OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction for staff for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including diabetes. Observations of the resident, interviews with staff, and review of the resident's clinical record between 03/19/26 to 05/26/26 were completed. Staff indicated the resident was able to transfer on his/her own but sometimes required hands on assistance or standby assistance and ambulated independently with a walker. The resident also had a wheelchair available for longer distances and was able to get around on his/her own with the wheelchair as well. The resident could make his/her needs known and required standby assistance with portions of his/her ADLs. The resident’s service plan was not reflective and lacked resident specific direction for staff in the following areas: * Brace use; * Verbal aggression towards staff and other residents; * Foot wounds; and * Upper body dressing assistance. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 15 (Regional RN) on 05/28/26. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 03/2026 with diagnoses including congestive heart failure. Observations of the resident, interviews with staff, and review of the resident's clinical record between 03/30/26 to 05/26/26 were completed. Staff indicated the resident required assistance with transfers, was unsteady on her feet and a high fall risk. The resident ambulated independently with a walker in his/her apartment. The resident had a wheelchair available for longer distances; staff would escort the resident throughout the building as needed. The resident could make some of his/her needs known but was not consistent, could be very confused, was difficult to redirect when having verbal or physical behaviors and required assistance with his/her ADLs. The resident’s service plan was not reflective and lacked resident-specific direction for staff in the following areas: * Verbal and physical aggression towards staff; * Hallucinations and elopement attempts; * Wheelchair use and seat positioning; * Cushion use in the recliner; * Dressing assistance; * Transfer assistance; and * Agitation, screaming in hall and behaviors related to call light use. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 15 (Regional RN) on 05/28/26. The staff acknowledged the findings.

1. The service plans for Residents 1 and 2 have been updated in all deficient areas and are now reflective of their current care needs. 2. Re-train staff on completing Stop and Watches when a resident care needs have changed to ensure service plans are reflective of care and give clear diretion to the staff. 3. Service plans reviewed by care team routinely for accuracy and updated quarterly and at change of condition. 4. Administrator, RCC

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition had monitored progress weekly through resolution, evaluated effectiveness of current interventions and determined additional interventions as indicated for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including diabetes. The resident’s service plan dated 04/28/26 indicated the resident was alert, oriented and could direct his/her own care. The resident required standby assistance for a portion of his/her ADLs. The resident had a walker and a wheelchair available for ambulation and could determine which device s/he wanted to use and when. The service plan did not reflect any current skin breakdown, foot wounds or history of foot wounds. Review of the clinical record from 03/19/26 through 05/26/26 showed the following: * On 03/26/26, a scab was noted on the top of the right foot. The area was attributed to poorly fitted shoes. * On 04/23/26, multiple open sores were noted on both of the resident’s feet, including the tops of the toes and ankle on the left side. The resident complained of pain to the areas and was sent out to the emergency room for evaluation. * On 04/24/26, the resident was started on antibiotics for cellulitis. No specific area was noted as the location of the infection. * On 04/29/26, the resident was referred to the outpatient wound clinic for treatment of the foot wounds on both feet. * On 05/26/26, Staff 6 (Resident Care Nurse) noted the resident “was out of facility for evaluation.” No other notes were documented by the nurse. There was no RN assessment documented of the wounds. There was no additional documentation related to facility monitoring of the foot wounds within the resident’s progress notes, alert charting or on the resident’s 04/01/26 to 05/26/26 MAR/TAR. In interviews on 05/27/26, Staff 10 (CG) and Staff 16 (MT), indicated the resident had significant wounds to both feet. Staff 16 stated the resident went out to wound care every two days for treatment. The staff further indicated wounds were located on the tops of the resident’s toes, on his/her ankle and on the bottom of one of the resident’s feet. Staff 16 was not aware of any specific orders related to the foot wounds. In interviews on 05/27/26 and 05/28/26, Staff 15 (Regional RN) indicated there was no additional information regarding the foot wounds in the resident’s record. Staff 15 then obtained orders, initiated a service plan update, added treatment orders/information to the MAR/TAR and communicated all the information to the appropriate staff. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 15 (Regional RN) on 05/27/26 and 05/28/26. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 03/2026 with diagnoses including congestive heart failure. The resident’s service plan, dated 04/28/26, indicated the resident required assistance that ranged from standby to one staff assistance for his/her ADLs. The resident had a walker and a wheelchair available for ambulation; the resident was unable to safely walk long distances. The service plan indicated the resident had a healing pressure sore on his/her coccyx; no other information was provided regarding the sore. Review of the clinical record from 03/30/26 through 05/26/26 showed the following: * On 03/30/26, the resident called for staff assistance due to pain on his/her bottom. The resident reported s/he had two pressure sores from sitting too long. Staff noted they observed a small open wound on the right buttock/coccyx and a small black spot on the left buttocks. The physician was to be notified about the areas. * On 04/20/26, a note indicated vital signs were stable and wound care was completed to the left bottom. The area was cleansed, barrier cream applied and a foam dressing put over the wound. * On 04/22/26, a note indicated wound care was completed to left buttocks cheek, cleansed, “Calmo cream and foam bandage.” There was no additional documentation related to facility monitoring of the coccyx/buttocks wounds within the resident’s progress notes, alert charting or on the resident’s 04/01/26 to 05/26/26 MAR/TAR. In interviews on 05/26/26 and 05/27/26, Staff 10 (CG), Staff 11 (MT) and Staff 16 (MT) indicated they were not aware of any current open wounds on the resident. In an interview on 05/26/26, Resident 2 denied any problems with the skin on his/her bottom. The resident did indicate s/he had a hard time standing up and walking and it was painful if bumped his/her backside or legs on the arms of the recliner. In an interview on 05/28/26, Staff 15 (Regional RN) indicated the resident no longer had an open wound on his/her buttocks/coccyx. The area was resolved based on the information she located from home health and from staff. Staff 15 was unable to locate any facility monitoring of the wound or information on the resident’s 04/01/26 to 05/26/26 MAR/TAR. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator) and Staff 15 (Regional RN) on 05/27/26 and 05/28/26. The staff acknowledged the findings.

1. Resident 1 and 2's short term changes of condition to be added to alert charting and monitored through resolution. 2. Retrain medaides, RCC/Nurse on current Policy and Procedure for Alert charting on short term changes of condition and requirement to progress note at least weekly through resolution. 3. Medaide to review daily. RCC/Nurse to review weekly. 4. Administrator, RCC/Nurse

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 2) who sustained open pressure sores. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including diabetes. The resident’s service plan, dated 04/28/26, indicated the resident was alert, oriented and could direct his/her own care. The resident required standby assistance for a portion of his/her ADLs. The resident had a walker and a wheelchair available for ambulation and could determine which device s/he wanted to use and when. The service plan did not reflect any current skin breakdown, foot wounds or history of foot wounds. Review of the clinical record from 03/19/26 through 05/26/26 showed the following: * On 03/26/26, a scab was noted on the top of the right foot. The area was attributed to poorly fitted shoes. * On 04/23/26, multiple open sores were noted on both of the resident’s feet, including the tops of the toes and ankle on the left side. The resident complained of pain to the areas and was sent out to the emergency room for evaluation. * On 04/24/26, the resident was started on antibiotics for cellulitis. No specific area was noted as the location of the infection. * On 04/29/26, the resident was referred to the outpatient wound clinic for treatment of the foot wounds on both feet. * On 05/26/26, Staff 6 (Resident Care Nurse) noted the resident “was out of facility for evaluation.” No other notes were documented by the nurse. There was no RN assessment documented of the wounds. There was no information about the foot wounds on the resident’s 04/01/26 to 05/26/26 MAR/TAR. In interviews on 05/27/26, Staff 10 (CG) and Staff 16 (MT), indicated the resident had significant wounds to both feet. Staff 16 stated the resident went out to wound care every two days for treatment. The staff further indicated wounds were located on the tops of the resident’s toes, on his/her ankle and on the bottom of one of the resident’s feet. Staff 16 was not aware of any specific orders related to the foot wounds but had been told the wounds were “scraped out” by the wound clinic. In an interview on 05/26/26, Resident 1 indicated s/he was heading to the doctor to “take care of my feet.” The resident stated his/her feet could be painful at times and the feeling “not quite right.” The resident indicated s/he received assistance from staff when s/he called for help and tried to do what s/he could on his/her own. The resident did not want to elaborate further about his/her skin conditions or treatment. In interviews on 05/27/26 and 05/28/26, Staff 15 (Regional RN), indicated there was no additional information regarding the resident’s foot wounds in the resident’s record. Staff 15 then obtained orders, initiated a service plan update, added treatment orders/information to the MAR/TAR and communicated all the information to the appropriate staff. Staff 6 (Resident Care Nurse) was unavailable for interview during survey. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions was discussed with Staff 1 (Administrator) and Staff 15 on 05/28/26. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 03/2026 with diagnoses including diabetes. The resident’s service plan, dated 04/28/26, indicated the resident was alert, oriented and could direct his/her own care. The resident required assistance that ranged from standby to one staff assistance for his/her ADLs. The resident had a walker and a wheelchair available for ambulation; the resident was unable to safely walk long distances. The service plan indicated the resident had a healing pressure sore on his/her coccyx; no other information was provided regarding the sore. Review of the clinical record from 03/19/26 through 05/26/26 showed the following: * On 03/30/26, the resident called for staff assistance due to pain on his/her bottom. The resident reported s/he had two pressure sores from sitting too long. Staff noted they observed a small open wound on the right buttock/coccyx and a small black spot on the left buttocks. The physician was to be notified about the areas. * On 04/20/26, a note indicated vital signs were stable and wound care was completed to the left bottom. The area was cleansed, barrier cream applied and a foam dressing put over the wound. * On 04/22/26, a note indicated wound care was completed to left buttocks cheek, cleansed, “Calmo cream and foam bandage.” No additional documentation was made regarding the open area on the coccyx. There was no RN assessment documented of the wounds. There was no information on the resident’s 04/01/26 through 05/26/26 MAR/TAR about the coccyx wound. Review of outside provider notes located in the resident’s record and dated 04/15/26 through 05/27/26 showed home health nursing visits for wound care to the left buttock at least weekly. The first visit note that could be located was dated 04/15/26. Documentation was unclear when the first visit by home health nursing occurred and the first discovery of the wound being treated by home health. Treatments used by home health nursing were reflected in visit notes as cleansing of the wound, application of calmoseptine cream and area covered with a foam bandage. Staff were instructed to change the existing dressing if it became loose or soiled and to encourage the resident to offload pressure from the buttocks. Additional home health notes beginning on 05/05/26 documented multiple behaviors from the resident, increased confusion, sundowning, and verbally and physically abusive behaviors towards staff. In interviews on 05/26/26 and 05/27/26, Staff 10 (CG), Staff 11 (MT), Staff 13 (CG) and Staff 16 (MT) indicated the resident was frequently confused, could not remember why s/he called for assistance when using the call light, would attempt to hit staff and would wander up/down the hall screaming. The resident was not easily redirectable and would become more agitated and aggressive with staff as they tried to redirect or assist to calm him/her. In an interview on 05/26/26, Resident 2 could explain some of his/her needs and experiences at the facility. The resident became increasingly confused when asked about how to get help from staff, how long s/he had resided at the facility and the names of some items s/he tried to describe or explain. The resident denied any problems with the skin on his/her bottom. The resident did indicate s/he had a hard time standing up and walking and it was painful if s/he bumped his/her backside or legs on the arms of the recliner. Staff 6 (Resident Care Nurse) was unavailable for interview during survey. In an interview on 05/28/26, Staff 15 (Regional RN) indicated the resident no longer had an open wound on his/her buttocks/coccyx. The area was resolved based on the information she located from home health and from staff. Staff 15 was unable to locate any facility monitoring of the wound or information on the resident’s 04/01/26 to 05/26/26 MAR/TAR. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (Administrator) and Staff 15 on 05/28/26. The staff acknowledged the findings.

1. Significant Change of Condition RN Assessment has been completed for both Residents 1 and 2. 2. Retrain RN on requirements for significant changes of condition to ensure assessments are timely and include resident status and interventions made. 3. With each significant change of condition. 4. Administrator, RN

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure that ABST care time accurately reflected resident care needs for 2 of 2 sampled residents (#s 1 and 2) whose ADL care time and service plans were reviewed. Findings include, but are not limited to: Review of Resident 1 and 2’s service plans and the facility ABST showed inaccurate minutes recorded for care time in one or more of the following areas: * Treatments; * Cueing/redirecting due to dementia; * Interventions for behaviors; * Responding to call lights; * Monitoring for behaviors: * Transfers; * Bowel and bladder management; * Monitoring for physical conditions; and * Interventions for pain management. The need to ensure care element minutes entered into the ABST were accurately reflective of the resident’s current care needs was discussed with Staff 1 (Administrator) and Staff 15 (Regional RN) on 05/26/26 and 05/27/26. The staff acknowledged the findings.

1. The ABST to be updated to accurately capture the care times for Resident 1 and 2 and unsampled residents. Resident service plans will be reviewed to ensure accurate care is accounted for and will then base staffing needs off of resident acuity. 2. Resident service plans will be reviewed to ensure accurate care is accounted for and will then base staffing needs off the resident acuity. 3. With each service plan update 4. Administrator, RCC

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review it was determined the facility failed to ensure that their ABST was updated for each resident in connection with their service plan at a minimum on admission, 30 days after admission, quarterly and when a significant change occurred for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents whose ABST update dates were reviewed. Findings include, but are not limited to: Review of the facility’s ABST showed the following: a. Eleven of the 24 total residents entered for the assisted living facility showed the last ABST update was completed on 12/28/25. Service plans were updated for the eleven residents were completed between 02/11/26 and 02/13/26, and minimal to no changes in care levels were noted. b. Resident 1 experienced a significant change of condition related to open pressure ulcers to both feet on 04/23/26. A significant change assessment was not completed, and the service plan was not updated at that time. c. Resident 2 experienced a significant change of condition related to an open pressure ulcer to his/her coccyx on 03/30/26. A significant change assessment was not conducted, and the service plan was not updated at that time. The ABST entries and service plan updates were reviewed with Staff 15 (Regional RN) on 05/26/26 and 05/27/26. The need to ensure the residents’ service plans and ABST were updated together at least quarterly, with significant changes, on admission and within 30 days of admission was discussed with Staff 1 (Administrator) and Staff 15 on 05/27/26. The staff acknowledged the findings.

1. The residents ABST that was not reflecting changes in care needs will be updated for Resident 1 and 2. 2. Admin/RCC to be retrained on ABST process of completing it prior to move in and with each care change. 3. At move in and with each resident's service plan update. 4. Administrator, RCC

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics for 4 of 4 newly-hired staff (#s 7, 8, 9 and 14) and pre-service dementia training for 2 of 4 newly-hired staff (#s 7 and 14) had been completed prior to staff beginning their job duties. Findings include, but are not limited to: The facility's training records were reviewed on 05/26/26 and 05/27/26. There was incomplete documentation to show Staff 7 (MT), Staff 8 (CG), Staff 9 (CG) and Staff 14 (CG), hired 03/27/26, 03/04/26, 02/24/26 and 03/27/26 respectively, completed one or more of the following pre-service orientation topics prior to beginning their job duties: a. Staff 7 and Staff 9 lacked documentation on the completion of topics including; resident rights and values of CBC care, abuse reporting and fire safety and emergency procedures; b. Staff 7, Staff 8 and Staff 9 had not signed a written job description; c. Staff 8 and Staff 14 had no food handlers card; d. Staff 14 had no documentation of completion of the approved HCBS course, approved LGBTQIA2S+ course and preservice infectious disease prevention; e. Staff 7 and Staff 14 had not completed the required pre-service dementia topics. The requirements for pre-service orientation and training for all employees were reviewed with Staff 1 (Administrator), Staff 2 (Business Office Manager), and Staff 15 (Regional RN) on 05/26/26 and 05/27/26. The staff acknowledged the findings.

1. Staff 7, 8 and 14 listed as deficient have completed required trainings. 2. New hire documents to be reviewed prior to being scheduled on the floor for compliance. 3. With each new hire and annually. 4. Office Manager, Administrator

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure and document direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire for 4 of 4 newly hired staff (#s 7, 8, 9 and 14). Findings include, but are not limited to: The facility's training records were reviewed on 05/26/26 and 05/27/26, and the following was identified: There was incomplete documentation that Staff 7 (MT), Staff 8 (CG), Staff 9 (CG) and Staff 14 (CG), hired 03/27/26, 03/04/26, 02/24/26 and 03/27/26 respectively, demonstrated knowledge and satisfactory performance in the following topics: * 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. Staff 7 (MT), Staff 8 (CG) and Staff 14 (CG) received first aid and abdominal thrust training during the survey and documentation provided at the request of the surveyor. Staff 15 (Regional RN) additionally provided 1:1 training with remaining facility staff related to abdominal thrust to ensure all staff had a refresher. The need to ensure the facility documented that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (Business Office Manager), and Staff 15 on 05/26/26 and 05/27/26. The staff acknowledged the findings.

1. Staff 7, 8 and 14 will complete required trainings and competencies. 2. New hire documents to be reviewed prior to 30 days of employment for compliance. 3. With each new hire and annually. 4. Office Manager, Administrator

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code on alternate months, for alternating shifts and other fire life safety training was completed on the alternating, non-drill months. Findings include, but are not limited to: 1. Fire and life safety records from 12/2025 to 05/2026 were reviewed and showed: a. Drills were not consistently documented as completed for the assisted living facility including documentation of all required drill components for alternating shifts. b. No documented evidence that alternate routes were used during the drills. c. Fire drills were not conducted on alternating months with fire life safety training. 2. Interviews conducted on 05/18/26 and 05/19/26 with multiple memory care staff showed the staff were unaware of the designated meeting point to take residents to in the event of an evacuation. 3. In interviews on 05/27/26, Staff 10 (CG), Staff 13 (CG) and Staff 16 (MT) reviewed the evacuation needs of the second-floor residents with the surveyor. The staff indicated there were four residents who required extensive assistance of one to two staff and a physical device to get down the stairs in the case of an emergency evacuation. The staff were unaware of any special device available to assist those residents down the stairs who could not walk on their own. On 05/27/26, the posted staffing plan and monthly staff schedule for night shift, 10 pm to 6 am, showed there was one staff on duty in the assisted living facility. In an interview on 05/27/26, Staff 15 (Regional RN) was made aware of the residents who required assistance to get to the first floor in an emergency evacuation. Staff 15 provided documentation that a stair chair was ordered to assist with movement down the stairs for the residents who could not ambulate on their own or with standby assist from staff. The stair chair was expected to arrive within the next week. Staff 15 further indicated there was a handled sheet/blanket currently in the facility that could be used. Staff 15 additionally stated she added an additional staff member to the night shift beginning 05/27/26. The facility would be using agency to fill this position for the next week until a new hire in training was cleared for independent work, who would then take over the second slot in the assisted living for night shift. The posted staffing plan was updated to reflect the new minimum staffing plan. The need to ensure fire drills were conducted on alternating months from life safety training, conducted on alternating shifts, and that resident evacuation needs were met was discussed with Staff 1 (Administrator) and Staff 15 (Regional RN) on 05/27/26 and 05/28/26. The staff acknowledged the findings.

1. Staff to be re-trained on fire drill procedure including how to how to evacuate residents and the evacuation location. 2. Maintenance supervisor to be trained on how to conduct a fire drill in accordance with OAR. During evacuation drills, Maintenance supervisor to review findings with RCC and Administrator. 3. Monthly after each drill and as needed after non-scheduled evacuations. 4. Maintenance supervisor, Administrator

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

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must 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 environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 05/26/26 and 05/27/26 showed the following areas in need of cleaning or repair: * Multiple walls, doors in the hallways on both floors, and baseboards in the dining room and front entryway of the facility had scrapes, dings, chips, missing pieces of wood, spills and/or dark accumulation noted; * The carpet and laminate flooring were pulling apart at the transition to the dining room; frayed edges of carpet were noted near loose rubber transition spots; * Multiple pieces of flooring in the dining room were pulling away at the seams, creating large gaps and bubbled edges in the flooring; * Linoleum flooring in the supply room/chart room was bubbled, raised and created large, raised waves along the outer edges of the floor. Chunks of flooring were missing near the doorway with large cracks noted. Cupboards and drawers had spills, stains and some debris. The counter surface was chipped, with small pieces missing from the edges of the surface; * Numerous black/gray or red carpet stains, of various sizes, were noted in the hallways and the entryways near the elevator on both floors; * Large, deep gouges and numerous small scratches were noted to the dining room floor; * Multiple dining room chairs, and chairs in the activity room had stains, spills and or debris on the seats or backs. A red chair on the second floor and a tan chair in the front lobby had stains on the seats; and * Cupboards and drawers in the activity room had spills, stains and debris on surfaces. The oven in the activity room had debris and spills in the oven and inside of the burners. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) and Staff 5 (Maintenance Supervisor) on 05/26/26. The staff acknowledged the findings.

1. The areas of concern to be cleaned, painted, repaired, etc. 2. Maintenance supervisor to be retrained on CPM policies and procedures to follow routine building maintenance tasks and logs. 3. Monthly building walks and audits of maintenance logs and task sheets. 4. Administrator, Maintenance supervisor

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. 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, 8, 9 and 14) whose training records were reviewed. Findings include, but are not limited to: Refer to C 370.

1. Staff 14, listed as deficient have completed required trainings. 2. New hire documents to be reviewed prior to being scheduled on the floor for compliance. 3. With each new hire and annually. 4. Office Manager, Administrator

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: