OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents’ rights to receive services in a manner that protected privacy, dignity and respect for 2 of 3 sampled residents (#s 1 and 5) who received ADL assistance including medication, meal service, and incontinence care. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 11/2023 with diagnoses including Parkinsonism and dysphagia (difficulty swallowing). The resident’s 07/08/25 service plan and 06/21/25 through 09/12/25 progress notes were reviewed. Observations and interviews with the resident and staff were conducted. The service plan indicated Resident 5 required one-person assistance with all transfers, was on a “mechanical Dental Soft Diet like soups,” had issues with swallowing, and preferred to go to bed by 10:00 pm and wake up around 7:30 to 8:00 am. During an interview on 09/16/25 at 12:05 pm, Resident 5 shared frustrations regarding s/he did not get his/her meals and/or medications on time. Resident 5 indicated s/he ate all meals in the apartment because of swallowing issues, difficulty using his/her hands, and taking an hour to eat. To help swallow his/her medications, the pills needed to be available during every meal. Resident 5 stated s/he always ordered two coffees, “often the soup du jour” and the main meal, if it was something s/he could eat, for lunch. Resident 5 indicated some days s/he did not get the lunch or beverages s/he ordered, breakfast was often late, and it interrupted his/her schedule. “One day it [breakfast] is at 8 am and another day it is at 10 am … and it throws my meds off,” Resident 5 stated. S/he noted some days the breakfast arrived on time, but the pills were delivered after the meal was completed. S/he indicated, “Going to bed is a challenge. I can’t go to bed until I’ve had my pills.” S/he indicated if the dinner and/or medications were not delivered in a timely manner, his/her bedtime schedule was delayed because s/he had to sit up for a while prior to going to bed. Observations of the resident on 09/16/25 at 10:35 am found him/her seated at the desk, eating oatmeal. At 12:05 pm, the resident’s pills were observed in a medication cup sitting on the desk, and s/he indicated “they are for me to take at lunch, but they haven’t brought my lunch yet.” The resident confirmed s/he ordered buttered noodles, two coffees, and soup du jour. Observations at 2:05 pm in the resident’s apartment identified the medication cup with the pills remained on the desk, and Resident 5 confirmed, “I can’t take my pills without my lunch, and no one has brought me any lunch or beverages.” On 09/17/25 at 10:08 am, Resident 5 relayed to a caregiver, “I was halfway through with my breakfast by the time my meds arrived this morning." The need to ensure residents were treated with dignity and respect, in regard to providing meal and medication services to maintain their preferred customary routines and schedule, was discussed with Staff 1 (ED) and Staff 2 (Wellness Director, LPN) on 09/18/25 at 12:44 pm. They acknowledged the findings. 2. On 09/16/25 at 9:25 am, Witness 1 (Private CG) and Staff 18 (CG) were observed providing incontinence care to Resident 1 in bed. The bed was positioned against the wall near a window. Both staff removed the resident’s blanket during the provision of care but did not close the window blinds to ensure privacy and dignity. During the incontinence care, two people walking outside were observed through the window. On 09/18/25 at 12:07 pm, the need to ensure the resident received care with privacy and dignity during personal hygiene was discussed with Staff 1 (ED). The staff acknowledged the findings.

Resident #5 1. Tray delivery assigned to sections to ensure all trays delivered per resident preferred time. - instructions added to MAR - ok to leave medications at meal table in apartment for independent administration -Monitor for correct food preferences and diets on room trays/dining room 2. Orders obtained from Primary Physician with approval to leave all medications with resident to take independently with meals. -Meal time preference and details added to service plan 3. RSD will review systems monthly. 4. RSD/ED Resident #1 1. 9/25/25 all staff in-serviced on dignity and privacy - all staff assigned to Relias training: Resident Rights in Assisted Living 2. Staff will be in-serviced on Resident Rights, dignity and privacy upon hire and annually. 3. RSD/WD to complete random audits of ensuring resident privacy is being maintained weekly x2 months then at least monthly. 4. RSD, WD, ED

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

OAR 411-054-0036 (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 readily available to staff, were reflective of the residents’ needs and preferences, provided clear direction regarding the delivery of services, and were implemented for 3 of 4 sampled residents (#s 1, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 03/2023 with diagnoses including congestive heart failure and atrial fibrillation (irregular heart rate). In the acuity interview on 09/15/25 at 1:35 pm, Staff 1 (ED) indicated staff had access to updated service plans in binders located at the reception desk. The date of the service plan in the binder for Resident 3 was 11/01/24. The resident’s record, including the service plan available to staff dated 11/01/24, TSPs from 06/12/25 through 08/27/25, and progress notes dated 06/14/25 through 09/15/25 were reviewed. Observations were made, and staff were interviewed. The following was identified: The 11/01/24 service plan was not reflective of Resident 3’s current care needs or did not provide clear instructions to staff in the following areas: * Type of catheter used; * Home health services for catheter management; * Use of side rails; and * Preferred pronouns and gender identity. In an interview with Staff 1 on 09/16/25 at 9:08 am, she stated the service plan had been updated three times since 11/01/24 and did not know why the updated plans had not been cycled through the binder available to staff. The current plan, dated 08/25/25, was visualized in the binder by the end of the day. The need to ensure service plans were readily available to staff, were reflective of the resident’s needs and preferences, and provided clear direction on the delivery of services was reviewed with Staff 1 and Staff 2 (Wellness Director/ LPN) on 09/18/25 at 1:25 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 10/2021 with diagnoses including multiple sclerosis and type 2 diabetes mellites. Observations of the resident, interviews with the resident and staff, and review of the 07/08/25 service plan, temporary service plans, and 05/13/25 through 09/15/25 progress notes showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff. * Level of assistance required for dressing, incontinence care, and repositioning/rotation; * Use of an air mattress; * Private caregiver services; * Conflicting information for managing the resident’s catheter care; * Ability to use small appliances; and * Assistance needed with pet care. The need to ensure service plans were reflective of resident care needs and provided instructions for staff was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 10:50 am. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 11/2023 with diagnoses including Parkinsonism and dysphagia (difficulty swallowing). Observations and of the resident, interviews with the resident and staff, and review of the resident’s 07/08/25 service plan, temporary service plans, and 06/21/25 through 09/12/25 progress notes showed the service plan was not reflective of the resident's current care needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: * Evacuation status; * Eating preferences and routines, including medication with meals, no talking while eating, meals in apartment, use of own utensils and dinnerware including staff responsibility to wash afterward, reheating food and beverages, and placement of food for accessibility; * Mobility devices including walker with PT only; * Transfer technique including allowing extra time, wheelchair placement, and use of the gait belt versus two hands on trunk; * Toileting including wheelchair placement, use of armrests versus grab bar for balance, bathroom door left ajar; and * Leaving items in place and asking before moving them. During an interview on 09/17/25 at 11:05 am, Staff 17 (CG) indicated she provided transfer assistance by placing her hands on Resident 5 for support and did not use the gait belt. Observations on 09/16/25 and 09/17/25 identified staff provided transfer assist with two hands under the armpits. The gait belt was observed in the apartment but never used during any transfer observations. The need to ensure resident service plans were reflective of current care needs and preferences, provided clear direction to staff, and/or were implemented was discussed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 12:44 pm. The staff acknowledged the findings.

Resident # 3 1. Service plans, upon completion, will be directly placed in the service plan binder. - resident #3 service plan reviewed, revised, printed and available for staff. 2. Training provided to the service planning team on proper procedure for service plan review and updating. 3. RSD to conduct monthly audits of the service plan book to ensure all information is updated and accurate. 4. WD/RSD/ED Resident # 1 1. Service plans, upon completion will be directly placed in the service plan binder. - resident #1 service plan reviewed, revised, printed and available for staff. 2. Training provided to the service planning team on proper procedure for service plan review and updating. 3. RSD to conduct monthly audits of the service plan book to ensure all information is updated and accurate. 4. WD/RSD/ED Resident # 5 1. Service plans, upon completion, will be directly placed in the service plan binder. - resident #5 service plan reviewed, revised, printed and available for staff. 2. Training provided to the service planning team on proper procedure for service plan review and updating. 3. RSD to conduct monthly audits of the service plan book to ensure all information is updated and accurate. 4. WD/RSD/ED

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 determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, failed to communicate the determined action or intervention to staff, and failed to document progress until the condition resolved for 2 of 4 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 02/2025 with diagnoses including cerebral infarction, major depressive disorder, and hemiplegia. A review of Resident 2’s clinical records, 06/17/25 through 09/12/25, including the current service plan, dated 07/01/25, showed the following: The following short-term changes of condition lacked documentation the facility monitored the resident through resolution of the condition for effectiveness and adverse effects of new medication: * On 06/18/25, a progress note revealed, “[Resident] then informed [MT] that [s/he] has a [Foley] catheter in place and [s/he] needs a syringe for it…. [Resident] clipped the tube of the catheter and pulled it out.” There was no documented evidence the facility evaluated the resident for presence of a Foley catheter and the reason it was placed, or monitored for complications such as urinary retention following removal of the catheter through weekly resolution of the condition; * On 07/14/25, the resident’s sertraline dosage (for depression) was increased from 100 mg daily to 150 mg daily. There was no documented evidence the resident had been monitored weekly through resolution for effectiveness and adverse effects of the new dose of antidepressant; and * On 07/25/25, the resident had hydrocodone-acetaminophen 5-325 mg increased from one tablet orally three times a day as needed to one tablet orally every six hours as needed to control pain following a nasal bone fracture secondary to a fall. There was no documented evidence the resident was monitored for effectiveness of new pain medication regimen and adverse effects. On 09/18/25 at 10:50 am, Staff 1 (ED) reported the facility nurse was new to the facility and spent most of the time in training, which could have affected the system. The need to ensure the facility had a system in place to evaluate and monitor each resident consistent with their evaluated needs and service plan was reviewed with Staff 1 and Staff 2 (Wellness Director/LPN) on 09/18/25 at 1:48 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 10/2021 with diagnoses including multiple sclerosis and type 2 diabetes mellitus. A review of Resident 1’s clinical records, 05/13/25 through 09/15/25, including the current service plan, dated 07/08/25, showed the following: * On 08/07/25, the resident received an antibiotic for a urinary tract infection, which was later changed to a different antibiotic on 08/17/25. There was no documented evidence the resident had been monitored weekly through resolution for the effectiveness of the antibiotic treatment for the urinary tract infection. On 09/18/25 at 10:50 am, Staff 1 (ED) reported the facility nurse was new to the facility and spent most of the time in training, which could have affected the system. The need to ensure the facility had a system in place to evaluate and monitor each resident, consistent with his or her evaluated needs and to document weekly progress notes until the condition resolves was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 10:50 am. They acknowledged the findings.

Resident #2 1. WD assigned and completed training on COC (via NurseLearn) - Additional training provided on RN notification - Additional training provided to WD, RSD and med techs on when to place someone on alert, adding a TSP and the removal of alert processes. - refer to C0290 for follow up information for outside appts or hospital visits 2. WD/RSD to review alerts via tracking form, TSP's and changes for documentation/follow up for completion. 3. Review will be completed at least 3x's a week and as needed 4. RSD/WD/ED Resident #1 1. WD assigned and completed training on COC (via NurseLearn) - WD signed up for Role of the nurse 11/2025 - Additional training provided on RN notification - Additional training provided to WD, RSD and med techs on when to place someone on alert, adding a TSP and the removal of alert processes. 2. WD/RSD to review alerts, TSP's and and changes for documentation/follow up for completion. 3. Review will be completed at least 3x's a week and as needed 4. RSD/WD/ED

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

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the facility coordinated with outside providers, including other privately paid supplemental healthcare providers, and have policies to ensure outside provider left written information and ensure staff were informed of new interventions and that service plans were adjusted if necessary for 2 of 3 sampled residents (#s 1 and 5) who received outside services. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 11/2023 with diagnoses including Parkinsonism and dysphagia (difficulty swallowing). During the acuity interview on 09/15/25, the resident was identified to have PT services. The resident’s 07/08/25 service plan, 06/21/25 through 09/12/25 progress notes, and temporary service plans were reviewed. Observations and interviews with the resident and staff were conducted. During an interview with Resident 5 on 09/16/25 at 12:05 pm, s/he indicated a “private PT is coming today.” S/he confirmed he visited one time a week and had made visits “for a while.” During an interview on 09/18/25, Staff 1 (ED) acknowledged the facility had not been keeping written records of the outside provider visits by the privately hired physical therapist. The need to ensure outside service providers left written documentation of all visits and to implement any recommendations made by the providers was discussed with Staff 1 and Staff 2 (Wellness Director/LPN) on 09/18/25 at 12:44 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 10/2021 with diagnoses including multiple sclerosis and type 2 diabetes mellitus. During the acuity interview on 09/15/25, the resident was identified to receive hospice services. The resident’s progress notes, dated 05/13/25 through 09/15/25, temporary service plans, and hospice visit notes, dated 07/07/25 through 09/16/25, were reviewed. Observations and interviews with the resident and staff were conducted. Resident 1’s clinical records, including recommendations, revealed the following: * 07/17/25: Would benefit from a scoop plate and cut up meals. 09/16/25 at 3:00 pm, Staff 15 (CG) reported the resident received a regular plate and was able to use regular utensils. However, the resident preferred to use his/her fingers to eat due to having a hand tremor and using his/her fingers was more comfortable. There was no documented evidence the recommendation for a scoop plate and cut up meals was communicated to the staff or the service plan was adjusted to ensure continuity of care. On 09/17/25 at 1:20 pm, the surveyor requested documented evidence the recommendation was communicated to staff. No further documentation was provided prior to the survey exit. The need to ensure staff were informed of on-site outside provider information and interventions, and the service plan if necessary, was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 10:50 am. They acknowledged the findings.

