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 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 11/2017 and had diagnoses which included a stroke, history of skin breakdown, and falls. During the entrance conference on 07/06/26, staff reported the resident required assistance with ADLs, had a history of skin breakdown on his/her bottom, falls, and was receiving home health physical therapy services. Resident 2’s clinical record, interviews with care staff, an interview with the resident, and observations during the survey revealed s/he needed staff assistance for ADLs, staff applied barrier cream to his/her bottom with incontinence care, needed one to two staff assistance with transfers, and smoked. Resident 2's current service plan, updated 05/20/26, was not reflective or did not provide clear directions to staff in the following areas: * Clothing preferences for sleeping; * Physical therapy services; * Two-person transfer assistance; * Use of barrier cream on his/her bottom; * Left hand contracture; and * Smoking interventions. The need to ensure the service plan was reflective of Resident 2's current needs and provided clear directions to staff was discussed with Staff 1 (Interim ED) on 07/08/26 at 12:20 pm. She acknowledged the service plan needed to be updated. No further information was provided.

The resident identified during the survey had his service plan reviewed and revised to accurately reflect his current assessed needs, preferences, interventions and services. The updated service plan includes clear instructions identifying who provides services, what services are provided, when, how and how often. The updated service plan was reviewed with direct care staff and signatures obtained after review, and were verified by the Health Services Director (RN). An audit of current resident service plans will be completed to ensure compliance with OAR 411-054-0036. Any service plan found to be incomplete, inaccurate, lacking resident preferences, missing required interventions or not reflecting resident needs will be corrected. Residents experiencing a significant change of condition will have their service plan reviewed and updated, reviewed with direct care staff and verified by the Administrator and Health Services Director (RN). The Administrator and Health Services Director (RN) will receive education regarding Oregon Administrative Rule 411-054-0036, including for initial service plans prior to move-in, 30 day updates, quarterly evaluations and service plan revisions, updates following significant changes of condition, documentation of resident preferences and individualized interventions, and dating and initialing all service plan revisions. This education will be provided by the company Clinical Compliance Nurse and monitored through weekly calls for four weeks with the Compliance Nurse, Administrator and Health Services Director (RN) to ensure compliance. The standardized service plan review checklist will be implemented to ensure required elements are addressed before completion. Service plans will be reviewed during care conferences and whenever there is a significant change in a resident's status. The Administrator or designee will audit resident service plans, or a minimum of 3 service plans per week for a consecutive three months. Audit findings will be documented and discussed with Health Services Director (RN) during daily Stand Up meetings. Any identified deficiencies will be corrected, with additional staff education provided as needed. Following three months of sustained compliance, audits will continue quarterly as part of the community's ongoing quality assurance program. The Administrator will be responsible to ensure the corrections are completed and monitored.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure short term changes of condition were monitored until resolution, interventions were determined, documented, and/or communicated to staff on each shift for 2 of 3 sampled residents (#s 2 and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted in 11/2017 with diagnoses which included a stroke and history of falls. Resident 2's clinical record and charting notes, reviewed from 04/15/26 through 07/07/26, revealed the following: The resident experienced short-term changes without documented monitoring at least weekly until resolution in the following areas: * Falls on 05/11/26, 05/19/26, 05/24/26 and 05/28/26; and * A skin tear. Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's condition at least weekly until resolution. Additional information was requested on 07/08/26. During an interview with Staff 3 (RN) on 07/08/26 at 11:30 am, she confirmed the lack of monitoring, at least weekly, until resolution for the falls and skin tear. The need to ensure short term changes of condition were monitored at least weekly until resolution was discussed with Staff 1 (Interim ED) on 07/08/26 at 12:20 pm. She acknowledged the findings. 2. Resident 3 moved into the facility in 10/2022 with diagnoses including atrial fibrillation and congestive heart failure (CHF). Resident 3’s clinical record including charting notes from 04/06/26 through 07/06/26 and six months of historical weight records were reviewed and identified the following: * On 04/03/26 : 177 pounds; * On 05/03/26 : 177.5 pounds; * On 06/03/26 : 212 pounds. A charting note identified the resident was hospitalized for exacerbation of CHF diagnosis on 04/06/26 and did not return to the facility until 04/28/26. Five days later, on 05/03/26, the facility recorded the resident’s weight was stable following the hospitalization. On 06/03/26, weight records showed Resident 2 experienced a weight gain of 34.5 pounds or an increase of 16.27% of total body weight since 05/03/26. During an interview on 07/07/26 at 1:05 pm, Staff 3 (RN) reported she didn’t evaluate the weight gain because she did not believe it was an accurate weight. Staff 3 reported the resident was not re-weighed to confirm the weight was inaccurate. There was no documented evidence actions or interventions were determined, communicated to staff on each shift and the condition monitored at least weekly through resolution. During an interview on 07/07/26 at 2:30 pm, Staff 3 provided documentation of the resident’s current weight of 185.5 pounds, which was a weight loss of 7.8 pounds or a decrease of 4.38% of total body since 06/03/26. Staff 3 acknowledged Resident 3 continued to have fluctuating weight and stated she was going to call the resident’s doctor to see if any changes were needed. The need to ensure short term changes of condition were monitored until resolution, interventions were determined, documented, and/or communicated to staff on each shift was discussed with Staff 1 (Interim ED), Staff 2 (Regional Operations Specialist) and Staff 3 on 07/08/26 at 1:03 pm. They acknowledged the findings.

The resident(s) identified during the survey were assessed by the Health Services Director (RN) and Administrator. Documentation of the resident's changes of condition were completed, interventions were implemented, monitoring initiated and the service plan reviewed and updated as indicated. The physician and responsible party were notified of service plan changes. Re-education will be provided to caregiving staff, medication aides and department heads on Oregon Administrative Rule 411-054-0040 regarding indentification, documentation, monitoring and follow-up of both short term and long term significant changes of condition will be provided. Our standard change of condition process in place has been reviewed, and will be fortified via Clinical Compliance Nurse training. Change of condition documentation and alert charting audit tool was added to daily Stand Up meetings to verify that required documentation, interventions, monotoring and service plan updates are being completed. The Administrator and Health Services Director (RN) will be receiving additional training with the Clinical Compliance Nurse pertaining to initiating, monitoring, and discontinuing significant change of condition status; as well as the related goals, interventions, and documentation. The Administrator and Health Services Director (RN) will audit residents placed on short term monitoring/alert charting or identified as having a change of condition. Audit will include verification of timely recognition and documentation, appropriate nursing assessment and appropriate notifications, completion of monitoring from onset through resolution, service plan revisions made when indicated, and completion of required documentation. Audit results will be reviewed during daily Stand Up meetings. Any identified deficiencies will result in staff coaching and additional education. This will be evaluated weekly. The Administrator will be responsible for ensuring that corrections are completed and monitored.

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

OAR 411-054-0037 (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 observation, interview, and record review, it was determined the facility’s acuity-based staffing tool (ABST) did not accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: A review of ABST documentation, interviews, and observations throughout the survey were completed. The following was identified: * The minutes recorded on the ABST did not match services provided by staff in multiple areas for Residents 2 and 3. The need for the ABST to accurately capture care time and care elements that staff were providing to each resident was discussed with Staff 1 (Interim ED) and Staff 3 (RN) during interviews on 07/08/26. They acknowledged the findings.

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, it was determined the facility’s acuity-based staffing tool (ABST) did not accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: A review of ABST documentation, interviews, and observations throughout the survey were completed. The following was identified: * The minutes recorded on the ABST did not match services provided by staff in multiple areas for Residents 2 and 3. The need for the ABST to accurately capture care time and care elements that staff were providing to each resident was discussed with Staff 1 (Interim ED) and Staff 3 (RN) during interviews on 07/08/26. They acknowledged the findings.

An audit of resident service plans and corresponding ABST entries has been initiated to verify that resident specific care elements are accurately reflected, care times are individualized and current, staffing plans meet both scheduled and unscheduled resident care needs, and posted staffing plans aligned with ABST recommendations/requirements. Staffing requirements have not changed as a result of the updated ABST. A process requiring ABST review will be established to ensure compliance with new move-ins, significant changes of condition, service plan revisions. A weekly review of staffing schedules against ABST will be implemented to ensure compliance. The Administrator or trained designee will audit two resident ABST data sets weekly for 8 weeks. The Administrator or trained designee will be responsible to see that corrections are completed/monitored.

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 the ABST was updated prior to move-in and no less than quarterly to correspond with the resident service plan update for 2 of 4 sampled residents (#’s 1 and 4) and three unsampled residents, and ensure the facility posted staffing plan contained the date it was effective. Findings include, but are not limited to: Review of the facility ABST from 07/06/26 through 07/08/26 identified the following: * Resident 4 and three unsampled residents were not entered into the facility ABST prior to move-in; * Resident 1’s ABST update didn’t correspond with the service plan update; and * The facility posted staffing plan lacked an effective date of when it was last reviewed and updated. The need to ensure the ABST was updated prior to move-in and no less than quarterly corresponding with the resident service plan update and the staffing plan included the date it was last updated was discussed with Staff 1 (Interim ED), Staff 2 (Regional Operations Specialist) and Staff 3 (RN) on 07/08/26 at 1:03 pm. They acknowledged the findings.

Immediately upon identification of the deficiency, the Administrator and Health Service Director (RN) initiated Acuity-Based Staffing Tool (ABST) updates to ensure data accuracy. The current staffing plan now has an updated and effective date on it. ABST will be updated with every admission, discharge, service plan update and change of condition. Health Services Director will receive additional education regarding this requirement. Education will be provided by Clinical Compliance Nurse by 8/7/2026. The Administrator will be responsible for overseeing the completion of the ABST audit and necessary updates.

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 4 of 4 newly hired direct care staff (#’s 6, 7, 8, and 9) had completed pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Interim ED) on 07/07/26 at 10:57 am. The following was identified: There was no documented evidence Staff 6 (MA/CG), hired 05/30/26; Staff 7 (CG), hired 04/24/26; Staff 8 (MA/CG), hired 05/14/26; and Staff 9 (CG), hired 04/26/26 had completed pre-service orientation training prior to beginning their job responsibilities in one or more of the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Food handler’s certificate; * Infectious disease prevention; * Home and community-based services training; * Dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating, and responding to behaviors, and reducing the use of antipsychotic medications; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Specific aspects of dementia care and ensuring the safety of residents with dementia, addressing pain, providing food and fluids, preventing wandering and elopement, and use of a person-centered approach. The need to ensure newly hired staff completed pre-service orientation training prior to beginning their job responsibilities was discussed with Staff 1, Staff 2 (Regional Operations Specialist), and Staff 3 (RN) on 07/08/26 at 1:03pm. They acknowledged the findings.

The community reviewed the personnel file of identified employees. Any missing pre-service orientation and required training topics are in the process of being completed and documented. Documentation will be placed in the employee personnel file.The Administrator is in the process of auditing employee personnel files to verify documentation of required pre-service orientation including written job descriptions review, resident rights, and values of community based care (including required LGBTQIA2S+ training), abuse reporting requirments, fire safety and emergency procedures, infectious disease prevenetion training, and any additional required orientation topics. Any deficiencies identified during the audit will be corrected and documented. The community will enforce its onboarding process to ensure no employee will begin job duties until all required pre-service orientation trainings have been completed and documented, a standardized new hire checklist will be completed and signed by the employee and the trainer before the employee is scheduled independently, the Business Office Manager and/or Administrator, or trained designee will verify completion of all required orientation documents prior to activation in the staffing schedule, and department managers responsible for hiring have been educated regarding the requirements of OAR 411-054-0070. The Administrator will audit all newly hired employee files to verify completion of required pre-service orientation before the employee begins providing resident care. Administrator will be responsible to ensure that the corrections are completed.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 6, 7, 8 and 9) had demonstrated competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (Interim ED) and Staff 2 (Regional Operations Specialist) on 07/07/26 at 11:40 am. There was no documented evidence Staff 6 (MA/CG), hired 05/30/26; Staff 7 (CG), hired 04/24/26; Staff 8 (MA/CG), hired 05/14/26; and Staff 9 (CG), hired 04/26/26 had demonstrated competency within 30 days of hire in one or more of the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving, and sanitation; * Other duties as applicable (med pass, treatments); and * First Aid and abdominal thrust. The surveyor requested Staff 6 and 8 refrain from passing medications and treatments until competency was demonstrated and documented. Staff 1 and 2 reported the MAs would not pass medications and they had a plan for Staff 3 (RN) to observe and document medication and treatment competency with Staff 8 on 07/08/26. They further stated Staff 9 was taking a Department-approved online medication course, and a medication pass would be observed on 07/09/26. The need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1, Staff 2, and Staff 3 on 07/08/26 at 1:03 pm. They acknowledged the findings.

The identified staff members will have completed all required compentency training and demonstrated satisfactory performance in the required areas through the return demonstration and competency validation. Training documentation will be been placed in each employee's personnel file. The Administrator will audit direct care employee's files to verify that the required orientation, compentency validation and 30-day training requirments are completed within the required timeframe. Any identified deficiencies are being corrected. Our standardized New Hire Onboarding checklist is being utilized to ensure all required orientation, competency and 30-day training requirements are met going forward. New direct care staff will remain under appropriate supervision until competency has been verified and documented for assigned duties. The Administrator will ensure that all direct care staff have completed required competencies within 30 days of hire.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drill and fire and life safety records from 01/2026 to 06/2026 were requested and reviewed with Staff 1 (Interim ED) on 07/08/26 at 11:28 am. During the review of the fire drill records the following was identified: * There was no documented evidence Resident 2 received annual re-instruction on fire and life safety; and * Resident 4, who moved into the facility in 06/2026, was not provided fire and life safety instruction within 24 hours of admission. Staff 1 confirmed the facility did not have documentation that Resident 4 was instructed on general fire safety procedures within 24 hours of admission and the facility would need to implement a system for annual re-instruction on general safety procedures. The need to instruct residents of general fire safety procedures within 24 hours of admission and re-instruct residents at least annually per the OFC requirements was discussed with Staff 1, Staff 2 (Regional Operations Specialist) and Staff 3 (RN) on 07/08/26 at 1:03 pm. They acknowledged the findings and Staff 1 provided documentation that Resident 2 was re-instructed on fire safety procedures on 07/08/26 during the re-licensure survey. However, she acknowledged the facility needed to provide annual re-instruction for other residents.

The community has reviewed resident record to identify residents missing required fire and life safety training documentation. Residents who had not received training will be provided instruction on general fire and life safety procedures, evacuation methods, resident responsibilities during fire drills, and the designated meeting place or fire-safe area in the event of an actual fire. A written record of the education including the date, and content presented will be placed in each resident's file. The community will enforce its move-in process to ensure that the resident receives training within 24 hours of move-in and annually thereafter. A copy will be kept in the residents file as well as the Fire and Life Safety Binder. Fire and Life Safety education will be incorporated into the community's annual resident education program. The Administrator will audit new move-in for compliance of 24 hour training requirements as well as annual training.

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