OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, included resident preferences that supported the principles of choice and individuality, and provided clear directions to staff regarding the delivery of services for 3 of 5 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2024 with diagnoses including type 2 diabetes mellitus with diabetic nephropathy, chronic kidney disease, and long-term use of insulin. During the acuity interview on 10/27/25, Resident 4 was identified as self-administering all of his/her medications, including insulin (to control blood glucose level). Observations were made of the resident's self-administration of medication on 10/28/25, interviews with the resident and facility staff were conducted, and the service plan, dated 10/09/25, was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Instructions for proper maintenance of blood glucose monitor on left upper extremity and how to monitor for malfunctions; * Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped meals; * Electric wheelchair equipment precautions and instructions for proper maintenance; and * Assistance required with dressing. During the interview with the resident on 10/28/25 at 11:29 am, s/he stated the need for one-person assistance with dressing and putting his/her left knee brace on. S/he also expressed a fear of blood glucose level dropping in the morning around 5:00 to 6:00 am: “I don’t know when my blood sugar goes low. I feel and know when it is low during the day. I have glucose tablets, but they don’t work fast. I like to have Pepsi. Then it [blood glucose] is up in five minutes.” Staff 14 (MT/CG) was interviewed on 10/30/25 at 12:25 pm and confirmed Resident 4 required one-person assist with “morning routine especially dressing, getting up, putting brace on … and reminders to go to meals because [s/he] likes to nap a lot.” Staff 14 and Staff 8 (MT), in an interview on 10/29/25 at 3:38 pm, both stated Resident 4 was fully independent with blood glucose monitoring and administration of all medications. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 2:14 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2025 with diagnoses including atrial fibrillation and hypertension. The resident’s record was reviewed, including the current service plan, dated 08/21/25, and interviews with staff and the resident were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and/or preferences in the following areas: * Activities in relation to preferred activities; and * Hearing deficit. The need to ensure service plans were reflective of the residents’ current care needs and preferences was reviewed with Staff 2 (Director of Health Services/RN), Staff 3 (LPN), Staff 6 (Arbor Administrator), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 4:00 pm. They acknowledged the findings. 3. Resident 2 moved into the community in 05/2022 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease stage 3, neuromuscular dysfunction of bladder, and disorientation. The resident’s record was reviewed, including the current service plan, dated 09/18/25, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and/or was not implemented in the following areas: * Fortified meals; * Meal set-up and as-needed assistance with preparing meals delivered to the resident’s room; and * Smoking status. On 10/28/25 at 10:57 am, Staff 19 (Cook) reported he had not been preparing fortified meals for the resident. The need to ensure service plans were reflective of the residents’ current care needs and were implemented, was reviewed with Staff 1 (ED), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 3:18 pm. They acknowledged the findings.

1. Service plans for resident 2, 3 and 4 have been updated to include all required information and to be reflective of current needs, preferences and interventions, including clear instructions to staff and have been printed for staff to review. Staff training has been completed that includes implementation of service plans. 2. To prevent recurrance, All residents’ service plans will be audited against their current care needs and preferences and updated to be reflective. Verifying all interventions provided clear directions regarding the delivery of services. Training will be completed with care staff and medication techs on reporting service plan discrepancies and changes in residents' care needs with health services team. Training will be conducted with Health Services Team on Arete policy and procedure related to resident service planning. 3. Service plans will be evaluated and reviewed upon admission, at 30 days, quarterly and with significant change of condition. 4. The Executive Director will be responsible for maintaining this system and will coordinate with the Health Services Team

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 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 5 sampled residents (# 2) whose orders were reviewed. This resulted in unnecessary pain and a visit to the emergency department for Resident 2. Findings include, but are not limited to: Resident 2 had a history of urinary tract infections (UTI) and had a standing, as-needed order to obtain a urine specimen if the resident showed signs or symptoms of a UTI, including frequency, burning, urgency, painful urination, blood in urine, or change in behavior, and if the licensed nurse determined a positive result, to send it in for a culture and sensitivity test. On 07/14/25, staff requested the resident’s legally authorized prescriber for a urinary analysis (UA) and culture and sensitivity order due to the resident having blood in his/her catheter bag, urge to urinate, complaints of pain, and increased confusion. On 07/15/25, the facility received a signed order for a UA and culture and sensitivity test. Staff continued to document the resident’s status including increased confusion. There was no documented evidence a urine sample was collected as ordered. On 07/28/25, a home health nurse reported blood in the resident’s urine bag and tubing, and a urine sample was collected for a UA and culture and sensitivity test. Staff continued to document the resident’s status, including that the resident had a possible UTI, had blood in his/her urine, and had increased confusion. On 08/01/25 the facility received the resident’s UA report indicating multiple abnormal results. Upon receipt of the UA results, there was no documented evidence the legally authorized prescriber was notified. On 08/01/25 the resident was placed on alert for possible UTI. Staff continued to document the resident’s status, including increased confusion and blood in his/her urine, from 08/01/25 through 08/04/25. On 08/05/25, Resident 2 was sent to the emergency department for “extreme pain,” signs of infection, and increased confusion. The resident was diagnosed with a UTI and provided an order for antibiotics. The facility failed to carry out physician orders as prescribed, which resulted in unnecessary pain and a visit to the emergency department. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 3:18 pm. They acknowledged the findings.

1. Resident 2 had been treated prior to the time of survey. Health Services staff have been trained and given instruction on signs and symptoms for when to send out resident 2 in the future. Service plan has been updated. 2. Re-education provided to med techs on 11/11/25 and 12/10/25 reviewing the importance of following treatment orders and following up with the LN if there is any barrier to following a treatment order so this can be corrected as soon as possible.Training will be completed with medication techs and health services team on policy and procedure related to the 'Triple Check Process' for verifying all orders are implemented and followed up on timely with nurse review. The 24-hour/72-hour report will be reviewed during Daily Clinical Stand-up Monday-Friday to identify documentation requiring urgent follow-up. 3. This system will be reviewed 5 days a week during daily stand up by reviewing 24 hour summary. 4. Executive Director and Health Care Team are responsible to monitor

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 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order for 1 of 1 sampled resident (# 3) with documented refusals. Findings include, but are not limited to: Resident 3 was admitted to the facility in 08/2025 with diagnoses including atrial fibrillation and hypertension. The resident’s MAR, dated 10/01/25 through 10/27/25, and physician’s orders were reviewed. The following was identified: Resident 3 had documented refusals on his/her MAR for the following orders: a. Polyethylene glycol powder (for bowel care), take 17 grams by mouth every morning. The resident refused the medication nine times during the reviewed period. There was no documented evidence the provider was notified of refusals on six occasions. b. Senna (for bowel care), 8.6 mg tablet, take two tablets by mouth at bedtime. The resident refused the medication 14 times during the reviewed period. There was no documented evidence the provider was notified of refusals on the 14 occasions. During an interview on 10/30/25 at 1:45 pm, Staff 3 (LPN) and Staff 18 (VP of Clinical Operations) acknowledged there was no documented evidence the facility notified the provider when Resident 3 refused to consent to physician’s orders. The need to notify the provider when a resident refused to consent to an order was reviewed with Staff 2 (Director of Health Services/RN), Staff 3, Staff 6 (Arbor Administrator), and Staff 18 on 10/30/25 at 4:00 pm. They acknowledged the findings. No further documentation was provided.

1. All of Resident #3 refusals for 30 days has been sent to the provider. 2. All Med techs trained on 11/11/2025 regarding notifying providers of resident refusals of medications and treatments timely, unless there is a signed order specifying not to notify of refusals. All residents have been audited for refusals and physicians have been notified of all resident refusals in October, November and December.A list of all residents that require provider notification for refusals has been created and posted in the medication rooms. The 24-hour/72-hour report will be reviewed during Daily Clinical Stand-up Monday-Friday to identify any resident refusals and verify notifications have been made. MAR audits will be conducted weekly to verify appropriate notification of resident medication and/or treatment refusals 3. This system will be reviewed 5 days a week during daily stand up by reviewing 24 hour summary and clinical alerts. 4. Executive Director and LNs will be responsible for maintaining this system.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. 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 in all required topics was completed prior to beginning job duties for 2 of 3 newly hired staff (#s 12 and 13) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 10/28/25 through 10/30/25. The following was identified: a. There was no documented evidence Staff 12 (CG), hired 04/04/25, had completed the following required pre-service orientation training prior to beginning their job responsibilities: * Approved Home and Community Based Services (HCBS) course; and * Pre-service dementia related to specific aspects of dementia including addressing pain, providing fluids, and use of person-centered approach. b. There was no documented evidence Staff 13 (CG/MT), hired 08/05/25, had completed the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of Community Based Care (CBC); * Fire safety and emergency procedures; and * Pre-service dementia training. On 10/30/25 at 11:15 am, Staff 7 (Business Office Manager) confirmed Staff 12 and Staff 13 had been working independently and stated they would be removed from the schedule, until they completed pre-service orientation. The need to ensure staff completed all required pre-service orientation and training prior to beginning their job responsibilities and for direct care staff to complete required pre-service dementia training prior to providing care to residents was reviewed on 10/30/25 at 1:05 pm with Staff 1 (ED) and Staff 7. They acknowledged findings.

1. Staff 12 and 13 were removed from the floor until all training was completed. 2. Business Office Manager reviewed all employees to ensure all pre-service has been completed. Updated the training grid to ensure all required courses are accounted for. The Business Office Manager will not allow staff to work the floor prior to completing all of their pre-service training. 3. During each new hire as they start their onboarding until they have verified completion. 4. Executive Director, Business Office Manager

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 2 of 3 newly hired direct care staff (#s 13 and 17) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 10/28/25 through 10/30/25. The following was identified: a. There was no documented evidence Staff 13 (CG/MT), hired on 08/05/25, and Staff 17 (MT), hired on 05/06/25, demonstrated competency within 30 days of hire in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; and * Conditions that require assessment, treatment, observation and reporting. b. Staff 17 (MT), hired on 05/06/25, demonstrated competency in medication passing on 08/20/25, 108 days after his/her hire date. The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was reviewed on 10/30/25 at 1:05 pm with Staff 1 (ED) and Staff 7 (Business Office Manager). They acknowledged the findings.

1. Staff #13 and 17 have completed all of their 30 day training and their competencies. 2. Relias training system was reviewed and updated with appropriate training plans for 30 day requirements, training grid updated to track all appropriate courses are being monitored and completed 3. Followed for all new hires throughout their onboarding and will not be scheduled to work the floor alone without finishing the training and competency 4. Executive Director and Business Office Manager

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed about fire and life safety procedures within 24 hours of admission in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 10/30/25 at 11:10 am. On 10/30/25 at 11:50 am, Staff 1 (Executive Director) and Staff 5 (Director of Maintenance) were asked to explain the facility's process for providing residents with instructions on fire and life safety procedures within 24 hours of admission. Staff 5 reported he was responsible for providing fire and life safety training to all residents. However, the facility was unable to produce any documented evidence confirming the training had been provided within 24 hours of admission. The need for residents to be instructed about fire and life safety procedures within 24 hours of admission per the OFC was discussed with Staff 1, Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 2:14 pm. They acknowledged the findings.

FIRE AND LIFE SAFETY TRAINING FOR RESIDENTS 1. Fire and Life Safety training conducted for residents every 6 months through Environmental Evals. 2. Audited all current residents to make sure everyone was updated on their Fire and Life Safety training. All new residents will receive training within 24 hours of move-in. Leadership team have received re-education on the process and expectation for completing this training. 3. During move-in process, follow environmental evaluation schedule every 6 months 4. Executive Director and Maintenance Director are responsible for maintaining this system

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: