OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the first revisit survey conducted 07/13/26 through 07/14/26, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations. Refer to the deficiencies in the report.

The management team will continue to meet on a regular basis to ensure facility corrects and remains in compliant in all reported deficiencies. This will be monitored on a weekly and as needed basis. This will be completed by August 28th, 2026. The Administrator and/or Assistant Administrator will be responsible in monitoring that this correction is complete.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity for 2 of 2 sampled residents (#s 1 and 2) who required assistance with ADLs or required wound monitoring. Findings include, but are not limited to: 1. Resident 2 moved into the community in 01/2023 with diagnoses including metastatic cancer and a history of a subarachnoid hemorrhage (bleeding in the brain). Interviews were conducted with Staff 10 (MT/CG) and Staff 11 (MT/CG) on 05/05/26 at 11:54 am and 05/06/26 at 9:24 am, respectively. Both caregivers reported Resident 2 required one-person assistance for toileting. On 05/05/26 at 9:30 am, Staff 10 was observed providing Resident 2 with toileting assistance. Staff 10 escorted the resident into his/her room and failed to close the apartment door. The resident’s bathroom door had been removed from its hinges; therefore, there were no doors to provide privacy for the resident when s/he used the restroom. Staff 10 assisted the resident to the toilet, doffed his/her pants and incontinent brief, and completed perineal care. Resident 2’s apartment door remained open for the duration of his/her care. On 05/06/26 at 9:15 am, Staff 10 and Staff 11 assisted the resident into his/her room and failed to close the resident’s apartment door. The staff assisted the resident to the toilet. Staff 10 left the room and failed to close the apartment door. Staff 11 continued to assist the resident with perineal care while the apartment door remained open. During an interview with Staff 11 on 05/06/26 at 9:24 am, she noted staff usually close the door, but she hadn’t because the surveyor was present. On 05/06/26 at 10:52 am during a third toileting observation, Staff 11 was instructed to provide cares as if the surveyor were not present. Staff 11 escorted the resident to the bathroom, provided toileting assistance, and failed to close the apartment door to maintain the resident’s privacy and dignity. The need to ensure residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 (RN) and Staff 5 (RCC) on 05/07/26 at 12:41 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2018 with diagnoses including quadriplegia and multiple pressure ulcers. In an interview on 05/06/26 at 12:30 pm, it was revealed staff were using cellular phones to send group texts containing protected health information and images. During the interview on 05/06/26, Staff 4 (RN) displayed images of Resident 1’s wounds and confidential identifying information about the resident on his cellular phone. The failure to ensure resident medical records were kept confidential was discussed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 and Staff 5 (RCC) 05/07/26 at 1:30 pm. They acknowledged the findings.

Staff have been reminded to completely shut bedroom and/or bathroom doors prior to providing personal care to maintin resident's privacy. A curtain has been installed in the specific resident's bathroom. Staff have been reminded not to use personal cell phones to share resident images and information. The management team is looking into options to properly share information while ensuring resident's medical records are kept confidential. This will be monitoried on a daily, weekly, and as needed basis. This will be completed by July 6th, 2026. The Administrator, Assistant Administrator, President/Chief Financial Officer, RCC, Lead Caregiver, and/or Office Manager will be responsible in monitoring this correction is complete.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the residents’ care needs, provided clear direction and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and were implemented for 2 of 4 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 11/2025 with diagnoses including chronic kidney disease and a history of colon cancer. The resident attended dialysis three days a week and had a colostomy. Resident 4’s clinical record, including the service plan dated 01/15/26 that was available to staff, was reviewed. Interviews with Resident 4 and facility staff were conducted during the survey. The service plan lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas: * The presence of pain; * Supplies needed for showering; * Precautions related to bilateral siderails; * Home health services; * Assist with ambulation with wheelchair to follow, gait belt and walker on non-dialysis days; * Where the resident took his/her meals and the preference of having tea with each meal; * Mental health issues including self-diagnosed Post-Traumatic Stress Disorder and assistance needed from staff; * Emptying and changing the colostomy bag; * Skin monitoring around the port and colostomy site; * Who ordered shower and colostomy supplies; * Environmental preferences; * Pick up and drop off times on dialysis days; and * Any precautions relating to taking vitals and the port placement. The service plan was not being implemented relating to obtaining a weight twice a month and consistently receiving showers twice a week. The need to ensure service plans provided clear direction, included a written description of who should provide the services and what, when, how, and how often the services should be provided, and were being implemented was discussed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 (RN), and Staff 5 (RCC) on 05/07/26 at 1:10 pm. They acknowledged the findings. 2. Resident 2 moved into the community in 01/2023 with diagnoses including metastatic cancer and a history of a subarachnoid hemorrhage (bleeding in the brain). The resident’s 02/03/26 to 05/03/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The service plan, dated 04/01/26, was not reflective of the resident’s current care needs and did not provide clear direction to staff in the following area: * Inappropriate urination including the typical locations where the urination occurred, management strategies, cleaning responsibilities, and when to report to the RN or administration. On 05/06/26 at 9:24 am, Staff 11 (MT/CG) stated the resident had a history of urinating in inappropriate places including garbage cans and on his/her bed. On 05/07/26, Staff 12 (MT/CG) and Staff 6 (Lead CG), at 9:24 am and 11:17 am, respectively, corroborated Resident 2’s inappropriate voiding. Between 05/05/26 and 05/07/26, multiple observations of Resident 2’s room and the hallway outside his/her room revealed a persistent urine odor. Additionally, on 05/07/26 at 10:47 am, a dark and wet area was visualized immediately next to Resident 2’s bed. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 (RN), and Staff 5 (RCC) on 05/07/26 at 12:41 pm. They acknowledged the findings.

The management team will meet on a regular basis to review resident service plans to ensure all information is included clearly and in full details so that all staff are aware of the resident's needs. This will include what, when, how, and how often the services should be provided in the following areas: presence of pain, supplies needed for showering, precuations related to bilateral siderails, home health services, assist with ambulation with wheelchair to follow, gait belt and walker on non-dialysis days, where the resident took his/her meals and the preference of having tea with each meal, mental health issues including self-diagnoses PTSD and assistance needed from staff, emptying and changing colostomy bag, skin monitoring around port and colostomy sites, who ordered shower and colostomy supplies, environmental preferences, pick up and drop off times on dialysis days, and any precautions relating to taking vitals and the port placement. The service plans will also include weight monitoring at least twice a month, shower schedules, and any inappropriate behaviors including with urination. This will be monitored on a weekly and as needed basis. This will be completed by July 6th, 2026. The Administrator, RCC, and RN will be responsible in monitoring this correction is complete.

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 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 4 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 3, and 4's current service plans were reviewed during the survey. There was no documented evidence service plans were developed and reviewed by a service planning team. On 05/07/26 at 11:30 am, Staff 5 (RCC) stated the service planning team consisted of herself, Staff 4 (RN), and Staff 3 (Assistant Administrator/Site Manager). Staff 5 stated that usually a copy of the service plan was sent to the resident’s power of attorney. Staff 5 stated the resident was not usually involved in the service planning process. In an interview on 05/07/26 at 11:45 am, Staff 4 acknowledged the resident was not involved in developing the service plan. On 05/07/26 at 3:40 pm, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 and Staff 5. They acknowledged the findings.

A service planning team which includes the resident, the resident's legal representative, if applicable, any person of the resident's choice, the administrator or designee, and at least one other staff person who is familiar with or who was going to provide services are included with developing the service plans. This will be monitoring on a weekly and as needed basis. This will be completed by July 6th, 2026. The Administrator, RCC, and RN will be responsible in monitoring this correction is complete.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure medications were kept secure between set-up and administration of medications for multiple unsampled residents. Findings include, but are not limited to: The RCF consisted of three buildings connected by sidewalks, called Buildings 1, 2, and 3. On 05/06/26 at 10:52 am, the Building 1 medication cart was observed parked in the hall between the shared bathroom and the resident dining room. The MT’s computer was open and logged in, and the drawers containing residents’ medication cards were unlocked. A tray with seven pill cups was observed on top of the cart, each filled with medications and marked with individual room numbers. Residents were observed walking past the cart as they entered the dining room. At 10:55 am, Staff 5 (RCC) approached the surveyor and stated the MT who was passing medications had left the building and taken the keys to the medication cart. Staff 5 then stood next to the med cart and monitored it until the MT returned at 11:02 am. The need to ensure medications were kept secure between set-up and administration of medications was discussed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 (RN) and Staff 5 on 05/07/26 at 1:30 pm. They acknowledged the findings.

Medication technicians have been retrained and reminded to not leave the medication cart unattended. If they do need to step away from the cart they need to put it back in the medicaton room if that is not possible they need to put any medication away, the cart must be locked, and the laptop must be shut or logged out of the medication administration records sytem. This will be monitored on a daily and as needed basis. This will be complete by July 6th, 2026. The Administrator, Assistant Administrator, RCC, RN, and/or Office Manager will be responsible in monitoring this correction is complete.

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 1 sampled resident (#2) who was prescribed a PRN medication for hypertension. Findings include, but are not limited to: Resident 2 moved into the community in 01/2023 with diagnoses including hypertension and a history of a subarachnoid hemorrhage (bleeding in the brain). Review of the resident’s 04/01/26 through 05/03/26 MAR and current physician orders identified the following: The resident was prescribed one half of a 50-12.5 mg tablet of losartan-hydrochlorothiazide daily as needed for systolic blood pressure readings above 140. According to Resident 2’s April MAR, the resident’s systolic blood pressure measured above 140 on five occasions which indicated the PRN losartan-hydrochlorothiazide should have been administered. However, there was no documented evidence the medication was administered in April. On 05/05/26 at 9:58 am, Staff 12 (MT/CG) confirmed Resident 2 did not receive the prescribed PRN hypertensive medication as ordered in five of five occasions. The need to ensure medications were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 (RN), and Staff 5 (RCC) on 05/07/26 at 12:41 pm. They acknowledged the findings.

Medication technician's have been retrained and reminded to follow resident's orders on the medication administrator records. If they have any questions they are to contact the resident care coordinator and/or the registered nurse. This will be monitored on a daily and as needed basis. This will be complete by July 6th, 2026. The Administrator, RCC, and RN will be responsible in monitoring this correction is complete.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 3 of 3 sampled residents (#s 5, 6, and 7) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 moved into the RCF in 04/2019 with diagnoses including chronic kidney disease, history of cerebral infarction (stroke), Type 2 diabetes, bilateral below the knee amputation, and was receiving dialysis treatment. A review of the residents’ clinical record and interview with Staff 4 (RN) on 07/14/26 at 10:34 am identified the following: * Prescribed Lispro Injection Solution 100 unit/ml, sliding scale dose based on the following units: 150-200 – 3 units; 201-249 – 6 units; 250- 300 – 9 units; 301- 350 – 12 units; 351 – 400 – 15 units; Greater than 400 – 18 units; and Notify MD (medical doctor) if greater than 500. * Review of the 7/2026 MAR showed on the following dates the sliding scale insulin order was not carried out as prescribed: 07/01/26 at 11:30 am CBG was recorded at 187; 07/01/26 at 4:30 pm CBG was recorded at 244; 07/02/26 at 11:30 am CBG was recorded at 197; 07/07/26 at 4:30 pm CBG was recorded 223; and 07/08/26 at 4:30 pm CBG was recorded at 161. The 7/2026 MAR showed zero sliding scale insulin units were administered for each of the above dates and times. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 3 (Assistant Administrator/Site Manager), Staff 4 (RN) and Staff 5 (RCC) on 07/14/26 at 2:00 pm. They acknowledged the findings. 2. Resident 6 moved into the RCF in 05/2023 with diagnoses including Parkinsonism/tremor and received dialysis treatment. A review of the residents’ clinical record and interview with Staff 5 (RCC) on 07/13/26 at 12:23 pm and Staff 4 (RN) on 07/14/26 at 10:34 am identified the following: There was no documented evidence written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer. The need to ensure the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications and treatments that the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 3 (Assistant Administrator/Site Manager), Staff 4 (RN) and Staff 5 (RCC) on 07/14/26 at 2:00 pm. They acknowledged the findings. 3. Resident 7 moved into the RCF in 03/2026 with diagnoses including end stage renal disease, hyperkalemia (high potassium levels), Type 2 diabetes, coronary artery disease, myocardial infarction with history of stent placement and was on dialysis. Review of the resident’s clinical record and interview with Staff 4 (RN) on 07/14/26 at 10:34 am identified the following: * Prescribed Lokelma 10g packet by mouth daily on non-dialysis days, space two hours apart from other medications (for high amount of potassium in the blood); * The 07/2026 MAR showed Lokelma was administered at 8:00 am; and * The 07/2026 MAR showed the following oral medications were provided at the same time (8:00 am) as the Lokelma: - Calcitriol oral capsule 0.25 mcg (for hyperparathyroidism); - Cinacalcet HCL oral tablet 90 mg (for hyperparathyroidism); - Clopidogrel Bisulfate oral tablet 75 mg (for heart disease); - Polyethylene Glycol oral powder (for constipation); - Senna oral tablet 8.6 mg (for constipation); and - Sucroferric Oxythydroxide 500 mg chewable tablet (for phosphate in the blood). Staff 4 reported that when the orders were received from the pharmacy, he and/or Staff 5 (RCC) would manually enter in the medications and treatments on the MAR. Staff 4 further stated, “it’s a scheduling error,” and he would correct the time frame for administrating the above medications. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 3 (Assistant Administrator/Site Manager), Staff 4 (RN) and Staff 5 (RCC) on 07/14/26 at 2:00 pm. They acknowledged the findings.

Medication techs will be retrained to ensure they are following medication orders correctly. Medication techs will be reminded to notify resident's primary care team, facility nurse, and/or resident care coordinator of any health changes, issues, and/or concerns. Resident's medication list will be sent for review and signature to the primary care physician on a regular basis to ensure all medication orders are up to date & correct. A system will be put in place to ensure medication orders are correctly added to the electronic medication administration record, Alis. This will be monitored on a weekly, quarterly, and as needed basis. This will be completed by August 28th, 2026. The Administrator, Resident Care Coordinator, and/or Nurse, will be responsible in monitoring that this correction is complete.

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 ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On 05/04/26 the acuity interview identified the following: * The facility was home to 41 residents; * The facility had three separate buildings – 1, 2, and 3; and * There was at least one resident who required two staff members for transfers in each building. On 05/05/26 at 10:39 am, the “Acuity Based Staffing Tool Entrance Questionnaire” was completed with Staff 6 (Lead CG), and the number of residents needing two staff members for transfers or care was identified: * Building 1: Two residents; * Building 2: Three residents; and * Building 3: Two residents. The staffing plan reflected the following: * Building 1 - Morning shift: Three CGs and one MT; - Swing shift: Two CGs and one MT; and - Night shift: Two CGs and one MT to float between the three buildings. * Building 2 - Morning shift: Two CGs and one MT; - Swing shift: Two CGs and one MT; and - Night shift: One CG. * Building 3 - Morning shift: One CG and one MT; - Swing shift: One CG and one MT; and - Night shift: One CG. Observations on 05/05/26 and 05/06/26 between 8:00 am and 3:00 pm in Building 3 showed one CG who stayed in the building, one CG who was in the building at times, and one MT who was in the building at times. The facility’s staffing schedule was reviewed and showed the MT floating between Building 1 and 3 for the morning and swing shifts on 04/27/26 and 04/28/26. An interview with Staff 7 (MT/CG) on 05/06/26 at 12:17 pm confirmed she was the MT on duty and floated between Buildings 1 and 3. An updated staffing schedule was received on 05/07/26 at 11:03 am that reflected at least two direct care staff in each of the three buildings for all three shifts. The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 (RN), and Staff 5 (RCC) on 05/07/26 at 1:10 pm. They acknowledged the findings.

The management team updated the schedule while surveyors were onstie on May 7th, 2026. All three buildings have sufficient direct care staff present at all times for the 24 hour scheduled and unscheduled needs of each resident according to the Acuity Based Staffing Tool. This will be monitored on a daily, weekly, and as needed basis. This will be complete by July 6th, 2026. The Administrator, Assistant Administrator, Lead Caregiver, RCC, and/or Office Manager will be responsible in monitoring this correction is complete.

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 qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and ensure ancillary staff including nursing and administrators were not used to meet the minimum caregiver staffing requirements. This is a repeat citation. The findings include, but are not limited to: On 07/13/26 the acuity interview identified the following: * The facility was home to 43 residents; and * The facility had three separate buildings – 1, 2, and 3. During the acuity interview on 07/13/26 at 10:19 am, Staff 5 (RCC) and Staff 6 (Lead CG) identified the following number of residents needing two staff members for transfers or ADL care needs was as follows: * Building 1: Two residents; * Building 2: One resident; and * Building 3: Two residents. The posted staffing plan dated 07/13/26 reflected the following: * Building 1: - Morning shift: Three CGs and one MT; - Swing shift: Two CGs and one MT; and - Night shift: Two CGs and one MT to float between the three buildings. * Building 2: - Morning shift: Two CGs and one MT; - Swing shift: Two CGs and one MT; and - Night shift: One CG. * Building 3: - Morning shift: One CG and one MT; - Swing shift: One CG and one MT; and - Night shift: One CG. Review of the staffing schedule from 07/13/26 to 07/19/26 showed the following: * Staff 3 (Assistant Administrator/Site Manager) was scheduled to provide direct care on five out of seven overnight shifts reviewed. * Staff 5 (RCC) was scheduled to provide direct care on seven shifts including day shift floating between Building 1 and 3. * Staff 4 (RN) was scheduled to work evening shift on 07/16/26. * 17 of 21 shifts, or 80% of the shifts were not staffed to the posted staffing plan. During an interview on 07/13/26 at 3:45 pm, Staff 18 (MT/CG) confirmed s/he was the MT on duty and floated between Buildings 1 and 3. S/he further stated, between him/herself and another MT, this was the usual staffing on the evening shift. Observations on 07/14/26 between 8:00 am and 4:30 pm identified the following: During the day shift on 07/14/26, Building 1 had two CGs. During an interview on 07/14/26 at 12:23 pm, Staff 6 (Lead CG) confirmed the lack of staff, including an assigned MT. During the day shift on 07/14/26, Building 3 showed one CG who stayed in the building and one MT who was in the building at times. During the evening shift on 07/14/26, observations showed Staff 19 (CG) was the only direct care staff in Building 3. While Staff 19 was providing care to a resident in the common space bathroom, other residents were heard calling for assistance. During an interview at 3:52 pm on 07/14/26, Staff 19 reported s/he often was left alone to work and needed to tell residents to wait because s/he “can’t be in two places at once.” Staff 19 reported Resident 7 and another unsampled resident had two-person care needs and transfers, and “there is nothing [Resident 7] can do for [him/herself].” The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident, including two-person care needs, and ensure ancillary staff including nursing and administrators were not used to meet the minimum caregiver staffing requirements was reviewed with Staff 1 (Administrator), and Staff 3 on 07/14/26 at 4:05 pm. They acknowledged the findings.

The Acuity Based Staffing Tool will continue to be updated as resident's care needs change. This will be used to ensure proper staffing needs are met for each building and shifts. This will be monitored on a weekly and as needed basis. This will be completed by August 28th, 2026. The Administrator, Assistant Administrator, Resident Care Coordinator, Lead Caregiver, and/or Office Manager will be responsible in monitoring that this correction is complete.

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 4 of 4 sampled newly hired direct care staff (#s 7, 9, 13, and 14) completed all required pre-service orientation training and required pre-service dementia training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were requested on 05/05/26 from Staff 3 (Assistant Administrator/Site Manager), and the following was identified: a. There was no documented evidence Staff 7 (MT/CG), Staff 9 (MT/CG), Staff 13 (CG), and Staff 14 (CG), hired 01/15/26, 09/01/25, 11/15/25, and 11/20/25, respectively, had completed 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 7, Staff 9, Staff 13, and Staff 14 had completed the following pre-service dementia care training topics prior to beginning their job responsibilities: * 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. On 05/07/26 at 2:45 pm, the need for direct care staff to complete all required pre-service orientation training and required pre-service dementia training was discussed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 (RN) and Staff 5 (RCC). They acknowledged the findings.

Employee files will be reviewed, especially newly hired, to ensure pre service orientation training and pre service dementia training are complete. The following required documents and training include 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 bases services training, and LGBTQIA2S+ training. The management team will implement a checklist to ensure these documents are complete for newly hired direct care staff . This will be monitored on a weekly and as needed basis. This will be complete by July 6th 2026. The Administrator, Assistant Administrator, and/or Office Manager will be responsible in monitoring this correction is complete.

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 3 of 3 sampled direct care staff (#s 7, 13, and 17) completed all required pre-service orientation training and required pre-service dementia training prior to beginning job responsibilities. This is a repeat citation. Findings include, but are not limited to: Staff training records were requested on 07/13/26 from Staff 3 (Assistant Administrator/Site Manager), and the following was identified: a. There was no documented evidence Staff 7 (MT/CG), Staff 13 (CG), and Staff 17 (MT/CG), hired 01/15/26, 11/15/25, and 04/10/26, respectively, had completed the following required pre-service orientation topics prior to beginning their job responsibilities: * Infectious disease prevention training; * Home and Community-Based Services training; and * LGBTQIA2S+ training. b. There was no documented evidence Staff 7 and Staff 13 completed the following pre-service dementia care training topics prior to beginning their job responsibilities: * 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. On 07/13/26 at 2:53 pm, the need for direct care staff to complete all required pre-service orientation training and required pre-service dementia training was discussed with Staff 3 and on 07/14/26 at 2:19 pm with Staff 1 (Administrator), Staff 4 (RN) and Staff 5 (RCC). They acknowledged the findings.

A checklist will be made to ensure newly hired direct care staff complete the required pre service training prior to providing care to residents. The following required documents and training include 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 bases services training, and LGBTQIA2S+ training. This will be monitored on an as needed basis. This will be completed by August 28th, 2026. The Administrator, Assistant Administrator, and/or Office Manager will be responsile in monitoring that this correction is complete.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 7, 9, 13, and 14) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 05/06/26 showed the following: There was no documented evidence Staff 7 (MT/CG), Staff 9 (MT/CG), Staff 13 (CG) and Staff 14 (CG), hired 01/15/26, 09/01/25, 11/15/25, and 11/20/25, respectively, had demonstrated competency in the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First aid/abdominal thrust. On 05/07/26 at 2:45 pm, the need to ensure all newly hired staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (President/Chief Financial Officer), Staff 4 (RN) and Staff 5 (RCC). They acknowledged the findings.

Employee files will be reviewed to ensure the completion of the following documents: role of service plans in providing individualized care, providing assistance in ADLs, changes associated with normal aging, identification, documentation and reporting of changes of condition, conditions that require assessment, treatment, observation and reporting, general food safety, serving and sanitation, and first aid/abdominal thrust. The management team will implement a checklist to ensure the documents are complete within 30 days of new direct care staff's hired date. This will be monitored on a weekly, monthly, and as needed basis. This will be complete by July 6th, 2026. The Administrator, Assistant Administrator, and/or Office Manager will be responsile in monitoring this correction is complete.

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 3 direct care staff (#s 7,13, and 17) demonstrated competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Review of the facility's training records on 07/13/26 showed the following: There was no documented evidence Staff 7 (MT/CG), Staff 13 (CG) and Staff 17 (MT/CG), hired 01/15/26, 11/15/25, and 04/10/26, respectively, had demonstrated competency in the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Additionally, Staff 7 lacked documented evidence first aid/abdominal thrust training was completed. On 07/13/26 at 2:53 pm, the need to ensure all direct care staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 3 (Assistant Administrator/Site Manager) and on 07/14/26 at 2:19 pm with Staff 1 (Administrator), Staff 4 (RN) and Staff 5 (RCC). They acknowledged the findings.

A checklist will be made to ensure all training and documents are complete within 30 days of new direct staff's hired date. Documents and training include role of service plans in providing individualized care, changes associated with normal aging, identification documentation and reporting changing of condition, conditions that require assessment, general food safety serving and sanitation, and first aid/abdominal thrust. This will be monitored on a weekly, monthly, and as needed basis. This will be completed by August 28th, 2026. The Administrator, Assistant Administrator, and/or Office Manager will be responsible in monitoring this correction is complete.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to: C 303, C 360, C 370, C 372, L 370, C 510, C 513.

Management team will continue to meet on a regular basis to ensure facility corrections are made and remains in compliant in all reported deficiencies. This will be monitored on a weely and as needed basis. This will be completed by August 28th 2026. The Administrator, Assistant Administrator, and/or Office Manager will be responsible in monitoring that this correction is complete.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure grounds were kept orderly and free of refuse, all maintenance equipment was stored, and that all chemicals and toxic materials were secured in a locked storage. Findings include, but are not limited to: The RCF consisted of three individual buildings connected by sidewalks, called Buildings 1, 2, and 3. On 05/06/26 at 11:00 am the facility grounds were toured with Staff 2 (President/Chief Financial Officer) and the following was identified: Building 1: * The resident smoking area was a deck outside Building 1. The ground below and around the deck had an accumulation of dry leaves, refuse, and cigarette ends; and * Empty oxygen tanks, an empty 50-gallon drum of solvent, ladders, and other maintenance equipment were stored on the ground between the maintenance shed and resident outdoor recreation area for Building 1. Building 3: * Six bins marked biohazard and containing used needles were stored on the edge of the resident outdoor recreation area. On 05/06/26 at 11:30 am the need to ensure a system was developed to ensure the smoking area was kept clear of litter and refuse, all maintenance equipment was stored, and that all chemicals, hazardous materials, and equipment were safely stored was discussed with Staff 2. He acknowledged the findings, and the oxygen tanks, solvent drum, and biohazard bins were removed on 05/06/26.

A checklist has been made to ensure the smoking area and all exterior areas are kept clear of liter and refuse, all maintenance equipment is properly stored, and all chemicals, hazardous materials and equipment are safely stored. This will be monitored on a daily and as needed basis. This will be complete by July 6th, 2026. The Administrator, Assistant Administrator, and/or President/Chief Financial Officer will be responsible in monitoring this correction is complete.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material and maintained in good repair, measures were taken to prevent the entry of rodents, flies, mosquitoes, and other insects, grounds were kept orderly and free of refuse with all maintenance equipment stored and to ensure the outdoor perimeter fencing was not secured to prevent exit. This is a repeat citation. Findings include, but are not limited to: The facility grounds were inspected on 07/13/26 through 07/14/26. The following was identified: The RCF consisted of three individual buildings connected by sidewalks, called Buildings 1, 2, and 3. a. The exterior pathway between Building 1 and 2 had two sections of the pathway where the concrete segments collapsed, creating an uneven surface and potential tripping hazards. Sidewalks connecting the three buildings had multiple areas of drop-offs from the sidewalk to the planting bed, up to 12 inches in some areas. b. There was evidence of an active nest of flying insects in the roof eaves near the outdoor resident use deck and smoking area. There were multiple resident use and common space windows and slider door screens missing, torn or threadbare in all three buildings allowing for the entry of flying insects, which were observed in all three buildings throughout the survey. c. On 07/13/26 and 07/14/26, ladders were stored outside of Building 3 and on the ground near the maintenance shed. d. The resident smoking area was a deck outside Building 1. The ground below, around, and underneath the deck had an accumulation of dry leaves, multiple empty plastic bottles, a one gallon can of roof patch, multiple pieces of wood with exposed nails, and metal pipes lying on the ground near the maintenance shed. e. The deck and smoking area off Building 1 had splintered handrails with exposed rusty nails and the deck flooring, including the ramp down from the deck, was bowed and uneven, creating potential tripping hazards. f. On 07/13/26, a perimeter fence gate had a keyed padlock securing the gate and prevented exit. The need to ensure a system was developed to ensure all exterior pathways were maintained in good repair, measures were taken to prevent the entry of rodents, grounds were kept orderly and free of refuse with all maintenance equipment stored, and ensure the outdoor perimeter fencing was not secured to prevent exit was discussed during a walkthrough of the facility grounds on 07/14/26 with Staff 1 (Administrator) and Staff 3 (Assistant Administrator/Site Manager). They acknowledged the findings.

The exterior pathway between building 1 and 2 will be fixed to ensure it is level. A border will be installed along the sidewalks to create a barrier from the drop offs. The nest of flying insects was removed and pest control is scheduled on a regular basis. All missing or damaged screens on doors and windows will be replaced or repaired. The ladder was moved to an appropriate storage location. All dry leaves, empty bottles, nails, and metal pipes were removed from under the outside deck. The outside deck and rails will be repaired A checklist will be created to ensure facility's exterior is properly maintained. This will be monitored on a daily, weekly, and as needed basis. This will be completed by August 28th, 2026. The Administrator, Assistant Administrator, and/or President/Chief Financial Officer will be responsible in monitoring this correction is complete.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior of the building was free from unpleasant odors and interior materials and surfaces were maintained in good repair. Findings include, but are not limited to: The RCF consisted of three individual buildings connected by sidewalks, called Buildings 1, 2, and 3. On 05/06/26 at 11:00 am the interior of the facility was toured with Staff 2 (President/Chief Financial Officer) and the following was identified: Building 1: * Floor damage and duct tape over cracks were observed in resident rooms 102 and 110; and * The short hall to the right of the Administrator’s office, laundry room, and shared bathroom outside room 109 had floor damage and duct tape. Building 2: * Resident Room 205 was missing the door to the bathroom; and * Room 205 and the hall outside were noted by surveyors to have persistent unpleasant odors throughout the survey. Multiple staff interviews and a family interview acknowledged the odors and attempts to clean the area due to odors. Building 3: * The shared resident shower and bathroom to the right of the kitchen had a ventilation fan missing the safety cover, and the fan was coated with dust. The cove base molding had come loose from the wall in the shower door. The need to ensure the interior of the building was maintained and kept free of odors was discussed with Staff 2 on 05/06/26 11:30 am. He acknowledged the findings.

All floor damage will be repaired and maintained. Resident 205 will have a curtain installed for their missing bathroom door. Housekeeping & management are looking into solutions to aide in the unpleasant odors in facility hallways. The noted bathroom ventilation fan has been repaired and cleaned. A checklist has been created to ensure facility's interior is properly maintained. This will be monitored on a daily, weekly, and as needed basis. This will be complete by July 6th, 2026. The Administrator, Assistant Administrator, and/or President/Chief Financial Officer will be responsible in monitoring this correction is complete.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior of the building, including walls, floors, and doors were maintained in good repair. This is a repeat citation. Findings include, but are not limited to: The RCF consisted of three separate and distinct buildings named Buildings 1, 2, and 3. The interior of the RCF was inspected during the survey from 07/13/26 through 07/14/26. The following was identified: 1. Building 1: a. Common areas: * Floor damage and duct tape over cracks were observed in resident rooms 102 and 110; * Laundry room, and shared bathroom outside room 109 had floor damage covered with duct tape; * Laundry room had an accumulation of dryer lint debris on the wall and floor behind the washing and drying machines; * Room 107 gap in the flooring near the entrance; * Room 116’s bathroom door and door jamb was damaged with missing trim and a missing/damaged screen on the slider door; * Multiple doors throughout, including 102, 103, 104, 105, 109, 110, 113, 114, 123, multiple hallway doors, exit door to the smoking area; and * Multiple handrails including near room 122, 123, and handrail leading to the dining room were loose, pulling away from the wall, and/or had gouges in the paint with exposed wood. b. Shared bathroom across from room 105: * Paint gouges in the door and door jamb; * Walls had gouges in the paint with exposed sheetrock; and * Ceiling had exposed sheetrock. c. Shared bathroom near room 120: * Floor/shower threshold on the floor was damaged allowing water to pool onto the floor; * Walls were damaged with holes and exposed sheetrock in some areas; and * Entrance door had paint damage. 2. Building 2: a. Common areas: * Multiple doors throughout the building had gouges, scrapes and missing paint; and * Handrails throughout the building had missing paint and exposed wood. b. Shared bathroom across from room 211: * Broken tile baseboard near the corner of the shower; * Holes and paint gouges in the wall with exposed sheetrock in multiple areas; and * A soiled and/or stained pillow and foam body wedges were stacked on a visibly dirty floor. c. Shared bathroom across from Room 205: * Multiple paint gouges with exposed splintered wood on the door and door jamb; * Paint gouges with exposed sheetrock; and * Floors, walls, and light switch had an accumulation of dirt and debris build-up. 3. Building 3: * The shared resident shower and bathroom to the right of the kitchen had a ventilation fan missing the safety cover; and * The cove base molding had come loose from the wall near the shower entrance. The need to ensure the interior of the building was maintained in good repair was discussed during a walkthrough of the building with Staff 1 (Administrator) and Staff 3 (Assistant Administrator/Site Manager) on 07/14/26. They acknowledged the findings.

All damaged floors will be repaired or replaced. Staff reminded to clean dryer lint debris throughout the laundry room. All damaged doors, handrails, and walls will be repaired, repainted, or replaced. All damaged bathroom floors/showers, baseboards, walls, and tiles will be repaired repainted, or replaced. All trash will be thrown away on a regular basis. A checklist will be created to ensure facility's interior is properly maintained. This will be monitored on a daily, weekly, and as needed basis. This will be completed by August 28th, 2026. The Administrator, Assistant Administrator, and/or President/Chief Financial Officer will be responsible in monitoring this correction is complete.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents' rights to privacy and dignity. Findings include, but are not limited to: Refer to C 200.

The management team has reminded and will continue to remind care staff the importance of ensuring resident's privacy are maintained specifically when staff are providing personal care. This will be monitored on a daily and as needed basis. This will be complete by July 6th, 2026. The Administrator, Assistant Administrator, President/Chief Financial Officer, RCC, Lead Caregiver, and/or Office Manager will be responsible in monitoring this correction is complete.

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

OAR 411-054-0070 (3)(b)(A)(B)(C) 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: (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) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 4 of 4 sampled newly hired staff (#s 7, 9, 13 and 14) whose training records were reviewed. Findings include, but are not limited to: Refer to C 370.

A checklist will be created to ensure all required documents and training are complete for all staff, especially newly hired direct care staff. This includes LGBTQIA2S+ traininig. This will be monitored on a weekly and as needed basis. This will be complete by July 6th, 2026. The Administrator, Assistant Administrator, and/or Office Manager will be responsible in monitoring this correction is complete.

OAR 411-054-0070 (3)(b)(A)(B)(C) 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: (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) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 3 of 3 sampled newly hired staff (#s 7,13, and 17) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to: Refer to C370.

A checklist will be created to ensure all required documents and training are complete for all staff, especially newly hired direct care staff. This includes LGBTQIA2S+ training. This will be monitored on a weekly and as needed basis. This will be complete by August 28th, 2026. The Administrator, Assistant Administrator, and/or Office Manager will be responsible in monitoring this correction is complete.