessment for resident #3 on 6/25/25, Temporary service plan implemented for pressure area left buttocks and scabs to legs, resident passed away on hospice services. 2)The RN will receive training regarding Changes of Condition using Oregon regulations and company policy. In addition the RN has enrolled in Leading Age "Nursing pratice in community based care" 9/9/25 through 9/11/25. 3)The system will be reviewed daily to ensure compliance is maintained through review of daily notes, EMR reports, monitoring reports, as well as weekly in clinical meetings, and monthly using Administrator Quality Assurance Audit. 4)The Administrator and/or designee and Registered Nurse will be respsonsible to ensure the corrections are completed and monitored, with oversight from the Regional Director of Operations.

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 establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 1 sampled resident (# 3) during ADL care. Findings include, but are not limited to: Resident 3 moved into the facility in 05/2020 with diagnoses including dementia with behavioral disturbance and insomnia. The resident was observed to require assistance from two direct care staff with bowel and bladder management. On 06/24/25 at 1:10 pm, during an ADL observation, the following was identified: Staff 9 (Universal Worker) and Staff 12 (Universal Worker) provided Resident 3 with incontinence care in the common area bathroom. Both staff donned single use gloves prior to providing ADL care; however, neither staff were observed to doff the single use gloves or perform hand hygiene after touching soiled incontinence products and before touching the resident’s clean clothes and assistive devices. Additionally, while Staff 9 and Staff 12 provided ADL care, the house emergency call system was activated on three occasions. Each time the system was activated, Staff 9 was observed to exit the bathroom without doffing his/her single use gloves or perform hand hygiene, after touching soiled incontinence products. The need to ensure the facility maintained effective infection prevention and control practices while providing ADL care was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings.

OAR 411-054-0050 (1-5) Infection Prevention & Control 1) Staff 9 and 12 were provided with training on infection prevention and control protocols including hand hygiene, procedures for donning and doffing gloves, and changing gloves after touching soiled incontinence products or other contaminiated items. 2) All staff including Administrator/designee will be provided training on infection prevention and control protocols including hand hygiene, procedures for donning and doffing gloves and changing gloves after touching soiled incontinence products or other contaminiated items. 3) The area will be evaluated using staff comptency check off procedures, as well as random observations of staff when providing care. 4)The Administrator/designee is responsible to ensure the system is corrected/monitored, with over sight from Regional Director of Operations.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: The facility consisted of four detached buildings. Building Manzanita 1 housed nine residents, Building Manzanita 2 housed nine residents, and Sage 2 housed nine residents. Building Sage 1 was unoccupied. The current facility staffing plan and Acuity-Based Staffing Tool (ABST) were reviewed, and interviews with facility staff were conducted. The following was revealed: * Building Manzanita 2 had no residents who required two-person assist or the use of a mechanical lift for transfers; * Building Manzanita 1 had one resident who required two-person assist for transfers; * Building Sage 2 had two residents who required two-person assist for transfers; * Based on the ABST-generated staffing model, the facility was required to schedule one direct care staff for Manzanita 1, one direct care staff for Manzanita 2, and two direct care staff for Sage 2 to cover the night shift; and * According to the facility’s actual staffing plan, only three dedicated direct care staff were scheduled and available for all three buildings at all times. The need to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/25/25 at 4:30 pm and 06/26/25 at 11:00 am. They acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing 1) The staffing plan was updated to reflect 2 direct care staff each shift at Sage 2. Resident #3 was moved to Sage 2. 2) The Administrator will be provided with training on completing an appropriate staffing plan when a resident requires the assistance of two direct care staff for scheduled and unscheduled needs. 3) The system will be reviewed daily using the staffing schedule to ensure each shift has 2 direct care staff on duty to meet the scheduled and unscheduled needs of the residents. 4)The Administrator/designee is responsible to ensure the system is corrected/monitored, with over sight from Regional Director of Operations.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 7 sampled residents (#s 1 and 3). Findings include but are not limited to: 1. Resident 1’s service plan, dated 06/19/25, was reviewed and indicated: * S/he used a wheelchair and required a staff person to push the chair; and * Observations on 06/23/25 and 06/24/25 and interviews with staff revealed Resident 1 required staff assistance going outside to smoke from 4 to 8 times each shift. Resident 1’s ABST profile did not document adequate allotted times for the above tasks. 2. Resident 3 was observed during survey to receive the assistance of two staff for transfers, toileting and incontinence care, and repositioning. The resident’s record noted s/he experienced behavioral and physical conditions or symptoms. Resident 3’s individual ABST minutes were reviewed and were not reflective in the following areas: * Monitoring behavioral conditions or symptoms; * Monitoring physical conditions or symptoms; * Providing non-drug interventions for pain management; * Supervising, cueing, or supporting while eating; and * Transferring in or out of bed or chair. The need to ensure the facility accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 3:00 pm. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool-ABST Time 1)The ABST tool will be adjusted/updated by the administrator/designee for resident #1, resident #3 passed away on hospice services. 2)The administrator/designee will be provided training on ensuring the ABST tool is updated per state regulations, including use of the ABST provider guide and residents current and reflective service plan to accurately capture care time and care elements that staff are providing to each resident. 3)The system will be monitored at move in, quarterly with service plan update, and with signifigant change of condition, using the move in audit tool as well as Monthly Administrator Quality Assurance Audit. 4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

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) was completed or updated and reviewed for each resident before the resident moved in and updated no less than quarterly for 2 of 2 (#1 and 3) sampled residents and multiple unsampled residents. Findings include but are not limited to: During the acuity interview at 1:00 pm on 06/23/25, Staff 1 (Administrator) confirmed the facility census was at 27 residents. The facility’s ABST data and posted staffing plan were reviewed at 11 am and revealed the following: Two sampled residents (#s 1 and 3) had no documented evidence the ABST data had been updated quarterly at the same time as the service plan. Resident 3 experienced two significant changes of condition and lacked documented evidence the resident’s ABST was reviewed and updated after the significant changes. The need to ensure residents’ ABST data was updated at move-in, quarterly at the same time as the service plan, and after a significant change of condition was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/25/25 at 4:30 pm and 06/26/25 at 11:00 am. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool- Updates & Staffing Plan 1)The ABST tool will be reviewed and adjusted/updated by the administrator/designee for all residents. 2)The administrator/designee will be provided training on ensuring ABST is updated per state regulations including quarterly or with significant change of condition and no less than quarterly using the ABST provider guide and residents current and reflective service plan. 3)The system will be monitored at move in, quarterly with service plan update, and with signifigant change of condition, using the move in audit tool as well as Monthly Administrator Quality Assurance Audit. 4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 9 and 10) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 06/26/25. The following deficiencies were identified: There was no documented evidence Staff 9 (Universal Worker), hired on 12/16/24, and Staff 10 (Universal Worker), hired on 02/10/25, demonstrated competency within 30 days of hire in the following areas: * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:00 am. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire-Direct Care Staff 1) Staff 9 and 10 are completing their demonstrated competencies including, Providing assistance with ADLs; Changes associated with aging;identification, documentation and reporting of changes of condition and Conditions that require assessment, treatment, observation and reporting 2) An audit of staff training records will be completed, any staff without the required demonstrated competencies within 30 days of hire will be provided the training. A review of training requirements will be completed with Administrator/ Designee and will include the process and documentation of staff training initially, within 30 days and ongoing. 3) To ensure the system is corrected and staff remain in compliance with all training requirements, a review of training documents will be completed within 30 days of hire date, as well as monthly using the monthly Administrator Quality Assurance audit. 4) The Administrator/Designee will be responsible to ensure the corrections are completed/monitored with Regional Director of Operations oversight

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 that direct care staff completed and documented 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 six hours of training on dementia care, for 1 of 2 long-term staff (# 11) whose training records were reviewed. Findings include, but are not limited to: There was no documented evidence Staff 11 (Universal Worker), hired 08/2023, completed 12 hours of required in-service training, including six hours of training on dementia care, between 08/2023 and 08/2024. The need to ensure staff completed and documented the required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator) and Staff 6 (Regional Director) on 06/26/25 at 11:00 am. They acknowledged the findings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff 1) Staff #11 is in process of completing 12 hours of required in-service training, including six hours of training on dementia care using Oregon Care Partners training. 2)The administrator/designee will be provided training on procedure for tracking and ensuring staff complete, and have documented required annual in-service training in the correct time frame including six hours of training on dementia care. Any staff that have not completed required training with be provided the training. 3)This will be evaluated monthly using the Administrator Quality Assurance Audit 4)The Administrator/designee is responsible to ensure the system is corrected/monitored, with over sight from Regional Director of Operations.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to: On 06/23/25 at 3:23 pm, the facility grounds were toured and identified a paved pathway in the backyard of the “Sage 2” house, with an uneven section that created a tripping hazard for residents. On 06/24/25 at 2:56 pm, the uneven pathway was observed with Staff 1 (Administrator) and Staff 3 (Maintenance) and they acknowledged the need to maintain pathways for resident safety. The need to ensure all exterior pathways were maintained in good repair was reviewed with Staff 1 and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior 1) Bids are in process to repair uneven section to outside paved pathway in Sage 2. 2) Administrator/Designee will be provided training on completing an Administrator daily walk through of communities to identify any deficiencies and ensure all items are in compliance, including training on proper notification to Maintenance Director for any deficiencies and planning for immediate action to correct areas in need of attention. 3) The Administrator/Designee will complete a daily walk through of community as well as monthly using the Administrator Quality Assurance Audit. Regional Director of Operations will complete Quarterly Environmental Audit. All concerns will be addressed promptly with the Maintenance Director. 4)The Administrator/Designee and Maintenance Director are responsible to ensure corrections are completed/monitored with Regional Director of Operations oversight.

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 all interior materials were kept clean and in good repair. Findings include, but are not limited to: The facility had residents residing in three separate unattached houses, “Manzanita 1,” “Manzanita 2,” and “Sage 2.” On 06/23/24 at 3:23 pm, the facility was toured and the following was identified: a. “Manzanita 1” was identified as being unclean and/or not in good repair in the following areas: * Carpet throughout common area had multiple large stains; * Living room wall was gouged, chipped, and had exposed material, approximately 10 feet in length; * The corners of the walls between the living room and dining room were chipped and broken and had exposed material; * The transition between the living room and dining room was missing; * The stationary desk in the dining room had a large area that was missing material on the right side and the right side had a broken and chipped corner that exposed material; * Room three’s door and door frame was chipped, gouged, and had exposed material; * The PTAC unit in the dining room was not attached securely to the wall; * Windowsills and window frames in the dining room had an accumulation of dust, dirt, and dead bugs; and * The public bathroom had multiple colored liquid appearing substances along the baseboards, shower, sink, and toilet. Additionally, throughout the survey, there was a pervasive odor noted throughout the house. b. “Sage 2” was identified as being unclean and/or not in good repair in the following areas: * Carpet throughout common area had large stains; * The toilet seat in the public restroom had bowel movement observed on the seat throughout survey and was partially stained yellow; * The door frame connecting the dining room to the corridor with rooms one, two, and three was gouged, chipped, and had exposed material; and * The door frames to rooms two and three were gouged, chipped, and had exposed material. On 06/26/25 at 2:56 pm, a walk-through of the above noted areas was completed with Staff 1 (Administrator) and Staff 3 (Maintenance). The need to ensure the facility was maintained clean and in good repair was reviewed with Staff 1 and Staff 6 (Regional Director) on 06/26/25 at 11:44 am. They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors 1) Manzanita 1-Carpet throughout common are had multiple large stains: flooring was replaced by 7/17/25, Living room wall was repaired 7/15/25, corners of walls between living room and dining room were repaired at survey, transition between living room and dining room were repaired at survey, maintenance will repair stationary dest in dining room and replace desk top, room 3's door and frame were repaired at survey, PTAC in dining room mounted to wall at survey, windowsills and frames were cleaned at survey, public bathroom will be cleaned and re-caulked by maintenance. Sage 2-Carpet in common area had large stains, this was cleaned on 7/9/25, toilet seat in public restroom was replaced at survey, door frame dining room to corridor was repaired at survey, door frames between rooms 2 and 3 were repaired at survey. 2. Once all of the concerns have been addressed the Administrator/Designee and the Regional Director of Operations will complete an audit of maintenance and cleaning needs. All staff will be re-trained on proper cleaning techniques by Administrator/Designee. 3. An Audit will be completed weekly by Administrator/Designee and monthly by Regional Director of Operations to ensure all maintenance and cleaning needs are being addressed. 4. Administrator/Designee and Maintenance Director will be responsible to ensure corrections are completed/monitored with over sight by Regional Director of Operations.