Resident #5 1. This community will coordinate with all outside providers - all communication with providers will be documented in the residents chart -Med techs inserviced on what to ask for from resident/family/outside provider post appt or hospital visit - WD/RSD to keep a list of any outside provders coming into the building. 2. WD will review notes/reccomendations left by providers weekly and as available. WD will document any new reccomendations and put them on TSP as appropriate. 3. Weekly, via written communication and/or verbal when provider in the community. 4. WD/ED/RSD Resident #1 1. WD to document in the chart and on the service plan/TSP, any and all follow up on provider recommendations, as appropriate. 2. All provider notes will be review by the WD. 3. Provider notes will be reviewed by the WD at least a weekly. WD/RSD/ED

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

OAR 411-054-0050(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, sanitary, and comfortable environment related to incontinence care and during meal service. Findings include but are not limited to: 1. Resident 1 moved into the facility in 10/2021 with diagnoses including multiple sclerosis and type 2 diabetes mellitus. Observations were made during the survey to determine adherence to universal precautions for infection control. On 09/16/25, at approximately 9:25 am, and 09/17/25 at 11:20 am, the surveyor obtained permission and observed Witness 1 (Private CG), Staff 11 (CG), Staff 16 (CG), and Staff 18 (CG) provide incontinence care to Resident 1. During the observation on 09/16/25, Witness 1 and Staff 18, and on 09/17/25 Staff 11 and 16, failed to change gloves after removing a soiled incontinence product and wiping Resident 1's bottom area. Staff applied clean brief and cream treatment to Resident 1 and touched the resident's blankets and pillows while wearing the same soiled gloves. When Staff were finished providing incontinence care, they removed the gloves. The need to ensure staff consistently followed universal precautions was discussed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 10:50 am. They acknowledged the findings. 2. During meal service observations on 09/17/25 at 11:30 am, direct care staff were observed entering the kitchen and covering bowls of soup and salad with plastic wrap and wrapping silverware in cloth napkins without performing hand hygiene or donning a protective barrier over potentially contaminated clothing. The food trays were then delivered to resident rooms by the direct care staff. The need to ensure staff maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during meal service was reviewed on 09/18/25 at 1:25 pm with Staff 1 (ED), Staff 2 (Wellness Director/ LPN). They acknowledged the findings.

Resident #1 1. 9/25/25 all staff in-serviced on proper hand washing - all staff assigned to Relias training: Hand Hygiene (Video), Hand Hygiene Basics and Resident Rights in Assisted Living 2. Every other month, hand hygiene will be reviewed/in-serviced at monthly all staff meetings 3. RSD/WD to complete competency for all associates. Additionally, random audits of proper hand hygiene of at least 3 staff weekly x2 months then at least monthly. - all new staff will demonstrate competency of above 4. RSD, WD, ED Food handling 1. 9.25.25 staff in-serviced on proper hand hygiene - staff assigned to trainings listed above (under Resident #1 info) - staff in-serviced on proper work uniform when serving food. 2. DSD to in-service on proper work uniform when assisting with food delivery every other month at monthly all staff meeting. 3. DSD to complete random audits, 2x per week for 2 months then monthly thereafter 4. DSD, ED

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)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for tracking controlled substances administered by the facility for 1 of 1 sampled resident (#1) whose MARs and Controlled Substance Disposition logs were compared for accuracy. Findings include, but are not limited to: Resident 1 moved into the facility in 10/2021 with diagnoses including multiple sclerosis and type 2 diabetes mellitus. Resident 1’s MARs indicated the resident received Ativan 0.5 mg every 4 hours as needed for anxiety/agitation, oxycodone 5 mg every 4 hours, and Morphine 5 mg every 15 minutes as needed for pain. Resident 1’s 08/01/25 through 09/15/25 MARs and Controlled Substance Disposition Log, dated 08/01/25 to 09/15/25, were reviewed and showed the following: • The MARs showed the PRN Ativan was administered 10 times to the resident, but Staff signed on the Controlled Substance log seven times; • The MARs showed the PRN oxycodone was administered 49 times to the resident, but Staff signed on the Controlled Substance log 51 times; and • The MARs showed the PRN Morphine was administered 21 times to the resident, but Staff signed on the Controlled Substance log 20 times. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 10:50 am. They reviewed the documentation and acknowledged the discrepancies.

1. PRN Narcotic book/MAR audit completed. Documentation completed - Med techs in-serviced on proper documentation of PRN's - med techs assigned to Relias training: Documenting medications 2. Audit of narcotic book and documentation (narc book and MAR), conducted by the RSD or LPN 3. Weekly and as needed 4. WD/RSD/ED

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to ensure medication orders were carried out as prescribed for 4 of 4 sampled residents (#s 1, 3, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 03/2023 with diagnoses including congestive heart failure and atrial fibrillation (irregular heart rate). The resident’s MARs, dated 08/01/25 through 09/15/25, and physician orders, dated 03/17/25, were reviewed and the following was identified: a. Resident 3 had an order for Amiodarone HCL 200 mg tablet once daily for atrial fibrillation. The resident had not been administered the medication from 08/29/25 to 09/18/25 due to “awaiting delivery.” In an interview on 09/16/25 at 10:30 am, Staff 23 (MT) confirmed the medication was not in the building. There was no documented evidence the facility followed up with the pharmacy, or that the LPN or prescriber were notified it was not administered. On 09/16/25 at 11:08 am, the surveyor requested Staff 2 (Wellness Director/ LPN) alert the prescriber to the non-administration of the Amiodarone HCl and alert the pharmacy to the need for the medication. At 3:00 pm, she reported the issue resolved, and the refill was pending. On 09/18/25 at 1:25 pm, Staff 2 confirmed the medication had been delivered and the resident had received a dose that morning. b. Resident 3 had an order for Atorvastatin 80 mg tablet once daily at bedtime. The facility did not administer the medication from 08/21/25 through 09/05/25 due to “awaiting mail order.” On 09/16/25 at 10:30 am, Staff 23 confirmed the prescriber was not notified, Resident 3 had not received his medication for 16 days, nor were the LPN or ED involved in an attempt to coordinate a timely refill of the medication. c. Resident 3 had an order for one PRN Nitroglycerin 0.4 mg tablet SL “every five minutes x 3 for chest pain.” The orders additionally instructed staff to “notify LN and PCP if medication is given and place resident on alert.” On 09/16/25 at 10:30, Staff 23 confirmed the resident was administered one tablet of Nitroglycerin on 08/04/25 and again on 09/15/25. There was no documented evidence the LN and PCP were notified of the administration, nor was the resident placed on alert charting. The need to ensure the facility carried out medication orders as prescribed was reviewed with Staff 1 (ED) and Staff 2 on 09/18/25 at 1:25 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2025 with diagnoses including multiple fractures of ribs and age-related osteoporosis. Resident 4's current physician orders, dated 06/10/25, and MARs from 08/01/25 through 09/15/25 were reviewed, and interviews with facility staff were conducted. Resident 4’s current facility records included a physician order to administer alendronate (for osteoporosis) one tablet by mouth every seven days with a full glass of water. Review of the MARs and an interview with Staff 9 (MT), on 09/18/25 at 11:41 am, revealed the medication had not been administered since the resident was admitted to the facility. Staff 9 stated the medication was never delivered by the pharmacy. Staff 9 processed the request to order the alendronate before the survey team exited the building on 09/18/25. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 1:48 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 11/2023 with diagnoses including Parkinsonism and dysphagia (difficulty swallowing). The resident's 08/01/25 to 09/16/25 MARs, 07/08/25 service plan, 07/07/25 quarterly evaluation, and physician orders dated 07/15/25 were reviewed. The following was identified: a. The following orders were missing on the 08/01/25 through 9/15/25 MARs: * Timolol 0.5%- 1 drop both eyes at bedtime (for glaucoma); * Timolol/dorzolam/bimatopros 0.5-2-0.1% - 1 drop to eye(s) at bedtime (for glaucoma); * Dexamethasone 0.1% 4 drops into both ears PRN itching; and * Wellness herbal knee patch- one patch PRN pain. During an interview on 09/16/25 at 3:20 pm, Staff 2 (Wellness Director) acknowledged the above orders were missing from the MAR. Staff 2 would fax the physician to get clarification of the orders not found on the MAR. No additional documentation was provided prior to exit from the survey on 09/18/25. b. A physician’s order stated “Patient is OK to self administer night time medications. OK to leave at bedside table for [him/her] to take.” The quarterly evaluation and service plan both stated, “Evening medications may be left at bedside for [Resident 5] to take on [his/her] own. Staff to check back to ensure [Resident 5] took [his/her] medications.” Observations on 09/16/25 through 09/18/25, during the morning and afternoon, identified medication tablets and liquid cough medicine had been left on the resident’s desk and/or on chairside table. On 09/16/25 at 12:05 pm, Resident 5 indicated the MT’s left the medication because s/he needed to take them with food “and it takes me an hour to eat.” The cough medicine was left daily in case s/he had immediate needs “and I don’t have to wait for the MTs to bring it to me. I have swallowing problems.” During an interview on 09/16/25 at 2:50 pm, Staff 9 (MT) indicated “We have an order we can leave the medication with [him/her] because [s/he] takes it with meals. I check back to make sure the medication is taken since I sign out for it.” During an interview on 09/18/25 at 10:14 am, Staff 2 acknowledged the order to leave evening medication with Resident 5 did not include other times of the day. She stated she would get clarification from the physician to include all hours of the day. No further information was provided. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 12:44 pm. They acknowledged the findings. 4. Resident 1 moved into the facility in 10/2021 with diagnoses including multiple sclerosis and type 2 diabetes mellitus. The resident’s 08/01/25 through 09/15/25 MARs and physician orders were reviewed, and staff interviews were conducted during the survey. The following was revealed: * A physician order, dated 07/31/25, indicated to apply Silvasorb Gel on buttocks twice weekly. The MAR showed the treatment was applied to the resident daily, not twice weekly as prescribed. On 09/17/25 at 2:45 pm, Staff 9 (MT) and Staff 23 (MT) reported and confirmed they applied the treatment to the resident every day. * The MAR directed staff to apply Betamethasone Dipropionate 0.05% cream as needed. However, there was no signed physician’s order for the treatment. On 09/17/25 at 1:57 pm, Staff 4 (RN Oversight) confirmed there was no signed physician’s order at this time. Staff 4 stated when the resident was on hospice services, many treatments were discontinued, and this treatment might have been one of them. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 10:50 am. They acknowledged the findings.

Resident # 3 1. Med techs in-serviced on documentation and Notification to WD/RSD of any medication they have not received within 48 hours of reorder. - med techs assigned to training; Documenting medications -WD to ensure physician has been notified of missed medication(s) - clinical meetings to look at missed medications 2. MAR report to be reviewed to ensure there are no missing medications. Follow up to be documented in the chart 3. Three times a week 4. WD/RSD/ED Resident # 4 1. Med techs in-serviced on ordering and re-ordering process. - in-serviced on who to notify when a medication is not in the community - WD to ensure physician has been notified of missed medications 2. Task list added to MAR to order medications monthly on residents that do not use house pharmacy. 3. WD/RSD monitor weekly. 4. WD/RSD/ED Resident # 5 1. Physicians orders obtained for medications not listed on the MAR - Med techs assigned training: Medication documentation - Physician orders obtained to allow medications to be left with resident to take independently. - WD to complete third checks on new orders to ensure times, route, and administration is correct in the MAR. 2. Audits of the MAR/Physician orders. 3. Monthly 4. WD/ED Resident # 1 1. WD/RSD to conduct an audit to ensure medications on the MAR are reflective of the physician orders. - med tech's assigned Relias additional training and in-serviced on following Physicians Orders. 2. Audits to be conducted by WD 3. Monthly audits of Physicians orders versus MAR 4.WD/RSD/ED

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

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were given only for specific behavioral symptoms and only after documented non-pharmacological interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 1) who had an order for PRN psychotropic medication. Findings include, but are not limited to: Resident 1 moved into the facility in 10/2021 with diagnoses including multiple sclerosis and type 2 diabetes mellitus. Resident 1’s 08/01/25 through 09/15/25 MARs were reviewed and showed the following: • Ativan 0.5 mg every four hours for “agitation/anxiety/nausea” as needed (PRN); • The PRN Ativan was administered on 10 occasions; • There were no instructions to non-licensed staff regarding the resident-specific parameters regarding how the resident demonstrated signs and symptoms of agitation or anxiety for which staff could consider administering the medication; • There was no information regarding non-pharmacological interventions on the MARs; and • There was no documentation of non-drug interventions being attempted with ineffective results prior to administering the medication. On 09/16/25 at 2:50 pm, Staff 9 (MT) and on 09/17/25 at 9:45 am, Staff 23 (MT) confirmed they did not document non-drug interventions. On 09/18/25 at 10:50 am, Resident 1’s record was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN), and the need to ensure resident-specific parameters were included on the MAR and non-pharmacological interventions and their ineffectiveness were documented prior to administering the as-needed psychotropic medication was discussed. They acknowledged the findings.

1. Parameters/interventions added to the MAR, to attempt prior to giving a psychotropic medication - Audit of any PRN psychotropic medications to ensure they have non-pharmacologic interventions listed 2. Any PRN psychotropic medication will have interventions incorporated into the MAR 3. Upon Physicians Order for a PRN psychotropic and quarterly evaluation/review of PRN psychotropic medication 4. WD/ED

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 1 of 3 sampled residents (#5) who used supportive devices with restraining qualities. Findings include, but are not limited to: Resident 5 was admitted to the facility in 11/2023 with diagnoses including Parkinsonism and dysphagia (difficulty swallowing). Observations of the resident and the resident's room on 09/16/25, at 12:05 pm, identified Resident 5 had side rails on each side of the bed in the up position and represented a device with restraining qualities. Review of Resident 5's record revealed there was no documented evidence the devices with restraining qualities had been assessed by an RN, PT, or OT, no documentation of other less restrictive alternatives were evaluated prior to use of the side rails, no documentation of instruction to caregivers on the correct use of and precautions for the device, and no documentation of the use of the side rails in the resident's service plan. During an interview on 09/17/25 at 3:05 pm, Staff 1 (ED) acknowledged she was not aware Resident 5 had side rails, and no assessment had been completed. She indicated she would have the RN complete an assessment immediately. On 09/18/25 at 11:42 am, Staff 1 provided a “Transfer/Positioning/Alarm Device Assessment and Consent” form completed by Staff 4 (RN) on 09/17/25. The assessment lacked documented evidence caregivers were instructed on the correct use of and precautions for the device and that the use of the device had been added into the resident’s service plan. During an interview on 09/18/25 at 11:57 am, Staff 4 acknowledged he had not instructed the caregivers regarding the correct use of and precautions for the device. Additionally, he indicated the information about the side rails would be added to the service plan when the quarterly update was due. This surveyor requested the assessment be updated to reflect education to the caregivers and that Staff 4 ensure the information was communicated to staff on all shifts at the time the assessment was completed. On 09/18/25 at 12:44 pm, Staff 2 (Wellness Director/LPN) confirmed the assessment had been updated to reflect caregiver instructions, and Staff 1 confirmed, “The information about the side rails will go to a TSP (temporary service plan).” The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 and Staff 2 on 09/18/25 at 12:44 pm. They acknowledged the findings.

1. WD/ED audit to ensure all supportive devices have had an RN/PT/OT eval related to the device in place. - ensure all devices have been evaluated for a less restrictive device has been attempted - RN to ensure staff and resident has been instructed on proper use and precautions for the device. - Quarterly letter sent to families and residents to remind them to inform us of any devices brought into the residents room. 2. Audits will be conducted - quarterly letter will be sent to families with reminders regarding supportive devices and our responsibility to ensure safety of resident use and the device. 3. Quarterly and PRN upon new device 4. Oversite RN/WD/ED

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

OAR 411-054-0037 (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 no less than quarterly at the same time as the service plan update or with a significant change of condition for 2 of 4 sampled residents (#s 2 and 3). Findings include, but are not limited to: 1. Resident 3 moved into the facility in 03/2023 with diagnoses including congestive heart failure and atrial fibrillation (irregular heart rate). The resident’s last quarterly service plan update from 08/25/25, progress notes dated 06/14/25 to 09/15/25, and the resident’s ABST evaluation were reviewed on 09/18/25 at 9:50 am. The last ABST update was 06/27/25; it had not been updated quarterly. The need to ensure residents’ ABST evaluations were updated no less than quarterly corresponding with the service plan update was discussed with Staff 1 (ED) and Staff 2 (Wellness Director/ LPN) on 09/18/25 at 1:25 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 02/2025 with diagnoses including cerebral infarction, major depressive disorder, and hemiplegia. The facility’s ABST data was reviewed on 09/16/25 at 10:10 am and revealed there was no documented evidence Resident 2’s ABST data had been updated following a significant change of condition on 07/25/25. The need to ensure residents’ ABST data was updated whenever there was a significant change of condition was discussed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 09/18/25 at 1:48 pm. They acknowledged the findings.

Resident #3 1. ABST/service plan reviewed and updated 2. ABST will be updated quarterly with quarterly evaluation/service plan review as well as with any changes in needs. 3. Monthly audits 4. WD/ED Resident #2 1. ABST/service plan reviewed and updated 2. ABST will be reviewed with any change in a residents needs and quarterly. 3. Monthly audits of ABST will be conducted 4. WD/ED

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 pre-service orientation was completed prior to providing services to residents for 3 of 4 newly hired staff (#s 8, 17, and 19) and pre-service dementia training was completed prior to beginning their job responsibilities for 1 of 3 newly hired direct care staff (# 19) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 09/16/25 at 12:50 pm with Staff 6 (Concierge/BOM). a. There was no documented evidence Staff 8 (MT), Staff 17 (CG), and Staff 19 (CG), hired 10/10/24, 08/19/25, and 08/01/25, respectively, had completed one or more of the following pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious Disease Prevention; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 19 completed the following pre-service dementia training topics: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach. The need for staff to complete all required pre-service orientation and dementia training prior to beginning their job responsibilities was reviewed with Staff 1 (ED) and Staff 6 on 09/18/25 at 10:50 am. They acknowledged the findings.

Staff # 8, # 17 and #19 1. All staff will have the required pre-service trainings completed prior to working with residents - Audit on all staff to ensure all required preservice, annual and biennial trainings are completed 2. New process for BOM (Business office Manager) to ensure pre-service is completed, with additional review by RSD/ED needed prior to employee working on the floor with residents - Excel tracking sheet revised for ease of tracking - additional training provided for BOM who oversees training - BOM will notify department heads and ED of any upcoming trainings needed. 3. Monthly audits of records and training will be completed 4. BOM/RSD/ED

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 4 of 4 newly hired staff (#s 8, 14, 17, and 19) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 09/16/25 at 12:50 pm with Staff 6 (Concierge/BOM). There was no documented evidence Staff 8 (MT), Staff 14 (CG), Staff 17 (CG), and Staff 19 (CG), hired 10/10/24, 07/31/25, 08/19/25, and 08/01/25, respectively, had demonstrated competency in one or more in the following required topics within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to ensure staff had demonstrated competence in any duty assigned within 30 days of hire was reviewed with Staff 1 (ED) and Staff 6 on 09/18/25 at 10:50 am. They acknowledged the findings.

Staff #8, #14, #17, #19 1. RSD reviewed with each staff and completed competencies with staff - audit of all staff to ensure competencies completed 2. New procedure in place so that file will not be put away until all documentation in complete. 3. Monthly audits 4. BOM/RSD/ED

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 2 of 4 long-term sampled direct care staff (#s 9 and 10) completed a minimum of 12 hours of in-service training annually on topics related to the provision of care, including 6 hours of dementia training for 4 of 4 sampled long-term direct care staff (#s 9, 10, 12, and 16) completed annual infectious disease and HCBS training. Findings include, but are not limited to: Staff training records were reviewed on 09/16/25 at 12:50 pm and on 09/18/25 at 11:10 am with Staff 6 (Concierge/BOM). There was no documented evidence that Staff 9 (MT) and Staff 10 (MT), hired 05/16/20 and 11/01/22, respectively, had completed a minimum of 12 hours of in-service training, including 6 hours of dementia training from their anniversary date of hire. Additionally, there was no documented evidence Staff 9, 10, 12 (CG), hired 06/11/21, and Staff 16 (CG), hired 07/18/22, had completed annual infectious disease and HCBS training. The need to ensure all direct care staff completed a minimum of 12 hours of in-service training annually on topics related to the provision of care, including 6 hours of dementia training, and completed annual infectious disease and HCBS training was discussed with Staff 1 (ED) and Staff 6 on 09/18/25 at 11:10 am. They acknowledged the findings.

Staff #9 and #10 1. Staff training completed. 2. Additional training provided to BOM for tracking training. - Trainings will be tracked by hire date 2. New process for BOM (Business office Manager) to ensure pre-service is completed, with additional review by RSD/ED needed prior to employee working on the floor with residents - Excel tracking sheet revised for ease of tracking - additional training provided for BOM who oversees training - BOM will notify deparment heads and ED of any upcoming trainings needed. 3. Monthly audits of trainings 4. BOM/RSD/ED

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 ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided on alternate months of fire drills. Findings include, but are not limited to: Six months of fire drill records and staff in-services dated 03/08/25 through 08/21/25 were reviewed on 09/16/25, and interviews were conducted. The following was identified: a. Two fire drills had been completed during the six-month time frame reviewed. The fire drill documentation lacked one or more of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Staff members on duty and participating; and * Number of occupants evacuated. b. The facility lacked documented evidence that staff were trained in fire and life safety procedures on alternate months of fire drills. The need to ensure the facility conducted fire drills according to the OFC and fire and life safety instruction to staff was provided on alternate months of the fire drills was reviewed with Staff 1 (ED), Staff 3 (Resident Services Director), and Staff 5 (Plant Operations Director) on 09/17/25 at 1:30 pm. They acknowledged the findings.

1.Fire drill completed with all required elements. 2. Fire drill schedule coordinated with POD - fire drills will be completed every other month - Fire and life safety added to all staff trainings to occur on the opposite month of the fire drill. 3. Quarterly audits to be completed ensuring all trainings and drills are complete. 4. POD/ED

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:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents' rights to privacy and dignity. Findings include, but are not limited to: Refer to C200.

Refer to C200

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

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to the following: Refer to C340.

Refer to C340

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: