OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, for 2 of 2 sampled residents (#s 3 and 4) who had injuries of unknown cause. Findings include but are not limited to: Resident 4 was admitted to the facility in 4/2019 with diagnoses including dementia, major depression, and a neurocognitive disorder. Review of the resident's clinical record, including progress notes from through 11/01/25 through 02/09/26 identified the following: * 11/09/25 - “med tech noted dark bruising to back of resident’s left hand. No other new bruising noted during this check.” * 12/12/25 - “It was brought to this RN attention that [Resident 4] has bruises on [his/her] hands. [S/he] has two on [his/her] left and one on [his/her] right. They are deep purple in color. No S/SX of infection. [S/he] is not sure how it happened.” * 12/19/25 - “it was noted [s/he] has some new bruising going up [his/her] left arm. They are scattered up [his/her] forearm. Again, [s/he] has no idea of how they happened.” These bruises represented injuries of unknown cause which were required to be reported to the local SPD office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. During an interview on 02/11/26 at 1:45 pm, Staff 1 (ED) reported there were no documented investigations completed for the above incidents. There was no documented evidence the facility immediately investigated the resident’s bruises to rule out suspected abuse or neglect, and there was no documented evidence the facility reported the incidents to the local SPD office. The need to ensure all incidents and injuries of unknown cause were immediately investigated to rule out suspected abuse, or reported to the local SPD office if abuse could not be ruled out, was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) at 11:45 am. They acknowledged the findings. Survey requested the facility report the above incidents to the local SPD office. Confirmation that the incidents were reported was received on 02/12/26 at 8:10 pm. 2. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage. Review of the resident's clinical record, including progress notes from through 01/12/26 through 02/12/26, identified the following: * On 01/19/26 staff documented in a progress note that Resident 3 “has visible bruising to the left side of [his/her] back.” * On 02/05/26 staff transcribed a hospice visit note into a progress note which read, “Bruises noted to left leg and right hip. Scabs noted all over legs and bruising on arms.” These conditions represented injuries of unknown cause which were required to be reported to the local SPD office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. There was no documented evidence the facility immediately investigated the injuries and documented how it reasonably concluded the injuries were not the result of abuse. The facility had not reported the injuries to the local office. The requirements for responding to an injury of unknown cause were reviewed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/12/26 at 11:50 am. They were unable to provide documentation of an investigation of the injuries of unknown cause. The surveyor directed the facility to report the incidents to the local office. Confirmation that the incidents were reported was received on 02/12/26 at 8:10 pm.

1. The following actions will be taken to correct the violation: a. Incident reports and investigations for resident 4's bruising on back on resident's left hand, bruises on left& right hand and bruising on her left was completed and self-report was sent Multnomah APS office. b. Incident reports and investigations for resident 3's 2 bruising on his back, left leg/ right leg & scabs all over legs & bruising on arms was completed & self-report was sent local SPD /Multnomah APS office. 2. How will the system to be corrected to this violation will not happen again? Training will be provided to all care staff and Med-Techs on the proper procedure for reporting new skin issues or bruising to the RCC/RN. Med-Techs will document any newly observed skin issues or bruising in the 24-hour report book to ensure timely review and follow-up by the RCC/RN. The RN/RCC will also review outside provider notes on a daily basis to ensure awareness of any newly identified skin issues or bruising and to initiate appropriate investigation and follow-up as needed. When there are new skin issues/ tear/ wounds and bruising RCC/RN will immediately do incident report and investigation and follow-ups to rule out abuse within 24-48 hours. If there are suspected abuse, injury of unknown cause will be reported to local SPD. 3. How often will the area needing correction be evaluated? The systems to ensure that Incident Reports and investigations are reviewed there will be a visual list of Incident Reports and be reviewed in the bi weekly clinicals that will be reviewed by Wellness Director RN, RCC and Executive Director. 4.Who will be responsible to see that the corrections are completed? The Wellness Director (RN) and Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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

OAR 411-054-0036 (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 the resident’s needs, provided clear direction regarding the delivery of services, and were implemented, for 2 of 5 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes and dementia. The resident’s clinical record from 11/05/25 to 02/09/26 was reviewed, observations were made, and interviews were conducted with the resident and staff. The following was identified: The service plan, dated 01/15/26, and 11/17/25 to 01/26/26 temporary service plans (TSPs), were not reflective of the resident’s current status and lacked clear instructions for staff in the following areas: a. During an observation of the resident’s room on 02/10/26 at 9:35 am, it was noted there was a half-length side rail and an air mattress on the bed. There was no information or instructions in the current service plan regarding the use of the side rail and air mattress. b. The current service plan indicated the resident had a catheter and included instructions for the catheter care. In an interview on 02/10/26 at 11:45 am, Staff 13 (MT/CG) reported the resident did not have a catheter at this time. The resident previously had a catheter, approximately two months ago, which was temporary and was no longer in place. c. The current service plan provided conflicting information regarding whether the resident required one- or two-person assistance for bathing. d. In an interview on 02/10/26 at 11:45 am, Staff 13 (MT/CG) reported the resident used a sensor to monitor his/her blood sugar level and staff changed the sensor every two weeks. However, the service plan did not include information about or care instructions for the blood sugar monitoring sensor. e. Review of the clinical record showed the resident received outside provider services - home health physical therapy and speech pathologist. However, the service plan did not provide information on these services, including who to contact and when. The need to ensure service plans were reflective of the resident’s status and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/11/26 at 10:30 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage without loss of consciousness, cerebral infarction, and weakness. The resident’s clinical record from 01/12/26 to 02/09/26 was reviewed, observations were made, and interviews were conducted with staff. The following was identified: The service plan, dated 01/12/26, and 01/18/26 to 02/02/26 temporary service plans (TSPs), were not reflective of the resident’s current status and lacked clear instructions for staff in the following areas: a. Review of the current service plan indicated that the resident required one-person assistance for transfers. During the acuity interview facility staff stated that Resident 3 required two-person assistance with transfers. During observations on 02/09/26 at 11:36 am and 02/11/26 at 11:58 am, two staff transferred the resident from the bed to the wheelchair. During an interview on 02/12/26 at 10:00am, Staff 11 and 12 (CGs) both confirmed that the resident required two staff for all transfers since the resident was admitted to the facility. b. The current service plan indicated the resident required one-person, full assistance with dressing, but could complete upper body dressing independently with verbal cueing. During observations on 02/09/26 at 11:36 am and 02/11/26 at 11:58 am it was noted that two staff were providing full assistance with dressing. In an interview on 02/12/26 at 10:00am, Staff 11 and 12 both confirmed that the resident required two-person assistance for dressing. c. The current service plan did not provide clear instruction for caregivers to apply barrier cream with every brief change or toileting. On 02/09/26 at 11:36 am observations were made during incontinence care. Staff 11 applied barrier cream. In interviews conducted on 02/12/26 with Staff 11, 12, and 13 (MT/CG) all confirmed that they applied barrier cream after toileting or incontinence care, per Hospice direction. d. The current service plan indicated that the resident was on aspiration precautions. There were no clear instructions to staff on what, how, or how often to monitor. In an interview on 02/11/26 at 1:58 pm, Staff 1 (ED) confirmed the service plan did not include clear instructions for staff. e. The current service plan indicated that the resident used multiple assistive devices for mobility and one-person transfers, including a walker, gait belt, and a wheelchair. In an interview on 02/12/26 at 10:00 am, Staff 11 and 12 both confirmed the resident did not use a walker or gait belt for transfers. The need to ensure service plans were reflective of the resident’s status and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 and Staff 2 (Wellness Director/RN) on 02/12/26 at 12:40 pm. They acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: 1. a. Resident 1's service plan, dated 2/10/26, has been reviewed and the service plan updated to reflect the the clear instructions to on how to use side rails & air mattress. b.Resident 1's service plan, dated 2/10/26, has been reviewed and service plan was updated and catheter and catheter care were taken out of the updated service plan. c. Resident 1s service plan, dated 2/10/26, was updated with clear instructions that bathing requires 1 person assist on bathing. d. Resident 1's service plan, dated 2/10/26, was updated with clear instruction on how to monitor blood sugar level & that staff changed sensor every 2 weeks and instructions on how to install sensor and care instructions for the blood sugar monitoring sensor. e. Resident 1's service plan, dated 2/10/26, has been updated that the resident is receiving Outside provider- home health PT and speech therapy, who are the providers and how often they visit. Resident 1's service plan have been updated with clear instructions to care staff on how to assist resident with his current care needs. Updates to Resident 1s service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting to allow for a clear understanding of responsibilities and forquestions and concerns to be discussed. 2.a Resident 3's service plan, dated 1/12/26, has been updated with clear instructions that resident requires 2 person assist with transfers. b. Resdient 3's service plan, dated 1/12/26, has been updated with clear instructions that resident require 2 person assist with dressing. c. Resident 3's service plan, dated 1/12/26, service plan has been updated with clear instructions that care staff are applying barrier cream after incontinence care/ toileting per hospice direction. d. Resident 3's service plan, dated 1/12/26, has been updated with clear instructions to the staff on what and how to monitor asperation precautions. e. Resident 3's service plan, dated 1/12/26, has been updated with what devices he uses and clear instructions on how to use & monitor current mobility devices. Resident 3's service plan have been updated with clear instructions to care staff on how to assist resident with his current care needs. Updates to Resident 3's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting to allow for a clear understanding of responsibilities and forquestions and concerns to be discussed. 2.How will the system be corrected so this violation will not happen again? To prevent reoccurance, all service plans will be audited weekly by the RCC to reflect the residents current care and and provide clear direction to the staff. RCC will do a weekly audit on the service plan binder to ensure the most current service plan ius availabe to the staff and that stafff has read and signed the service plans that have been reviewed. A portion of all staff meeting will be set aside to discuss any concerns and questions about how to provide care services to any resident to ensure understanding of staff responsibilities. 3. How often will the area needing evaluation be corrected? The systems to ensure the thorough completion of quarterly service plans, including clear directions to staff, will be evaluated by Wellness Director RN and and the Excutive Director monthly during Monthly Wellness Meetings. 4. Who will be responsible to see that corrections are completed and monitored. The Executive Director and the Wellness Director RN will be responsible for overseeing that the above systems are in place and continously monitored.

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 and document what action was needed for a short-term change of condition, ensure weekly progress for short-term changes of condition was noted until the condition resolved, and the resident was monitored consistent with his or her evaluated needs and service plan, for 3 of 5 sampled residents (#s1, 2, and 3) with changes of condition requiring monitoring. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including lichen planus and candidal stomatitis. The resident’s clinical record was reviewed during the survey, and interviews were conducted with the resident and facility staff. The resident was identified with a significant weight loss on 09/02/25. The facility RN assessed the resident’s status, met with the resident, a family member, the ED, and the former chef, and developed a plan to address the weight loss. The new interventions were documented in the resident’s service plan and included providing a smoothie every breakfast, obtaining weekly weights, and offering the resident meal options that were soft in texture so as not to irritate the resident’s mouth. Observations during the survey indicated the resident did not receive any smoothies. In an interview on 02/10/26 at 12:07 pm, Resident 2 stated the facility initially provided smoothies for approximately the first few weeks but had rarely provided smoothies since then. In an interview on 02/10/26 at 10:15 am, Staff 7 (Kitchen Chef/Director) stated the kitchen made bottles of Ensure (protein supplement) available and staff could take them as needed for residents. Staff 7 did not make smoothies for Resident 2. Staff 7 said there were a variety of soft foods any resident could request from the facility’s menu. In an interview on 02/10/26 at 2:20 pm, Staff 13 (MT/CG) stated she did not always make a smoothie for Resident 2. Staff 13 said there was no procedure for documenting when Resident 2 was given a smoothie. The reports that Resident 2 had not been receiving the smoothies each morning per the service plan were discussed with Staff 2 (Wellness Director/RN) on 02/10/26 at 2:30 pm. She stated she was not aware that staff were not providing the smoothies as service planned. She acknowledged this would explain why the resident had not regained all the lost weight yet. She said the plan had been developed with the previous Kitchen Director and said she was unsure whether Staff 7 had been informed of the weight loss interventions, including providing the smoothies. She said she would schedule a meeting with the resident, family, RCC, and Staff 7 to review the weight loss plan and update it as needed. The facility failed to monitor the service planned interventions to ensure they were being implemented and were effective. The need to ensure the resident was monitored consistent with his or her evaluated needs and service plan was reviewed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 02/11/26 at 2:30 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage. The resident’s clinical record was reviewed during the survey, and interviews were conducted with the resident and facility staff. The following was identified: a. Upon move-in, the facility placed the resident on “Alert Charting” and instructed staff to “monitor/observe how resident is adjusting to community.” Review of the subsequent Alert Charting documentation by staff indicated the staff did not document on how the resident was adjusting to the community as instructed. b. On 01/19/26, staff documented bruising to the left side of the resident’s back and on 01/30/26 staff documented the resident sustained a skin tear to the right lower leg/knee. In an interview on 02/12/26 at 11:50 am, Staff 2 (Wellness Director/RN) and Staff 3 (RCC) acknowledged no specific instructions had been developed and documented for monitoring the injuries. They acknowledged no weekly progress was noted regarding the conditions or whether they were resolved. The facility failed to determine and document what action was needed for the resident following these short-term changes of condition and failed to ensure weekly documentation of the conditions until they were determined to have resolved. The need to ensure actions/interventions were determined and documented following a change of condition, and the progress of the condition was noted at least weekly until resolved, was reviewed with Staff 1 (ED), Staff 2, and Staff 3 on 02/12/26 at 11:50 am. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes, and dementia. The resident’s clinical records, including 01/15/26 service plan, 11/07/25 through 01/26/26 temporary service plans, and 11/05/25 through 02/09/26 charting notes, were reviewed. Staff interviews were conducted which indicated the resident experienced multiple changes in condition. The following was identified: * On 11/10/25, the resident was sent to the emergency department and admitted to the hospital due to low oxygen saturation and low heart rate; * On 12/10/25, the resident’s diet was changed to thin liquids; * On 12/14/25 and 12/15/25, the resident’s right leg was swollen. The resident had an urgent care visit and was prescribed an antibiotic to treat the leg; * On 12/19/25, the resident was found on the bathroom floor; and * On 01/24/26, the resident was sent to the emergency department and returned to the facility on 01/26/26. The facility developed the temporary service plans for the above changes in condition to inform staff what to monitor and document, and staff initiated progress notes. However, there was no documented evidence the facility monitored the resident’s conditions until resolution. In an interview on 02/10/26 at 12:35 pm, Staff 3 (RCC) acknowledged the facility did not document on the progress of the resident’s changes of condition until the conditions were resolved. The need to ensure the facility monitored and documented weekly progress in the resident’s record until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 on 02/11/26 at 10:30 am. They acknowledged the findings.

The following actions will be taken to correct the violation for each resident: 1 a. Resident 2's weight loss intervention having shake every breakfast was updated by adding monitoring in EMAR as a treatment that Med-techs will be checking daily if she received shakes, if she has not received on Med-tech will remind the kitchen. The kitchen staff was given an updated list of specialized diets. Clear and specific directions have been provided to staff via written documentation in EMAR, in the resident's service plan & the kitchen has given clear instruction about updated specialized diet list for Resident 2. 2 a. Resident 3's alert charting . Wellness RN and RCC will update and give clear instructions when a resident is on alert charting what to monitor and what to document specifically. Re-training on Med-techs on documenting alert charting. b. Resident 3's injuries was re-assesed by Wellness Director RN and most current treatment and monitoring was added Treatment Administration Record on EMAR. Registered Nurse will continue to evaluate, monitor, and document on Resident 3's injury progression and effectiveness of current interventions and ordered treatments weekly until resolved. The Registered nurse will provide education to all care staff members on what signs and symptoms to monitor for, when to alert a licensed nurse of concerns, how to alert a licensed nurse of concerns, and when the wounds need urgent medical attention. Clear and specific directions will be provided to staff via written documentation in EMAR and in the resident 3's service plan. Registered Nurse will continue to monitor of any potential signs that the injuries has progressed to a significant change of condition. c. Resident 1's service plan was updated including previous significant change of condition low oxygen and low heart rate, edema on his legs and multiple visits to hospital due to low oxygen issues. Registered Nurse will continue to evaluate, monitor, and document on Resident 1's oxygen issues and effectiveness of current interventions and ordered treatments weekly until resolved. The RN will provide education to all care staff members on what signs and symptoms to monitor for, when to alert a licensed nurse of concerns, how to alert a licensed nurse of concerns, and when resident needs urgent medical attention. Clear and specific directions will be provided to staff via written documentation in EMAR and in the resident 3's service plan. Registered Nurse will continue to monitor of any potential signs that conditon has progressed to a significant change of condition or until condition has resolved. How will the system be corrected so this violation will not happen again? A visual list of residents with skin issues, wounds, falls, changes of condition, and re-admission from hospitalization will be placed on a communication board in the Wellness Office, along with the most recent date of evaluation. This list of residents will be discussed during weekly clinical meetings with the RCC, Wellness Director (RN), and Executive Director. Any updates to resident-specific interventions will be communicated to care staff by providing clear instructions via the service plan. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24- hour alert logs to identify any changes of condition or wounds that have not yet been addressed by the licensed nurse. 3.How often will the area be needing correction be evaluated? The effectiveness of the visual list of residents via a communication board and the discussions of changes of conditions during bi- weekly clinical meetings will be reviewed by the Wellness Director (RN) and the Executive Director monthly during monthly Wellness Management meetings. 4. The Executive Director and th Wellness Director RN will be resposible for ensuring that the correction are completed and monitored.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 1 sampled resident (#3) whose personal care was observed. Findings include but are not limited to: Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage. Observations were made during the survey to determine adherence to universal precautions for infection control. On 02/11/26, at 11:50 am, the surveyor obtained permission and observed Staff 13 (MT/CG) and Staff 15 (CG) provide incontinence care to Resident 3. During the observation, Staff 13 and Staff 15 failed to change gloves after removing a soiled incontinence product and wiping urine from Resident 3's perineum and before handling clean items. Staff continued to use the same gloves while touching the resident’s clothing and wheelchair during transfer from bed to chair. Staff 13 then began to change the bed, tossing linens onto the roommate’s bed (spouse) to change the sheets. Staff 15 took Resident 3 into the bathroom to assist with personal hygiene, oral care, and grooming. In an interview immediately following the observation, Staff 13 and 15 acknowledged they both forgot to change their gloves after handling soiled items and before handling clean items. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 4 (Business Office Manager) on 02/12/26 at 12:50pm. They acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: Resident 3 on 3/6/26 All staff in-service on Universal precautions: proper handling use of gloves after handling soiled items and before handling clean items. All staff were assigned to take About Infection Control and Prevention training through Oregon Care Partners-Relias video. 2 How will the system be corrected so this violation will not happen again? Every other month, universal precautions will be reviewed/in-serviced at monthly all-staff meetings. 3. How often will the area needing correction be evaluated? RCC / OR Wellness Director RN 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 univeral precaution and proper use of gloves. 4. Who will be responsible to see that the corrections are completed/ monitored? The Executive Director and th Wellness Director RN will be resposible for ensuring that the correction are completed and monitored.

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)(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 physician orders were carried out as prescribed for 1 of 5 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes, and dementia. Resident 1's physician’s orders, dated 09/28/25 and 01/26/26, and MAR/TARs, dated 01/01/26 through 02/09/26, were reviewed. The following was identified: a. The resident had a physician's order to administer finasteride 5 mg for bladder retention daily. The MAR showed 14 occasions staff documented the medication was not administered because it was unavailable. b. The resident had a physician's order to apply Nystatin powder three times daily. The TAR showed two occasions staff documented the treatment was not applied because it was unavailable. The need to ensure all medication orders and treatments were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN

1. The following actions will be taken to correct the violation: a. Resident 1 Med techs will have an in-serviced on documentation and Notification to RCC/ Wellness Director RN of any medication they have not received within 48 hours of reorder. In-service includes medication ordering, follow-up, documentation, notifying physicians for missed medications. b. Resident 1 Nystatin. Med techs will have an in-serviced on documentation and Notification to RCC/ Wellness Director RN of any medication they have not received within 48 hours of reorder. In-service includes medication oredering, follow-up, documentation, notiying physicians for missed medications. 2. EMAR dashboard report for Exceptions - order unavailable, missed meds and order expring soon will be printed daily and be reviewed by Med-tech and RCC after each shift, follow-up to be documented in the chart notes. 3. RCC and/ or Wellness Director RN will be reviewing at least 2x a week EMAR dashboard during clinical meeting. 4.The Executive Director and the Wellness Director RN will be responsible for ensuring that the corrections are completed and monitored.

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 consent to orders for 2 of 2 sampled residents (#s 4 and 5) who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 4/2019 with diagnoses including dementia, major depression, and neurocognitive disorder. The resident's 01/01/26 through 02/09/26 MARs and all physician orders were reviewed. On 02/02/26, the resident was documented as refusing: * Betamethasone (corticosteroid) .05% ointment; * Minocycline (antibiotic) 100 mg caplet; * Prescription anti-itch lotion (anti-inflammatory); and * Valerian root (supplement) 500 mg capsule. There was no documentation that the facility notified the resident’s physician/practitioner of these refusals. During an interview on 2/11/26 at 2:45 pm, Staff 1 (ED) confirmed that she was unable to find documentation of notification. The need to notify the practitioner when a resident refused to consent to orders was discussed with Staff 1, Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/12/26 at 11:45 am. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 08/2024 with diagnoses including severe protein-calorie malnutrition. The resident's 01/01/26 through 02/09/26 MARs and all physician orders were reviewed. The MAR indicated Resident 5 refused multiple prescribed medications on: * 01/02/26; * 01/06/26; * 01/07/26; * 01/23/26; * 01/24/26; * 01/26/26; and * 02/05/26. There was no documented evidence the facility notified the resident’s physician/practitioner of these refusals. In an interview on 02/11/26 at 12:40 pm, Staff 2 (Wellness Director/RN) acknowledged that she was unable to find documentation of notification. The need to notify the practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 02/11/26 at 2:30 pm. They acknowledged the findings.

1. The following actions will be taken to correct the violation: a. RCC will review Resident 4 's MAR/TAR and alert her primary care physician (PCP) of any refusals for medications or treatments for the last quarter. In addition, the PCP's preference will be requested on how often they want to be alerted of medication refusals. This will be added to QuickMAR as an order for MedTechs to fax a list of medication refusals to the PCP at their preferred frequency. b. RCC will review Resident 5's MAR/TAR and alert her primary care physician (PCP) of any refusals for medications or treatments for the last quarter. In addition, the PCP's preference will be requested on how often they want to be alerted of medication refusals. This will be added to QuickMAR as an order for MedTechs to fax a list of medication refusals to the PCP at their preferred frequency. 2. All med-techs will have an in-service/ re-training for medication documentation including re-ordering medication, follow-up docmentation, notifying physicians for missed medications. The RCC will add physicians preference communication on EMAR for missed meds and will review this system 2x a week to ensure timely communications with the physicians. 3. The audit and review of alerting physicians of resident refusals to ordered medications or treatments will be reviewed by the Wellness Director RN and the Executive Director monthly during monthly Wellness Management meetings. 4.The Wellness Director RN and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an accurate Medication Administration Record (MAR) was kept for all medications that were ordered by a legally recognized prescriber and administered by the facility, for 2 of 4 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage without loss of consciousness, cerebral infarction, and weakness. The resident’s clinical record from 01/12/26 to 02/09/26 was reviewed, observations were made, and interviews were conducted with staff. The following was identified: a. On 02/03/26, the resident was prescribed PRN Ativan 0.5 mg every four hours as needed for nausea and/or agitation and/or anxiety, with parameters describing agitation and anxiety as evidenced by restlessness, calling out, fearful, inconsolable yelling, pacing, and/or physical aggression towards self or others. The resident was also prescribed morphine 5 mg every 15 minutes as needed for pain or shortness of breath, with parameters describing shortness of breath and pain as evidenced by labored respirations and/or respiratory rate greater than 25 per minutes or moderate pain as evidenced by grimacing, moaning, stiffening, or guarding of body parts, and/or pain rated 4-6 out of 10 on a verbal or PAINAD pain scale; the order also included instructions for when to notify the hospice RN. However, the parameters from the physician orders were not transcribed to the MAR. In an interview on 02/11/26 at 1:25 pm, Staff 13 (MT/CG) confirmed there were no clear parameters on the MAR to determine when to administer these medications to the resident. The facility failed to accurately transcribe the prescriber orders with resident specific parameters for PRN medications. b. The TAR directed staff to administer 2L per minutes oxygen via nasal cannula as needed for shortness of breath or if the resident’s oxygen saturation was below 92%. Staff monitored the resident’s oxygen saturation three times per day on the MAR. Between 02/01/26 and 02/09/26, the MAR indicated the resident’s oxygen saturation was below 92% on two occasions; however, there was no documented evidence that staff administered oxygen as prescribed. In an interview on 02/11/26 at 1:30 pm, Staff 13 (MT/CG) stated oxygen was administered when the resident had low oxygen saturations. The facility failed to accurately document on the MAR when PRN oxygen was administered. c. On 02/05/26 instructions were added to the MAR for staff to monitor Resident 3’s pressure reduction air mattress and ensure the bed and pressure redistribution functions were “on” every day and night. Between 02/05/26 and 02/08/26 staff documented daily in the morning and evening that they had checked the air mattress. During an observation by the RN surveyor, it was discovered that Resident 3 did not have a pressure reduction air mattress on his/her bed. The facility failed to ensure an accurate MAR because staff documented having checked an air mattress that did not exist. The inaccurate documentation regarding the air mattress was discussed with Staff 1 (ED) and Staff 3 (RCC) on 02/11/26 at 1:58 pm. The need to ensure that prescriber orders were transcribed accurately and that the facility accurately documented when treatments were administered was discussed with Staff 1, Staff 2 (Wellness Director/RN), and Staff 4 (Business Office Manager) on 02/12/26 at 12:40pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes, and dementia. Resident 1's 01/01/26 through 02/09/26 MAR and TAR were reviewed. The following was identified: * Staff were directed to administer vitamin C 1 to 2 tables daily. However, there were no clear parameters indicating when to administer one tablet versus two tablets. * Staff were directed to administer albuterol 2-4 puffs as needed for wheezing and shortness of breath. However, there were no clear parameters indicating when to administer two puffs versus four puffs. * There were multiple blanks on the MAR for routine wound care and oxygen therapy, where the facility failed to document whether the treatments were performed. The need for resident-specific parameters and instructions for PRN and scheduled medications and treatments, as well as MAR accuracy, were discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/11/26 at 10:30 am. They acknowledged the findings.

1. The follwing actions will be taken to correct the violation for each resident: 1. a. Resident 3's current PRN orders for Ativan and Morphine will be reviewed by the Wellness Director RN. The Wellness Director RN will add clear parameters to provide instructions for med-tech as to when to administer each medication for nausea and/or agitation and/or anxiety, and pain or shortness of breath as needed. b. Wellness Director RN will review Resident 3's treatment order for administering 2L oxygen and give clear instructions to med-tech when to adminster 2L oxygen as needed. c. Wellness Director RN will physically check DME equipment and will give clear instructions to care staff on how to accurately monitor equipment. 2.Resident 1's current order will be reviewed by Wellness Director RN and will add clear parameters for Vitamin C when to administer 1-2 tablets and Albuterol when administer 1-2 puffs as needed. Resident 1's MAR has multiple blanks for oxygen therapy & wound care, Wellness Director RN will be reviewing MAR weekly to ensure that med-techs are following treatments. 2. How often system will be corrected so this violation will not happen again? All med-techs for the community will receive a re- training conducted by Wellness Director RN regarding policies and procedures, including importance of parameters and clear instructions on how to administer PRN medications and treatments. The Wellness Director RN will review and audit the MAR/TAR and add clear parameters to multiple PRN orders for the same diagnosis. The Wellness Director RN will add clear parameters to all PRN medications and treatments as prescribed if needed. The Wellness Director RN will review all PRN orders and include parameters, if needed, prior to sending out the 90 day physician orders every quarter.

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

OAR 411-054-0060 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 interview and record review, it was determined the facility failed to ensure the use of supportive devices with restraining qualities were included in the resident’s service plan, evaluated on a quarterly basis, and the facility documented other less-restrictive alternatives were evaluated prior to the use of the device, for 3 of 3 sampled residents (#s 1, 3, and 5) who used a device with restraining qualities. Findings include, but are not limited to: During the acuity interview on 02/09/26, Staff 1 (ED) and Staff 2 (Wellness Director/RN) reported Residents 1, 3, and 5 used side rails on their beds. A side rail is considered a device with restraining qualities which requires an assessment, documentation, and inclusion in the resident's service plan. 1. Documentation regarding the use of a supportive device with restraining qualities was reviewed for Residents 1, 3, and 5. The form the facility used to assess the use of the device lacked documentation of what other less-restrictive alternatives had been evaluated prior to the use of the current device. The lack of this required documentation was reviewed with Staff 2 (Wellness Director/RN) on 02/11/26 at 12:40 pm. She acknowledged the form the facility used to document the use of the device lacked the required information. The lack of the required documentation was reviewed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 02/11/26 at 2:30 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes, and dementia and was observed to have a half-length side rail on the bed. Review of the resident's clinical record showed the assessment for the side rail use was completed by the RN on 06/27/25. However, it had not been reviewed quarterly as required. In an interview on 02/11/26 at 10:30 am, Staff 2 (Wellness Director/RN) confirmed the assessment for the side rail use had not been completed quarterly. The need to ensure any device with potential restraining qualities was evaluated on a quarterly basis was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 02/11/26 at 10:30 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage without loss of consciousness, cerebral infarction, and weakness. Observations of the resident and the resident's room on 02/09/26 showed bi-lateral quarter-length side rails were installed at the head of the hospital bed and were in the up position while the resident was in bed. The side rails appeared intact and in good repair. Review of the resident's 01/12/26 service plan indicated the resident used the side rails for bed mobility and transfers. There was no information providing clear instruction to staff about the correct use and precautions related to the use of the side rails. The need to ensure clear instruction for the correct use and precautions for side rails was included in the resident’s service plan was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 4 (Business Office Manager) on 02/12/26 at 12:40 pm. They acknowledged the findings.

The following actions will be taken to correct the violation for each resident: 1. Wellness Director RN will be updating the form for Use of Supportive Devices with Restraining Qualities with adding a section of what other less-restrictive alternatives has been evaluated prior to the use of the current device. All residents using supportive devices will be re-assessed using the new form. Wellness Director RN will re-assess / update for use of ½ side-rails quarterly. Wellness Director RN will update service plan and provide clear instructions to care staff about the correct use and precautions related to the use of side-rails. 2. A visual list of residents with devices that have restraining qualities in the Wellness Department along with the most recent date assessed, the list will be discussed in the weekly clinical meeting with RCC and Wellness Director RN. 3. The list of residents with Use of Supportive with Restraining Devices be reviewed by the Wellness Director RN and the Executive Director monthly during monthly Wellness Management meetings. 4.The Wellness Director RN and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to: The building had two floors where residents resided. There was a device stored on the second floor that was to be used to evacuate second floor residents who could not walk down the stairs in the event of an emergency. The “ABST (acuity-based staffing tool) Facility Entrance Questionnaire,” completed by Staff 1 (ED), was reviewed, and interviews with staff were conducted. The following was identified: * The community was currently home to 50 residents; * Six residents were noted to require the assistance of two staff with transfers; * Four of the six residents who required two-person assists required the use of a mechanical lift for transfers; and * Two residents who required the assistance of two staff and the use of a mechanical lift for transfers resided on the second floor. Staffing schedules indicated two direct care staff were assigned to the overnight (NOC) shift, from 10:00 pm to 6:00 am. In an interview on 02/12/26 at 8:40 am, Staff 1 confirmed the above information was accurate and at 11:02 am, Staff 1, Staff 2 (Wellness Director/RN), and Staff 3 (RCC) stated they were unaware how to use the assistive device to help residents down the stairs in the event of an emergency. They also stated they were unsure if two direct care staff were sufficient on the overnight shift to meet the fire safety evacuation standards. The need to ensure a sufficient number of direct care staff were present at all times to meet the fire safety evacuation standards during the overnight shift was reviewed with Staff 1, Staff 2, and Staff 3 on 02/12/26 at 11:14 am. They acknowledged the findings. Refer to C420 and C422.

1. The following actions will be taken to correct the violation for each resident: All staff will be trained to use the device for emergency evacuation using stairs. The Executive Director will be discussing with residents that use Hoyer lift if they are willing to move on the 1st floor if there are apartments that would be available. The community will be adding an additional care staff at NOC shift to be able to meet the fire safety evacuation standards. 2. Maintenance Director will train care staff every 2 months on all staff meeting on how to use device for emergency evacuation using the stairs. Aside from using ODHS ABST for staffing to accurately reflect current needs per shift based on information from each resident service plan and Executive Director will ensure a sufficient number of direct care staff are present at all times to meet the fire safety evacuation standards during the overnight shift. 3 Executive Director will evaluate with use of ABST and fire safety evacuation standards to define staffing needs once a month. 4.The Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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

OAR 411-054-0037 (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) evaluations were completed before a resident moved in and no less than quarterly at the same time the resident’s service plan was updated, for multiple unsampled residents. Findings include, but are not limited to: On 02/09/26 the current resident roster with move-in dates was provided, and the facility’s ABST data was downloaded for review. Interviews with staff were conducted, and the following was identified: The current resident roster and ABST indicated there were 50 residents who currently resided at the community. a. The move-in dates noted on the resident roster were reviewed with each resident’s ABST evaluation creation date, and determined that at least 26 residents’ ABST evaluations were not completed prior to moving in. b. The facility ABST indicated 30 resident evaluations were not reviewed and updated at least quarterly. On 02/11/26 at 2:28 pm, the above was reviewed with Staff 1 (ED), and she reported she reviewed each resident evaluation at least quarterly; however, she acknowledged the manner in which she reviewed them did not reflect the date they were reviewed. The need to ensure the ABST evaluations were completed before a resident moved in and no less than quarterly at the same time the resident’s service plan was reviewed, was discussed with Staff 1, Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/12/26 at 11:14 am. They acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: a. RCC will enter new residents and in ABST 1-2 days prior to move-in to ensure that staffing accurately reflects current needs of residents per shift based on information on initial assessment for the new resident. b. RCC will update ABST simultaneously as the service plan is updated. 2. A visual list of service plan due dates and ABST update check list as service plans are reviewed and updated. For new resident an ABST update will be included in the new- move in checklist. 3. The list of service plan due dates reviewed by the Wellness Director RN and the Executive Director monthly during monthly Wellness Management meetings. 4.The Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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 2 of 4 newly hired staff (#s 10 and 17) completed all required pre-service orientation training and 2 of 4 newly hired direct care staff (#s 9 and 10) completed the required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed on 02/10/24 at 12:15 pm with Staff 4 (Business Office Manager), and the following was identified: a. There was no documented evidence Staff 10 (CG) or Staff 17 (MT/CG), hired 01/22/26 and 11/05/25, respectively, had completed one or more of the following required 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; * Written job description; * Infectious disease prevention training; * Home and Community-Based Services training; and * LGBTQIA2S+ training. b. There was no documented evidence Staff 9 (MT/CG) and Staff 10, hired 01/23/26 and 01/22/26, respectively, had completed one or more of the following pre-service dementia care training topics: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need to ensure staff completed all required pre-service orientation training and pre-service dementia training was reviewed with Staff 1 (ED) on 02/10/26 at 12:57 pm. She acknowledged the findings, and no additional documentation was provided.

1. The following actions will be taken to correct the violation: a. Staff 10 & Staff 17 will have all required pre-service orientation topics: resident rights & values of CBC care, Abuse reporting requirements, Fire safety & emergency procedure, Written job description, Infectious disease prevention training, HCBS training and LGBTQIA2S+ training will be completed before working with residents and continuing their job duties. b. Staff 9 & Staff 10 will have required pre-service Dementia care training topics will be completed before working with residents and continuing their job duties. 2.Pre-service training for all current employees will be completed prior to beginning their job duties. For the newly-hired employees,all pre-service trainings including pre-service dementia, pre-service infection disease, resident rights and values of CBC, abuse reporting requirements, HCBS training, Fire & Safety emergency procedure, Providing Inclusive Care: Training for Oregon Long-Term Care Facility Staff and food handler's certification, will be required prior to beginning their job duties. 3. The system to ensure all employees have completed all required pre-service trainings prior to working with residents will be evaluated monthly during the monthly management meetings. RCC and BOM Director will do a monthly audit of pre-service training requirements to ensure compliance. 4.The Executive Director will be the responsible for ensuring the above corrections are completed and monitored.

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 3 of 4 newly hired direct care staff (#s 9, 10, and 17) demonstrated satisfactory performance in assigned job duties prior to working independently and 2 of 4 newly hired direct care staff (#s 10 and 17) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 02/10/24 at 12:15 pm with Staff 4 (Business Office Manager), and she reported staff identified below worked independently. There was no documented evidence Staff 9 (MT/CG), Staff 10 (CG), and Staff 17 (MT/CG), hired 01/23/26, 01/22/26, and 11/05/25, respectively, had demonstrated satisfactory performance within 30 days of hire and prior to working independently, in one or more of 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; * Conditions that require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitization; and * First Aid / abdominal thrust. The need to ensure direct care staff demonstrated satisfactory performance in any duty they were assigned and completed First Aid and abdominal thrust training within 30 days of hire was reviewed with Staff 1 on 02/10/26 at 12:57 pm. She acknowledged the findings and verified Staff 9, Staff 10, and Staff 17 worked independently. No additional documentation was provided.

The following actions will be taken to correct the violation: a. Staff 9, 10, and 17 will have all required trainings topics: Role of service plans in providing individualized care; Providing assistance with ADLs; Changes associated with normal aging; Identification, documentation, and reporting changes of condition; Conditions that require assessment, observation, and reporting; General food safety, serving, and sanitization; and First Aid / abdominal thrust within 30 days of hire completed before working with residents and continuing with their job duties. Staff 9,10 and 17 will have a care competency pass reviewed and signed by RCC and will have demonstrated satisfactory performance in their required job duties. 2. All current employees will be required to complete all the 30-day training requirements immediately. For newly-hired employees, all 30-day training requirements will be completed prior to their 30th day of hire. All Care staff will have required care competency pass and reviewed and signed by RCC. All med-tech will have completed medication pass training and demonstrated medication competency pass signed off by the HSD/Nurse. The Business Office Manager (BOM) and the RCC will be monitoring the care competency pass and medication pass competency for medication aides and 30-day training checklist for each employee. Those who have been unable to complete the 30-day training checklist prior to their 30th day of hire will be taken off the schedule until all required trainings has been completed. 3.The system to ensure that all employees have completed all required trainings prior to their 30th day of hire will be evaluated monthly during the monthly Management Meetings. The Executive Director and BOM director will do a monthly audit of the pre-service training requirements to ensure timely compliance. 4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct and record unannounced fire drills every other month in accordance with the Oregon Fire Code (OFC) and, if unable to meet the applicable evacuation level, make an immediate effort to ensure the evacuation standard is met and failed to ensure fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: On 02/10/26, fire drill and fire and life safety records for the previous six months were requested. a. Review of the documentation provided revealed there was no documented evidence the facility provided fire and life safety training for staff or conducted unannounced fire drills on alternate months. b. On 02/12/26, Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) reported the facility had a device to evacuate residents who resided on the second floor; however, they were unable to demonstrate how the device was used. The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months and make an immediate effort to ensure evacuation standards were met, was reviewed with Staff 1, Staff 2 and Staff 3 on 02/12/26 at 11:14 am. They acknowledged the findings.

The following actions will be taken to correct the violation: a. Maintenance Manager will have required fire and life safety training for all staff and conduct unannounced fire drills on alternate months. b. Maintenance Manager will be conducting training for all staff on how to use device to evacuate residents on the second floor. All staff will be able to demonstrate that they are able to use the device for evacuation. 2. The Maintenance Manager will schedule an unannounced fire drill in TELS what shift it will occur and on alternating months what training he needs to conduct for fire life safety training. Twice a year training on how to use device for evacuation of residents on the second floor. 3. The system to keep resident safe will be evaluated once a month during monthly meeting management. 4. The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct residents, 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. Findings include, but are not limited to: On 02/10/26, the facility fire and life safety records were reviewed. The facility lacked documented evidence residents were instructed within 24 hours of admission and re-instructed, at least annually, on general safety procedures, evacuation methods, and responsibilities. In an interview on 02/10/26 at 10:29 am, Staff 1 (ED) confirmed the facility did not have documentation of a system for instructing residents of fire and life safety procedures at move-in or annually. The need to ensure that residents received instruction in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area within 24 hours of admission, and were re-instructed at least annually, was reviewed with Staff 1, Staff 2 (Wellness Director/RN) and Staff 3 (RCC) on 02/12/26 at 11:14 am. They acknowledged the findings.

The following actions will be taken to correct the violation: a. All current residents will receive training on the facility's Fire and Life Safety Policies in March 2026 during the Town Hall Meeting and individually in small groups for those who are not in attendance. 2. All newly admitted residents will receive training on the facility's Fire and Life Safety Policies within 24 hours of admission - this task will be added on the new resident checklist for the Marketing Director, to complete during the admission process. The Maintenance Manager, or designee, will complete the annual training for fire and life safety procedures with all residents once a year - presently scheduled on January 31st through the TELS system. Residents who are unable to attend the annual training will be provided the information for fire and life safety procedures one-on-one. The Maintenance Manager will keep a record of annual trainings provided for each resident and when they were completed in the Fire and Life Safety Binder. 3. The system to complete annual trainings and provide proper documentation of fire and life safety policies and procedures to all residents within 24 hours of admission and annually will be reviewed once a month during the monthly Management Meetings. 4. The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

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: