OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident injuries were promptly investigated to rule out abuse and/or neglect and reported to the local Department office if abuse could not reasonably be ruled out for 2 of 2 sampled residents (#s 1 and 2) who experienced injuries of unknown cause and a fall with injuries. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia without behavioral disturbance and Parkinson’s disease. The resident’s clinical record was reviewed, dated 05/01/26 through 08/17/26, and interviews with staff were conducted. The following was identified: * 07/08/26: Staff documented the resident had a new skin injury on the right lower leg near the ankle area. Staff further documented the resident was “unsure how [s/he] got it [the injury];” and * 07/14/26: The resident had an abrasion on the left elbow. Staff further documented the resident was unaware of what happened or when the injury occurred. These incidents represented injuries of unknown cause for which an investigation to rule out abuse was required. There was no documented evidence that the facility promptly investigated these incidents to determine the cause of the injury to rule out suspected abuse or neglect. On 08/18/26 at 2:02 pm Staff 2 (Health Services Director/LPN) confirmed the facility did not investigate to rule out abuse and did not report the incidents. During the survey, the facility was instructed to report these incidents to the local department. On 08/18/26 at 3:03 pm, these incidents were reported to the local department and confirmation was received. The need to ensure injuries of unknown cause were immediately investigated to rule out suspected abuse or reported to the local office if abuse could not be ruled out was discussed with Staff 1 (Administrator) and Staff 2 on 08/19/26 at 11:30 am. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 02/2020 with diagnoses including Alzheimer’s disease. Interviews with staff and review of the service plan, dated 08/10/26, and 05/17/26 through 08/17/26 progress notes, were completed. The following was identified: * 06/06/26: Staff documented “found resident sitting on bathroom floor with light off, walker was in the other room, resident had no shoes and no call pendant... right knee and foot pain”. On 06/09/26 staff documented “at first [s/he] reported [s/he] did not fall when asking how [s/he] got the bruise on the right foot”, and no cause of the injury could be identified. On 06/16/26 an x-ray confirmed the right foot was fractured; and * 08/11/26: Staff documented “[r]esident assistant reported bruise/skin discoloration on his/her right buttock... dark purple with some light purple around the center. Resident reported he/she is unsure how that happened”. Both injuries were unwitnessed, and Resident 2 was unable to say how they happened. There was no documented evidence the facility immediately investigated the resident’s injuries of unknown cause to rule out suspected abuse and there was no documented evidence the facility reported the incident to the local Department office. On 08/17/26 at 2:30 pm, the injuries of unknown cause were reported to the local Department office and confirmation was received. The need to ensure injuries of unknown cause were immediately investigated to rule out suspected abuse or reported to the local office if abuse could not be ruled out was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director/LPN) on 08/19/26 at 12:15 pm. They acknowledged the findings.

1. The injury of unknown cause identified during the survey wah reported to the local department office on 8/17/26 at approz. 2:30pm and confirmation of the report was received. The Administrator and Health Services Director/LPN will ensure that the incident is fully investigated and that the investigation includes, as applicable, the time, date, location, individuals present, and description of the event, staff response at the time of the event, follow-up actions taken, and the Administrator review. The resident will be assessed for any ongoing or additional injury, changes in condition, or safety concerns, and appropriate medical follow-up and monitoring will be provided as indicated. 2. Rose Schintzer Manor will reinforce its Abuse Prevention, Reporting, and Investgation process to ensure that all physical injuries of unknown cause are immediately recognized, investigated, documented, and reported to the local Department office as suspedted abuse unless an immediate facility investagation reasonably concludes and dcocuments that the injury was not the result of abuse. The Administrator and Health Services Director/LPN will review the facility's current incident reporting and investgation procedures with all licensed nursing staff and approiate supervisory staff. Training will specifically address: a) The definition and recognition of an injury of unknown cause b) The requirement for immediate reporting of abuse, suspected abuse, and injuries of unknown cause. c) The circumstances under which an injury of unknown cause may be resolved through an immediate investigation rather than a report to the Department. d) The required elements of an abuse/suspected abuse investigation e) The requirement that the Administrator review and document completion of the investigation. f) The process for obtaining Department reporting confirmation and maintaining that documentation in the incident record. All staff will be reminded that any employee who becomes aware of an injury of unknown cause must immediately report the concern to the Administrator, Health Services Director, or disignated supervisor in accordance with facility policy. Staff will not be expected to determine independently whether an injury constitutes abuse. A standardized review process will be implemented so that incident reports involving an injury of unknown cause are specifically identified and reviewed by the Administrator or designee for appropriate investigation, reporting, follow-up, and documentation. 3) For the first 90 days following implementation of ths plan of correctgion, the Administrator or designee will review 100% of incident reports involving injuries of unknown cause, suspected abuse, or allegations of abuse to verify: a)the incident wass identified and reported appropriately b) Required Department notification was made immediately when required. c) An investigation was completed promptly. d) The investigation contains all required elements e) Appropriate resident assessment and follow-up occurred. f) The administrator or designee reviewed and signed the investigation. g) Documentation of Department notification and confirmation is present when applicable. Re results of these reviews will be documented and maintained as evidence of compliance. Following the initial 90-day monitoring period, incident reporting and investigation compliance will continue to be reviewed as part of the facility's ongoing QAPI process and during regular clinical/leadership review of incident reports. Any identified variance will be immediately corrected, and additional staff educatio or corrective action will be provided as indicated. 4) The Administrator is responsible for overall implementation and monitoring of this Plan of Correction. The Health Services Directio/LPN is responsible for ensuring that nursing staff recognize, iummediately report, investigate, and appropriately document injuries of unknown cause and suspected abuse. The Administrator and Health Services Director/LPN will jointly monitor compliance and address any identified deficiencies immediately. Lastly, we would like to the five elements that are identified in an investigation: tiem/date/place/individuals present, description, staff response, follow-up and Administrator review part of our audit tool supporting the general chart review.

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

OAR 411-054-0045 (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 interview and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner 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 experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 02/2020 with diagnoses including Alzheimer’s disease. Interviews with staff and review of the service plan, dated 08/10/26, and 05/17/26 through 08/17/26 progress notes, physician communications, and weight records were completed. A note dated 06/23/26 documented: * “Doctor’s office reported that resident had a fracture to his/her right foot along with a skin impairment to his/her right leg”; * “CT scan showed acute or subacute infarct (stroke)”; and * “At the hospital presented with deficits in strength, balance, activity tolerance and functional mobility.” On 06/23/26, Staff 2 (Health Services Director/LPN) documented “Community RN to review the change of condition.” The fractured bone, stroke, hospital visit, and decreased functional ability constituted a significant change of condition for which an RN assessment was required. There was no assessment by the facility RN, or review until 07/16/26, when a note documented “RN reviewed LPN assessment.” There was no documented evidence of an RN assessment that documented findings, resident status, and interventions made as a result of the assessment. On 08/19/26 at 12:15 pm, the requirement for a timely RN assessment of significant changes of condition was reviewed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia without behavioral disturbance and Parkinson’s disease. The resident’s clinical record was reviewed, dated 03/30/26 through 08/17/26, and interviews with staff were conducted. The following was identified: Review of the weight record indicated Resident 1 experienced a loss of 11.6 pounds, or 9.61% of his/her body weight, between 05/04/26 and 06/03/26. This represented a significant change of condition for which an RN assessment of the weight loss was required. On 06/03/26, Staff 2 (Health Services Director/LPN) entered a note, and a follow-up was conducted on 07/16/26 regarding significant weight loss. The 06/03/26 note indicated the facility notified the physician and family members of the changes and added nutritional boost shakes. There was no assessment by the facility RN or review until 07/16/26, which was more than 30 days after the significant change in condition was identified. The note documented “this nurse does agree with change of condition plan of care for weight loss.” On 08/19/26 at 10:15 am, Staff 2 stated the facility had an RN who was on call but did not have a set schedule to be onsite. On 08/19/26 at 11:30 am, the requirement for a timely RN assessment for significant changes of condition was reviewed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

1) Resident 1&2 charts reviewed and addressing changes of conditions within 48 hours and will communicate with community RN for review. Facility LPN and RN will be in-serviced regarding the RN assessment for significant change of condition in a timely manner. 2) THe Health Services team will also be in-serviced regarding the requirements to notify the RN of the changes in status initiating an RN assessment as required for both short-term and long-term changes of conditions. 3) All residents with signifcant change of conditions will have their charts monitored at daily clinical meetings and by Health Services Director/LPN weekly. Administrator will follow up as well with consistent reviews weekly & monthly as needed. 4) The Administrator and Health Services Dirctor/LPN will monitor for the as mentioned above as well as for the next 90 days then quarterly.

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 (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 complete, update and review the acuity-based staffing tool (ABST) evaluation for each resident before a resident moved in, and failed to use the results of the ABST to develop and routinely update the posted staffing plan, and failed to ensure the staffing plan outlined the staffing numbers required to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to: a. Resident 3 moved into the facility in 07/2026. The resident’s ABST evaluation was not created until 15 days after move-in, not prior to move-in. b. On 08/17/26 at 11:02 am, the posted staffing plan was observed in the lobby and noted it was effective 07/23/26: * Day shift: Four Resident Assistants and two Health Care Coordinators (MTs); * Evening shift: Three Resident Assistants and two Health Care Coordinators; and * Night shift: Two Resident Assistants and one Health Care Coordinators. On 08/17/26, the facility’s ABST showed the minimum direct care staff required to address scheduled needs were: * Day shift – 6.5 (rounded up from 6.41); * Swing shift – 5.5 (rounded up from 5.12); and * NOC shift – 1 (rounded up from 0.99). On 08/19/26 at 12:41 pm, Staff 2 (Health Services Director/LPN) acknowledged the ABST minutes did not include time for unscheduled resident needs. In addition, she confirmed the facility was not using the results of the ABST to develop and update the posted staffing plan. The need to ensure residents’ ABST data was updated prior to move-in, the facility used the results of the ABST to develop and routinely update the posted staffing plan, and the staffing plan outlined the staffing numbers required to meet the scheduled and unscheduled needs of the residents was reviewed with Staff 1 (Administrator) and Staff 2 on 08/19/26 at 12:41 pm. They acknowledged the findings.

1) Resident 3's ABST evaluation was completed 15 days after the resident moved into the facility rather than prior to move-in as required. The Health Services Director/LPN and Administrator will review Resident 3's current ABST evaluation to ensure that it accurately reflects the resident's current care needs, including scheduled and unscheduled care needs. Any necessary corrections or updates will be completed immediately. The resident's service plan and ABST will be compared to ensure that the resident's identified care needs are accurately represented in the ABST and that the staffing requirements generated by the ABST are incorporated into the facility's staffing plan. Posted Staffing Plan The posted staffing plan observed on 08/17/2026 was not consistent with the staffing levels identified by the facility's ABST. The facility will immediately review and revise the posted staffing plan to accurately reflect the current ABST results and the staffing required to meet the scheduled and unscheduled needs of all residents on each shift. The revised staffing plan will include, at a minimum, consideration of: • ABST-generated direct-care staffing requirements for each shift. • Scheduled resident care needs. • Unscheduled resident care needs. • Required staffing under OAR 411-054-0070. • Staff meal and break periods. • Any segregated areas, if applicable. • Residents receiving services through a Specific Needs Contract, if applicable. • Residents receiving exceptional payments, if applicable. • Any anticipated operational disruptions or other factors that may affect the facility's ability to meet resident care needs. The facility will maintain documentation demonstrating that actual staffing meets or exceeds the posted staffing plan 24 hours per day, seven days per week. 2) Rose Schnitzer Manor will revise its admission and staffing processes to establish clear accountability for completion and review of the ABST. Pre-Move-In ABST Process Effective immediately, an ABST evaluation will be completed and reviewed before every new resident moves into the facility. The admission process will include a specific ABST verification step. The Administrator or Health Services Director/designee will verify completion of the ABST before the resident's move-in is approved. No resident's admission process will be considered complete until the ABST has been completed, reviewed, and incorporated into the facility's staffing plan as appropriate. Ongoing ABST Review The facility will maintain a tracking system for every resident's ABST review date. ABST evaluations will be reviewed and updated: • Prior to a resident's move-in; • Whenever there is a significant change of condition; • At least quarterly, consistent with the resident's service plan review schedule. The Health Services Director/LPN will be responsible for maintaining the ABST tracking system and ensuring required reviews are completed timely. Staffing Plan Process The facility will establish a formal process requiring the posted staffing plan to be updated whenever ABST results indicate a change in required staffing. The Health Services Director/LPN and Administrator will review the ABST results and staffing plan together to ensure that the staffing plan accurately reflects the total staffing required to meet both scheduled and unscheduled resident care needs. A documented reconciliation will be completed between: ABST results ? required staffing ? posted staffing plan ? actual staffing. Any discrepancy identified during the reconciliation will be corrected immediately. The facility will also implement a daily staffing review process to identify whether actual staffing is sufficient to meet resident needs and the posted staffing plan. If staffing falls below the posted plan, the Administrator, Health Services Director, or designee will take immediate action to obtain additional staffing or otherwise ensure that resident care needs are met. Staff Education The Administrator and Health Services Director/LPN will provide education to individuals responsible for admissions, ABST completion, staffing assignments, and staffing-plan development. Education will include: • OAR 411-054-0037 requirements; • Required timing of ABST completion and review; • Significant-change requirements; • Quarterly ABST review requirements; • Use of ABST results in developing the posted staffing plan; • Accounting for scheduled and unscheduled resident care needs; • Required staffing levels; • Documentation of actual staffing; • The process for identifying and correcting discrepancies between the ABST, staffing plan, and actual staffing. Completion of education will be documented. 3) For the first 90 days, the Administrator or designee will conduct a weekly audit of ABST and staffing-plan compliance. The weekly audit will include: 1. A sample of new admissions to verify that the ABST was completed before move-in. 2. Review of residents with significant changes of condition to verify timely ABST updates. 3. Review of residents approaching or completing their quarterly service-plan review to verify the ABST was reviewed/updated as required. 4. Comparison of current ABST staffing requirements with the posted staffing plan. 5. Verification that the staffing plan accounts for scheduled and unscheduled resident care needs. 6. Review of actual staffing records to verify the facility consistently staffed to meet or exceed the posted staffing plan. 7. Verification that meal/break periods and other applicable staffing requirements have been appropriately accounted for. Audit results will be documented and retained. After the initial 90-day monitoring period, compliance will be incorporated into the facility's ongoing Quality Assurance/Performance Improvement process and reviewed monthly for an additional three months, or more frequently if a variance is identified. Any identified variance will be corrected immediately and additional education or corrective action will be provided as appropriate. 4) The Administrator has overall responsibility for implementation and ongoing monitoring of this Plan of Correction. The Health Services Director/LPN is responsible for ensuring: • ABST evaluations are completed and reviewed timely; • Significant changes of condition trigger an ABST review; • Quarterly ABST reviews are completed; • ABST results are incorporated into the staffing plan; • Scheduled and unscheduled resident care needs are accounted for; • Staffing levels are monitored against the ABST and posted staffing plan. The Administrator and Health Services Director/LPN will jointly review audit findings and ensure that any identified discrepancy is corrected promptly.

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 sampled direct care staff (#s 7, 8, 9, and 10) completed all required pre-service orientation training and required pre-service dementia training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were requested on 08/18/26 from Staff 1 (Administrator), and the following was identified: a. There was no documented evidence Staff 7 (Health Care Coordinator), Staff 8 (Resident Assistant), Staff 9 (Resident Assistant) and Staff 10 (Resident Assistant), hired 06/12/26, 07/14/26, 05/12/26 and 06/05/26, respectively, had completed the following required pre-service orientation topics prior to beginning their job responsibilities: * Abuse reporting requirements; and * Infectious disease prevention training. b. There was no documented evidence Staff 7, Staff 8, Staff 9 and Staff 10 completed one or more of the following pre-service dementia training topics prior to beginning their job responsibilities: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. In an interview on 08/18/26 at 3:50 pm, Staff 1 indicated the facility had been without a human resources position for over six months, but a new staff had started within the last two weeks. The need for direct care staff to complete all required pre-service orientation training and required pre-service dementia training was discussed with Staff 1 and Staff 2 (Health Services Director/LPN) on 08/19/26 at 12:10 pm. They acknowledged the findings.

1) Facility will ensure that all staff complete all required pre-service orientation and pre-service demential training. The required training will include, at a minimum, the identified deficient areas: a) Abuse and reporting requirements b) Infectious disease prevention training, including all required components c) Dementia disease process, including progression of the dsease, memory loss, asns psychiatric and behavioral symptoms d) Strategies for addressing the social needs of persons with dementia and engaging residents in meaningful activities e) Specific aspects of dementia care and resident safety, including identifying and addressing pain, providing food and fluids, preventing wnadering/elopment, and utilizing a person-centered approach. The facility will obtain and maintain documentation of completion of the required training in each employee's personnel/training file. Until the required training and documentation have been completed, affected direct care staff will not independently perform duties for which the required pre-service training has not been completed. Direct care staff will receive appropriate supervision until they have successfully demonstrated satisfactory performance, as requir.ed by the rule 2)Rose Schnitzer Manor will implement a standardized Pre-Service Employee Training Checklist and Verification Process for all newly hired employees. Prior to beginning job responsibilities, the Administrator/designee and/or designated onboarding staff will verify that each employee has completed and has documented all required pre-service orientation and training applicable to their position. For all direct care staff, the verification process will specifically include completion and documentation of required pre-service dementia training and orientation to the resident and applicable service plan prior to providing personal care services. A centralized employee training tracking system will be maintained to identify each required training, date completed, and documentation of completion. The facility will also establish a final pre-service training verification checkpoint. The employee will not be released to begin applicable job responsibilities until the required training has been verified and documented. The Administrator/designee will review the completed checklist and training documentation before authorization for the employee to begin applicable job responsibilities. The facility will also ensure that the required Department-approved training curricula are used for applicable training, including approved pre-service infectious disease and dementia training. 3) The Administrator/designee will conduct a 100% review of all newly hired employee files for three consecutive months to verify that required pre-service training has been completed and documented prior to the employee beginning applicable job responsibilities. Following the initial three-month monitoring period, the facility will continue to conduct monthly audits of newly hired employee files for an additional three months. Any identified deficiency will be corrected immediately, and the Administrator/designee will determine whether additional education or process improvement is necessary. The results of the audits will be documented and maintained for review. 4) The Administrator will have overall responsibility for ensuring that the corrective actions are completed and maintained. The Health Services Director/LPN will be responsible for verifying completion of required pre-service training applicable to direct care staff, including dementia training and resident-specific orientation. The designated onboarding/employee records staff will be responsible for maintaining required training documentation and updating the employee training tracker. The Administrator will monitor the process through the audits described above and will ensure that any identified deficiencies are corrected promptly.

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 7, 8, 9, and 10) 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 (Administrator) and Staff 2 (Health Services Director/LPN) on 08/19/26 at 12:10 pm. The following was identified: There was no documented evidence Staff 7 (Health Care Coordinator), Staff 8 (Resident Assistant), Staff 9 (Resident Assistant) and Staff 10 (Resident Assistant), hired 06/12/26, 07/14/26, 05/12/26 and 06/05/26, respectively, 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 need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 and Staff 2 on 08/19/26 at 12:41 pm. They acknowledged the findings, and no additional documentation was provided.

1) The facility will review the employee training and competency records for Staff #7, #8, #9, and #10 to identify all areas in which competency was not documented within 30 days of hire. Each identified staff member will be evaluated by qualified facility staff on all applicable assigned duties and will demonstrate satisfactory knowledge and performance in the required areas, including: • The role of service plans in providing individualized resident care; • Assistance with activities of daily living; • Changes associated with normal aging; • Identification, documentation, and reporting of changes in a resident's physical, emotional, and mental functioning; • Conditions requiring assessment, treatment, observation, and reporting; • General food safety, serving, and sanitation; • Medication administration and/or treatments, if applicable to the employee's assigned duties; and • First Aid and abdominal thrust procedures. Competency will be documented using the facility's standardized Direct Care Staff 30-Day Competency Evaluation. Any staff member who does not demonstrate satisfactory performance will receive additional training, instruction, and direct supervision until competency is demonstrated and documented. 2) Rose Schnitzer Manor will implement a standardized 30-Day Direct Care Staff Training and Competency Process for all newly hired direct care staff. At the time of hire, each direct care staff member will be assigned a training and competency checklist identifying all required areas applicable to their position and assigned duties. The facility will establish a designated 30-day competency completion date for each newly hired direct care employee. The employee's supervisor or other qualified staff member will observe and evaluate the employee's knowledge and performance in each applicable area and document satisfactory completion. The competency evaluation will specifically identify each required competency, the date evaluated, the evaluator, and whether competency was demonstrated. If competency is not demonstrated, the evaluator will document the additional training or supervision provided and establish a follow-up evaluation date. For staff whose duties include medication administration or treatments, competency will be separately observed and evaluated by appropriately qualified facility staff in accordance with applicable requirements. The Administrator/designee will verify completion of the 30-day competency evaluation before the employee's 30-day anniversary and ensure documentation is maintained in the employee's training record. The facility will also incorporate First Aid and abdominal thrust training/competency into the onboarding and competency tracking process. 3) The Administrator/designee will conduct a 100% audit of all newly hired direct care staff competency records monthly for six consecutive months to verify that required competencies have been demonstrated and documented within 30 days of hire. The audit will verify: • A 30-day competency evaluation is present; • All applicable required competency areas have been evaluated; • Competency was demonstrated within the required timeframe; • The evaluator's name/signature and date are documented; • Additional training and follow-up are documented when competency was not initially demonstrated; and • Medication/treatment competency is documented when applicable. Any identified deficiency will be corrected immediately, and the Administrator/designee will determine whether additional education or process correction is necessary. Following the six-month monitoring period, competency records will continue to be reviewed as part of the facility's ongoing employee training and quality assurance process. 4) The Administrator will have overall responsibility for ensuring that the corrective action is implemented and maintained. The Health Services Director/LPN will be responsible for ensuring that direct care staff receive the required training, observation, and competency evaluation within 30 days of hire and that competency is appropriately documented. Direct supervisors and/or other qualified designated staff will be responsible for conducting and documenting competency evaluations within their areas of responsibility. The Administrator/designee will monitor compliance through the monthly audits and will ensure that any identified deficiencies are corrected promptly.

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 every other month and recorded according to Oregon Fire Code (OFC), and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, dated 02/2026 through 07/2026, were reviewed and identified the following: a. Fire drills lacked documentation of one or more of the following components: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Evidence alternate escape routes were used. b. During multiple staff interviews between 08/18/26 and 08/19/26, staff failed to identify the designated point of safety. c. There was no documented evidence the facility provided fire and life safety training to staff on alternate months. In an interview on 08/19/26 at 10:40 am, Staff 3 confirmed there was no evidence training in fire and life safety had been provided to staff on alternate months of fire drills. The need to ensure fire drills were conducted according to the OFC and staff were provided fire and life safety instruction on alternate months was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director/LPN) on 08/19/26 at 12:10 pm. They acknowledged the findings.

1) Rose Schnitzer Manor will review the fire drill records from February 2026 through July 2026 and identify any missing or incomplete required documentation. The facility will implement a standardized Fire Drill Record that includes all required elements, including: • Date and time of the fire drill; • Location of the simulated fire origin; • Escape route used; • Problems encountered; • Comments regarding residents who resisted or failed to participate; • Evacuation time period; • Staff members on duty and participating; • Number of occupants evacuated; and • Identification of the alternate exit route used. The Administrator/designee will ensure that required fire drills are conducted every other month at varying times of day, evening, and night shifts, in accordance with the Oregon Fire Code and applicable requirements. The facility will ensure that alternate exit routes are utilized during fire drills to address varying potential fire origin points. The facility will provide fire and life safety instruction to staff during the alternate months between required fire drills. Training will include, at a minimum, the facility's fire evacuation procedures, staff responsibilities, evacuation assistance, use of alternate routes, and the designated point of safety. The designated point of safety will be clearly communicated to all staff and incorporated into fire and life safety orientation and ongoing training. If a fire drill identifies that the facility is unable to meet the applicable evacuation level, the Administrator/designee will immediately evaluate the circumstances and implement appropriate corrective measures, including changes in staffing levels, staff assignments, resident room assignments, or special equipment, as applicable. 2) The facility will establish a Fire and Life Safety Compliance Calendar that identifies all required fire drills and alternate-month fire and life safety training for the entire year. The calendar will identify: • Month and required date of each fire drill; • Required shift/time variation; • Alternate evacuation route to be used; • Month and date of fire and life safety instruction; • Person responsible for conducting the drill or training; and • Person responsible for reviewing and verifying documentation. A standardized Fire Drill Documentation Form will be used for every drill. The person conducting the drill will be required to complete every applicable section before the drill record is considered complete. Following each fire drill, the Administrator/designee will review the completed documentation to verify that all required elements have been recorded, including the escape route, resident participation/resistance, evacuation time, participating staff, number of occupants evacuated, and alternate exit route. The facility will maintain documentation of all alternate-month fire and life safety instruction, including the date of training, subject matter, staff participating, and instructor/trainer. All newly hired staff will receive instruction regarding fire and life safety procedures, including the designated point of safety and their responsibilities for assisting residents during an evacuation. The designated point of safety will be identified in the facility's emergency preparedness/fire safety materials and communicated to staff during orientation and ongoing fire and life safety instruction. 3) The Administrator/designee will review 100% of fire drill records and fire/life safety training records after each occurrence to ensure all required elements have been completed and documented. The Administrator/designee will conduct a monthly audit for six consecutive months to verify that: • Fire drills are occurring every other month as required; • Drills occur at varying times/shifts; • Alternate exit routes are being used; • The fire alarm system is activated during drills unless otherwise directed by the Fire Authority having jurisdiction; • All required fire drill documentation is complete; • Fire and life safety instruction is provided during alternate months; • Staff attendance and training are documented; and • Staff can identify the designated point of safety and their responsibilities during an evacuation. Any deficiency identified through the audit will be corrected immediately, and additional staff education or corrective action will be provided as necessary. Following the six-month monitoring period, fire drill and fire/life safety training compliance will continue to be monitored through the facility's ongoing quality assurance and emergency preparedness processes. 4) The Administrator will have overall responsibility for ensuring compliance with OAR 411-054-0090 and for monitoring the facility's fire and life safety program. The Administrator/designee will be responsible for maintaining the annual Fire and Life Safety Compliance Calendar, ensuring required drills and alternate-month training occur, and reviewing completed documentation. The designated staff member conducting each fire drill will be responsible for completing the Fire Drill Documentation Form in its entirety. The Health Services Director/LPN and/or designated qualified staff will assist with staff education and verification that staff understand their responsibilities for resident evacuation and can identify the designated point of safety. The Administrator/designee will review audit results and ensure that any identified deficiencies are corrected promptly.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission in fire and life safety procedures as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records, dated 02/2026 to 07/2026, were reviewed and Staff 3 (Building Services Director) was interviewed on 08/17/26 at 2:18 pm and again on 08/19/26 at 11:30 pm. The following was identified: There was no documented evidence residents were instructed within 24 hours of admission on general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. The need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission as required by the OFC was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director/LPN) on 08/19/26 at 12:10 pm. They acknowledged the findings.

1)Rose Schnitzer Manor will conduct an audit of all current resident records to determine whether documentation is present demonstrating that each resident received required fire and life safety instruction within 24 hours of admission and annual re-instruction, as applicable. For residents for whom required fire and life safety instruction is not documented, the facility will provide the required instruction as appropriate and document completion. Resident fire and life safety instruction will include: • General fire and life safety procedures; • Evacuation methods; • Resident responsibilities during fire drills; • The designated meeting place outside the building or within the designated fire-safe area in the event of an actual fire; and • Any facility-specific emergency procedures applicable to the resident. The facility will assess whether the resident is capable of understanding and participating in the required instruction. For residents whose mental capability does not allow them to follow such instruction, the facility will document this determination in the resident's record. Documentation of resident fire and life safety instruction will include the date of instruction, content reviewed, resident's name, and staff member providing the instruction. 2) Rose Schnitzer Manor will incorporate fire and life safety instruction into the new resident admission/move-in process. Within 24 hours of each resident's admission, designated staff will provide the resident with fire and life safety instruction in accordance with OAR 411-054-0090(5) and the Oregon Fire Code. A standardized Resident Fire & Life Safety Orientation Form will be added to the admission checklist. The form will document: • Resident name; • Date and time of admission; • Date and time fire/life safety instruction was provided; • General safety procedures reviewed; • Evacuation methods reviewed; • Resident responsibilities during fire drills; • Designated meeting place/fire-safe area reviewed; • Staff member providing instruction; and • Resident participation or limitations, when applicable. The resident's designated meeting place and appropriate evacuation information will be reviewed with the resident and, when appropriate, incorporated into the resident's individualized emergency planning. A copy of the completed Resident Fire & Life Safety Orientation Form will be maintained in the resident's record. The facility will also establish an annual resident fire and life safety re-instruction schedule to ensure each applicable resident receives the required annual re-instruction. New employees responsible for resident admissions/orientation will be educated regarding the requirement that fire and life safety instruction occur within 24 hours of admission and that the instruction must be documented. 3) The Administrator/designee will review 100% of new resident admissions monthly for six consecutive months to verify that required fire and life safety instruction was provided and documented within 24 hours of admission. The audit will verify: • Instruction occurred within 24 hours of admission; • Required training content was addressed; • The designated meeting place/fire-safe area was reviewed; • Resident participation or inability to participate was documented when applicable; and • The staff member providing the instruction and date/time were documented. The Administrator/designee will also conduct a monthly review of the annual resident fire and life safety training schedule to ensure residents approaching their annual re-instruction date are identified and scheduled. Any deficiency identified during an audit will be corrected immediately, and the admission/orientation process will be reviewed to determine whether additional corrective action is necessary. Following the six-month monitoring period, compliance will continue to be monitored through the facility's ongoing quality assurance and resident admission process. 4) The Administrator will have overall responsibility for ensuring compliance with OAR 411-054-0090(5). The Health Services Director/LPN or designated qualified staff will be responsible for ensuring that applicable residents receive fire and life safety instruction within 24 hours of admission and receive annual re-instruction. The designated staff member completing the resident admission/orientation process will be responsible for providing the instruction and completing the required documentation. The Administrator/designee will monitor compliance through the monthly audits and will ensure that any identified deficiencies are corrected promptly.

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:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways and patio areas on 08/17/26 and 08/19/26 identified the following: * Multiple drop-offs of one to two and a half inches were noted along multiple pathways leading from exterior doorways and around the perimeter of the facility; and * Cracked and/or lifting pieces along the exterior pathways near the back of the facility. The need to ensure pathways around the facility were in good repair with no potential tripping hazards were shown to and discussed with Staff 1 (Administrator) and Staff 3 (Building Services Director) on 08/19/26 at 10:40 am. The staff acknowledged the findings.

1)The facility will immediately assess and correct all identified exterior pathway and courtyard surface hazards. The multiple drop-offs ranging from approximately one to two and one-half inches along pathways leading from exterior doorways and around the facility perimeter, as well as the cracked and/or lifting pathway surfaces near the back of the facility, will be repaired or replaced to ensure pathways are hard, smooth, accessible, and maintained in good repair. Building Services will complete a documented inspection of all exterior pathways, patios, and courtyard surfaces to identify any additional trip hazards, uneven surfaces, cracks, lifting materials, or other conditions that could present a risk to residents, visitors, or staff. Until permanent repairs are completed, any identified area presenting an immediate safety risk will be appropriately barricaded, marked, or otherwise restricted from use, as appropriate, and residents will be redirected to a safe accessible route 2) The facility will implement a documented Exterior Grounds and Pathway Safety Inspection Process. Building Services will conduct routine inspections of all exterior pathways, entrances, exits, courtyards, patios, and other resident-accessible exterior areas. Inspections will specifically evaluate for: • Uneven or deteriorated walking surfaces; • Cracks, lifting, or separation of pathway materials; • Changes in elevation or potential trip hazards; • Accessibility of resident pathways; • Deterioration around exterior doorways and high-traffic areas; • Adequate condition of courtyard and patio surfaces; and • Other environmental conditions that could create a safety hazard. Any deficiency identified during an inspection will be documented on a Building/Environmental Safety Work Order or Corrective Action Log, assigned to a responsible person, given a completion date, and tracked through resolution. Issues presenting an immediate risk of injury will be addressed immediately through repair, temporary restriction, barricading, or another appropriate interim safety measure until permanent correction can be completed. The Administrator and Building Services Director will review outstanding exterior safety concerns to ensure identified repairs are appropriately prioritized and completed. 3) Building Services will conduct and document an inspection of all resident-accessible exterior pathways, courtyards, patios, and entrances/exits at least monthly. In addition, exterior areas will be visually monitored during routine daily operations, and staff will be instructed to immediately report any newly observed trip hazard, damaged surface, or accessibility concern to Building Services. The Administrator or designee will review the monthly inspection documentation and any outstanding work orders monthly for six months to verify that identified concerns have been corrected timely and that the inspection process is being consistently followed. Following the initial six-month monitoring period, the process will continue as part of the facility's routine environmental safety and preventive maintenance program. 4) The Building Services Director will be responsible for conducting and documenting the exterior pathway and grounds inspections, initiating and tracking corrective work, and ensuring identified hazards are repaired or appropriately addressed. The Administrator or designee will be responsible for reviewing inspection records, monitoring outstanding corrective actions, and ensuring that identified safety hazards are corrected timely. The Administrator will maintain overall responsibility for ensuring continued compliance

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0300 (7)(b-d) House Keeping and Sanitation (b) HOUSEKEEPING AND SANITATION.(A) An ALF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use when a time schedule for resident-use is provided and equipment is of residential type.(A) If the primary laundry facility is not suitable for resident-use, an ALF must provide separate resident laundry facilities.(B) Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) An ALF must provide covered or enclosed clean linen storage that may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(E) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, and blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linen and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen area must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant and provided a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area that precluded the potential for contamination of clean linens and clothing. Findings include, but are not limited to: A tour of the facility laundry rooms on 08/18/26 at 11:55 am identified the following: * The laundry rooms, located on all three floors in each of the four wings, had residential washing machines and dryers, with a utility sink and one point of entry; * The detergent being used within the community laundry rooms did not have a chemical disinfectant included; * The laundry rooms were simultaneously shared by residents and staff; and * There was no identified one-way flow of soiled linens and clothing. Interviews with multiple housekeepers and Resident Assistants on 08/18/26 and 08/19/26 identified the following: * Housekeepers washed the sheets and towels weekly in the laundry room on the wing of the resident’s apartment, including soiled linen. If they were soiled with feces, staff would use the utility sink in the laundry room to wash off the feces. If soiled with blood, the soiled linen was washed in cold water. * Resident Assistants would wash resident’s laundry if requested and if soiled in blood it would be washed in cold water. Two Resident Assistants indicated they would use the hopper, rinse off the feces, then return to the laundry room on the resident’s wing and finish washing the soiled items. However, one of the Resident Assistants did not know if there was a hopper in the facility but would use if one was available. On 08/19/26 at 10:40 am, the room with the hopper was toured with Staff 1 (Administrator) and Staff 3 (Building Services Director). The hopper was located on the first floor and did not offer a one-way flow for soiled linens. They acknowledged the detergent used to wash clothes did not have a chemical disinfectant. In an interview on 08/19/26 at 11:40 am, Staff 4 (Housekeeping Coordinator) indicated “highly” soiled items were washed by Resident Assistants and a “little blood, urine or feces” would be washed separately by the housekeepers in the resident’s washing machine on their floor. She acknowledged the staff could use additional training in how to properly launder soiled resident linens and clothing. The need to ensure the facility properly laundered soiled resident linens and clothing and meet housekeeping and sanitation requirements was reviewed with Staff 1 and Staff 2 (Health Services Director/LPN) on 08/19/26 at 12:10 pm. They acknowledged the findings.

1) The facility will immediately discontinue the practice of washing soiled linens and clothing contaminated with bodily fluids in the resident wing laundry machines without a compliant disinfection process and without a defined one-way flow from the soiled area to the clean area. All current laundry practices involving soiled linens and clothing will be reviewed and corrected. Soiled linens and clothing contaminated with urine, feces, blood, or other bodily fluids will be placed directly into designated closed/contained soiled-linen receptacles and transported to the designated soiled-linen processing area in a manner that prevents contact with clean linens and resident clothing. Staff will no longer use utility sinks, resident laundry rooms, or other non-designated areas to rinse fecal matter, blood, or other bodily-fluid contamination from soiled linens or clothing. The facility will establish a compliant laundering process in which soiled linens and clothing are processed using either: • A washing process that achieves the required minimum 140°F rinse temperature, with documented verification; or • A facility-approved chemical disinfectant process that meets applicable requirements. The facility will verify the selected process before returning it to routine use. A designated one-way flow for soiled laundry will be established and clearly communicated to staff. The process will prevent the movement of soiled items back through or across areas where clean linens or clothing are stored, handled, folded, or distributed. All staff who handle or process soiled linens and clothing will be instructed on the revised process, including appropriate use of waterproof gloves, containment, transportation, washing/disinfection procedures, and separation of soiled and clean laundry. 2) The facility will implement a standardized Soiled Linen and Clothing Processing Procedure applicable to all departments and all staff who handle resident laundry or facility linens. The procedure will establish a consistent process from the point a linen or clothing item becomes soiled through containment, transportation, processing, drying, folding, storage, and return to the resident. The system will include: 1. Identification and containment: All linens and clothing contaminated with bodily fluids will be immediately placed in designated closed/contained soiled-linen receptacles. 2. Transportation: Soiled laundry will be transported using a designated process that prevents contamination of clean linens, clothing, resident areas, and staff. 3. One-way workflow: A designated soiled-to-clean workflow will be established and posted in the laundry/processing area. Soiled items will not travel back through the clean side of the process. 4. Washing/disinfection: The facility will use a documented laundering process that either achieves the required 140°F minimum rinse temperature or incorporates an appropriate chemical disinfectant. 5. Temperature/disinfection verification: The facility will establish a method for verifying that the selected laundering/disinfection process is functioning as intended, with documentation maintained. 6. Equipment and supplies: Required equipment, chemicals, waterproof gloves, closed containers, and other supplies will be maintained and readily available. 7. Staff competency: Housekeeping staff, Resident Assistants, and other employees responsible for resident laundry will receive education and competency validation regarding the complete soiled-laundry process. 8. Resident laundry: The facility will clearly define when and how staff may process resident clothing that is contaminated with bodily fluids so that individual staff members are not determining their own method of processing. 9. Visual controls: The designated laundry process and one-way flow will be posted in applicable laundry/soiled-linen areas. 10. Prohibition of non-compliant practices: Staff will be specifically instructed that feces, blood, urine, or other bodily-fluid contamination is not to be rinsed or processed in an area or manner that could contaminate clean laundry or resident-use areas. The facility will also review the physical configuration of the laundry rooms and designated soiled-linen processing area to determine whether additional equipment, signage, barriers, workflow modifications, or other environmental changes are necessary to maintain separation between soiled and clean laundry. 3) The designated laundry and soiled-linen processing areas will be inspected weekly for the first three months to verify compliance with the established process. The weekly inspections will include verification that: • Soiled linens are contained appropriately; • Staff are following the designated one-way flow; • Soiled laundry is not being rinsed or processed in unauthorized areas; • Clean and soiled laundry remain appropriately separated; • Required disinfecting/temperature procedures are being followed; • Required supplies and waterproof gloves are available; • Laundry equipment is functioning appropriately; • Required documentation is completed; and • Staff are following the established procedure. In addition, the Administrator or designee will conduct monthly observational audits for six months, including direct observation of staff processing laundry. Any identified deviation will be corrected immediately, and additional education or competency validation will be provided when indicated. Following the initial six-month monitoring period, the process will continue to be incorporated into the facility's routine environmental sanitation and quality assurance program. 4) The Building Services Director will be responsible for ensuring the laundry environment, equipment, supplies, and designated workflow are established and maintained in accordance with the required process. The Housekeeping Coordinator will be responsible for day-to-day implementation of the Soiled Linen and Clothing Processing Procedure, ensuring housekeeping staff follow the process, required documentation is completed, and supplies and protective equipment are available. The Health Services Director/LPN will be responsible for ensuring Resident Assistants and other applicable direct-care staff receive education and competency validation regarding the proper handling and laundering of soiled resident clothing and linens. The Administrator will have overall responsibility for ensuring the corrective actions are implemented, monitoring audit results, addressing identified deficiencies, and ensuring continued compliance. 2. The facility will establish a written, standardized soiled-linen procedure that applies to Housekeeping, Resident Assistants, and any other staff responsible for handling resident laundry. The procedure will clearly define: • How soiled linen and clothing are identified and contained. • Where soiled items are placed prior to processing. • How soiled items are transported. • The required one-way flow from the soiled portion of the process to the clean portion. • Prohibition of rinsing or pre-cleaning soiled items in resident laundry rooms or inappropriate sinks. • Required use of the approved chemical disinfectant during processing. • Appropriate personal protective equipment, including waterproof gloves. • Proper handling and storage of clean linen following processing. All affected staff will receive education and demonstrate understanding of the revised process before independently handling soiled laundry. New employees will receive the training during orientation, and refresher education will be provided whenever monitoring identifies a deficiency. 3. The laundry areas and soiled-linen handling process will be evaluated monthly to ensure compliance with the established procedure, including appropriate separation, containment, transportation, chemical disinfection, and one-way flow. Once sustained compliance has been demonstrated, monitoring will continue quarterly to ensure the corrective system remains effective and the deficiency does not recur. Any concerns identified during monitoring will be corrected immediately, documented, and followed up by the responsible department. 4. The Manager of Housekeeping will be responsible for overseeing implementation of the corrective actions and conducting the required monitoring. The Manager of Housekeeping will ensure that applicable staff receive education on the revised soiled-linen handling and processing procedures, that the established process is followed, and that any identified concerns are corrected promptly. Infection Prevention and Health Services leadership will provide additional oversight and support with education and monitoring as appropriate. Documentation of staff education, monitoring audits, and corrective actions will be maintained.

OAR 411-054-0300 (7)(b-d) House Keeping and Sanitation (b) HOUSEKEEPING AND SANITATION.(A) An ALF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use when a time schedule for resident-use is provided and equipment is of residential type.(A) If the primary laundry facility is not suitable for resident-use, an ALF must provide separate resident laundry facilities.(B) Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) An ALF must provide covered or enclosed clean linen storage that may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(E) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, and blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linen and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen area must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture. This Rule is not met as evidenced by: