OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 09/08/26 through 09/11/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the severity of citations. Refer to deficiencies in the report.

1. Correction for each example/resident: The Executive Director reviewed the 09/11/2026 re-licensure survey findings and created a corrective action tracker identifying each tag, required correction, responsible party, due date, and evidence of completion. 2. System correction to prevent recurrence: The corrective action tracker will be used to monitor completion of each item in this Plan of Correction. Monitoring results identified under each tag will be reviewed by the Executive Director until corrections are complete and sustained. 3. How often it will be evaluated: Weekly until all corrections are completed, then monthly for three months. 4. Responsible party: Executive Director.

OAR 411-054-0025 (8 & 10) Facility Administration: Records & Electronic Consent Temporary rule language in effect until 02/05/2027 (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility must not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility must take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if the facility inadvertently or accidentally discloses such information to unauthorized persons. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. (10) ELECTRONIC MONITORING CONSENT MODEL FORM. If a resident or their designated representative chooses to have a camera or electronic monitoring device in the resident’s room, the resident or their designated representative must complete an Electronic Monitoring Consent form. The form is maintained on the Department’s website for facilities to use. Facilities may develop and use their own forms. The signed form must be maintained in the resident’s records. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed prohibit the falsification of records for 2 of 3 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 04/2026 with diagnoses including depression and heart failure. Clinical records from 06/07/26 through 09/08/26 were requested and reviewed. When documentation regarding an assessment of devices with restraining qualities was requested, Staff 3 (Resident Services Director) provided an assessment dated 09/08/26 for the sampled resident. Additional documentation for an initial assessment was requested, and Staff 3 provided a handwritten assessment dated 04/01/26. During an interview on 09/10/26 at approximately 1:30 pm, Staff 2 (Health Services Director/RN) indicated she was hired on 03/30/26, in the first week completed online training and did not start performing resident assessments until after training in a sister facility, approximately two to three weeks after her date of hire. Staff 2 acknowledged the side rail assessment dated 04/01/26 had been completed during survey. The need to ensure the facility prohibited the falsification of records was discussed with Staff 1 (ED), Staff 2, and Staff 3 on 09/11/26 at 11:25 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 03/2023 with diagnoses including Type 2 diabetes with diabetic kidney disease. The resident’s clinical record from 06/07/26 through 09/08/26 was reviewed, and the following was identified: During the acuity interview on 09/08/26 at 9:26 am, with Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 3 (Resident Services Director), Resident 1 was identified as having chronic diabetic wounds managed by HH. On 09/09/26 at 11:25 am, a request was made for outside provider documentation from Staff 1. Staff 1 provided the surveyor with documentation from HH on 09/09/26 at 11:25 am. The documentation was unsigned when provided. At 12:40 pm, the surveyor asked Staff 2 for documented evidence of her review of the documentation. At 1:28 pm, Staff 1 returned the same documentation reviewed at 11:25 am to the surveyor, and the documents had been signed by Staff 2 with a note that she “agreed with the plan of care.” The notes and signature on the documentation from Staff 2 were undated. An interview with Staff 1 at 1:28 pm confirmed that Staff 2 had signed the documentation between when the information was first provided to the surveyor at 11:25 am and when the documentation was provided to the surveyor again at 1:28 pm on 09/09/26. The need to ensure the facility did not falsify records was discussed with Staff 1, Staff 2, and Staff 3 on 09/11/26 at 2:00 pm. They acknowledged the findings.

1. Correction for each example/resident: Resident 3 has a current Supportive Device Safety Evaluation completed 09/08/2026, and the service plan was updated with staff instructions for device use and monitoring. Resident 1 had nursing review and agreement with the PACE wound care plan documented on 09/11/2026. 2. System correction to prevent recurrence: Staff responsible for resident records were retrained that records must reflect the actual completion date, late entries must be identified as late entries, training/practice documents must not be filed as resident records, and nursing review and agreement of outside provider wound plans must be documented when the resident remains in community care. 3. How often it will be evaluated: The Executive Director or designee will audit resident records monthly for three months, including supportive device documentation, late entries, and outside provider documentation. Findings will be reviewed with Health Services and corrected as identified. 4. Responsible party: Executive Director or designee.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility?s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reviewed and updated when a resident experienced a significant change of condition, were reflective of residents' needs, and provided clear direction regarding the delivery of services for 1 of 3 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2024 with diagnoses including bi-polar disorder and delirium due to known psychological condition. The resident’s clinical record was reviewed, including the service plan dated 05/21/26. Observations of the resident were made, and interviews were conducted. a. Between 06/06/26 and 08/31/26, Resident 2 experienced a significant change of condition, and there was no documented evidence the resident’s service plan was reviewed and updated as needed following the significant change of condition. On 09/10/26 at 2:12 pm, Staff 1 (ED) confirmed the resident’s service plan had not been updated since 05/21/26. b. The service plan was not reflective of the resident’s current care needs and/or did not provide clear direction regarding the delivery of services in the following areas: * Fall risk and precautions including the use of nonskid socks and ensuring the bedside commode was in a “red box” taped to the floor; * Toileting assistance instruction and number of staff needed; * Transfer assistance including instruction and number of staff needed; * Dress and undress assistance including instructions related to pain and number of staff needed; * Bed change instructions and number of staff required; * Ambulation assistance including instructions and number of staff needed; * Bathing assistance including number of staff needed; * Air pressure mattress instructions to staff; * Activities noted in the service plan contradicted activities noted in the resident’s behavioral plan; * Meal assistance including instructions for set-up assistance in the resident’s room and to encourage soft foods; and * Fire evacuation instructions including number or staff to evacuate resident to a point of safety. Observations conducted from 09/08/26 through 09/10/26 revealed the resident was in bed without the use of nonskid socks, the bedside commode was not placed in the “red box” taped to the floor, and two staff were observed to enter the resident’s room at the same time to provide toileting, bed changes, or transfer assistance. The need to ensure resident service plans were updated with a significant change of condition, were reflective of current care needs and provided clear direction to staff was reviewed with Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 3 (Resident Services Director) on 09/11/26 at 11:51 am. They acknowledged the findings.

1. Correction for each example/resident: Resident 2’s service plan was reviewed and updated on 09/10/2026 and 09/11/2026 after significant change of condition and increased falls. The updated service plan includes current fall interventions, transfer and mobility assistance, toileting/commode support, bathing and dressing assistance, assistive device/fall mat instructions, meal support, hospice/pain considerations, and staff notification expectations. 2. System correction to prevent recurrence: Service plans will be reviewed and updated after significant changes of condition and at least quarterly. Reviews will compare the service plan with the resident’s ABST, current orders, hospice/provider information, and observed care needs to ensure staff have clear current direction. 3. How often it will be evaluated: any upcoming evaluations and as needed service plan updates will be reviewed daily at SMART meeting. Service plans will be audited monthly for three months. 4. Responsible party: Executive Director or designee.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine and document what resident-specific action or intervention was needed for short-term changes of condition, communicate the action or intervention to staff on each shift, and monitor residents consistent with their evaluated needs and service plan for 1 of 2 sampled residents (# 2) who were reviewed with multiple falls. Resident 2 continued to experience injury falls. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2024 with diagnoses including acute kidney failure and delirium due to known psychological condition. During the acuity interview on 09/08/26 at 9:26 am, the resident was identified to have had recent falls. The resident’s clinical record, dated 06/06/26 through 09/08/26, was reviewed, observations of the resident were completed, and interviews with facility staff were conducted. The following was identified: * Resident 2 experienced unwitnessed injury falls on 06/09/26, 07/07/26, 07/16/26, 08/03/26, 08/16/26, 08/30/26, and 08/31/26. * Resident 2 experienced unwitnessed non-injury falls on 06/06/26, 07/15/26, 07/17/26, 07/26/26, 08/17/26, and three falls on 08/22/26. The resident’s service plan, dated 05/21/26, instructed staff to keep items s/he may need within reach and remove potential slip hazards. The service plan further indicated that due to pain, mobility was challenging and s/he was no longer able to pick items up off the floor. Facility temporary service plans (TSPs) for the falls, dated 06/06/26 and 07/07/26, were generic templates that lacked resident-specific information. On 07/11/26, a TSP directed staff to “check in on resident [six] times throughout the shift” and to ensure the resident wore nonskid socks while in bed to help reduce the risk of falls during transfers. Observations from 09/08/26 through 09/10/26 showed the resident was not wearing nonskid socks in bed. Additional TSPs, dated 07/15/26, 07/16/26, 07/17/26, 07/26/26, 08/07/26, 08/16/26, 08/17/26, 08/22/26, 08/22/26, 08/30/26, and 08/31/26, were generic templates that lacked resident-specific actions or interventions. There was no documented evidence current fall interventions were monitored for effectiveness or that new interventions were developed. On 09/08/26 at 11:45 am and 11:57 am, Staff 17 (Care Partner) and Staff 16 (Care Partner) reported the resident’s door was kept open, with permission from the resident, so staff could keep a close eye on him/her. On 09/08/26 at 1:48 pm, Staff 14 (Care Partner) confirmed the resident needed two-person transfer assistance in and out of his/her bed and on and off the bedside commode. Staff 14 also reported the resident had multiple falls in the past two to three months and stated the door to the resident’s room was kept open for staff to ensure s/he wasn’t on the floor. On 09/10/26 at 4:24 pm, Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 3 (Resident Services Director) confirmed the lack of documentation related to determining actions or interventions and monitoring the resident consistent with evaluated needs and service plan, including reviewing current fall interventions for effectiveness and developing new interventions. The facility failed to determine and document resident-specific actions or interventions, communicate the actions or interventions to staff on each shift, and monitor the resident consistent with his/her evaluated needs and service plan, and the resident continued to experience injury falls. The need to ensure the facility determined and documented what resident-specific action or intervention was needed, communicated the action or intervention to staff on each shift, and residents were monitored consistent with evaluated needs and service plan was reviewed with Staff 1, Staff 2, and Staff 3 on 09/11/26 at 11:51 am. They acknowledged the findings.

1. Correction for each example/resident: Resident 2’s falls and change of condition were reviewed on 09/10/2026 and 09/11/2026. Resident-specific fall interventions were added to the service plan, including items within reach, pathway/clutter checks, lighting, assistive device placement, fall mat placement, transfer assistance, toileting/commode support, pain/hospice considerations, and staff notification instructions. Current residents with falls or changes of condition were reviewed by 09/25/2026. 2. System correction to prevent recurrence: Falls and changes of condition will be reviewed, classified as short-term or significant, documented with resident-specific interventions, communicated to staff, and monitored for effectiveness. Significant changes will trigger nursing review and service plan update as needed. 3. How often it will be evaluated: Residents with falls or changes of condition will be reviewed daily at SMART meeting. Change of condition and fall follow-up documentation will be audited monthly for three months. 4. Responsible party: Executive Director or designee.

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 significant change of condition assessment was completed which included documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 2 and 3) who had significant changes of condition. Resident 2 continued to experience injury falls. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2024 with diagnoses including acute kidney failure and delirium due to known psychological condition. During the acuity interview on 09/08/26 at 9:26 am, the resident was identified to have had recent falls with injuries including skin tears and bruising. The resident's clinical record, dated 06/06/26 through 09/08/26, was reviewed, and interviews with facility staff were conducted. The following was identified: a. From 06/06/26 through 08/31/26, Resident 2 experienced 15 unwitnessed falls, some of which resulted in injury and staff reported in interviews that the resident’s ADL needs had changed to needing assistance of two staff for ADLs including transfers, bed changes, dressing and undressing assistance. The change in the resident’s status constituted a significant change of condition, which required an RN assessment; however, there was no documented evidence of an RN assessment that included findings, resident status, and/or interventions developed to minimize the risk of ongoing falls as a result of the assessment. On 09/10/26 at 2:12 pm, Staff 1 (ED) confirmed there was no documented evidence of an RN assessment that included findings, resident status, and interventions made as a result of the assessment. Refer to C270. b. Prior to the 05/13/26 admission to hospice, Resident 2 was evaluated as independent with ADLs. After admission to hospice, the resident was evaluated to require assistance with transferring, toileting, ambulation, and repositioning. The change in the resident’s status constituted a significant change of condition, which required an RN assessment; however, there was no documented evidence of an RN assessment that included findings, resident status, and/or interventions made as a result of the assessment. On 09/10/26 at 2:12 pm, Staff 1 confirmed there was no documented evidence of an RN assessment that included findings, resident status, and/or interventions made as a result of the assessment. The need to ensure RN significant change of condition assessments were completed which documented findings, resident status, and interventions made as a result of the assessment was reviewed with Staff 1, Staff 2 (Health Service Director/RN), and Staff 3 (Resident Services Director) on 09/11/26 at 11:51 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2026 with diagnoses including depression and heart failure. The residents’ clinical record from 04/01/26 to 09/08/26 was reviewed, and the following was identified: a. Between 04/01/26 and 05/03/26, the resident lost nine and a half pounds, or 5.2% of his/her total body mass, in one month. This constituted a significant change of condition which required an RN assessment. b. Between 08/03/26 and 09/02/26, the resident gained 15 pounds, or 8% of his/her total body mass, in one month. This constituted a significant change of condition which required an RN assessment. There was no documented evidence the facility RN had completed a significant change of condition assessment for the weight loss or the weight gain, which included findings, resident status, and interventions made as a result of the assessment. On 09/09/26 at 1:30 pm, Staff 2 (Health Services Director/RN) stated she was new to the setting and acknowledged she had not reviewed weights and was scheduled to receive training the following week. The need to ensure an RN assessment was completed for all residents with a significant change of condition discussed with Staff 1 (ED), Staff 2 and Staff 3 (Resident Services Director) on 09/11/26 at 11:25 am. They acknowledged the findings.

1. Correction for each example/resident: Nursing review was documented for Resident 2’s significant change related to repeated falls, falls with injury, transfer status, and ADL assistance needs. Nursing review was documented for Resident 3’s significant change related to weight changes. Service plans were reviewed and updated as applicable. 2. System correction to prevent recurrence: Significant changes of condition will have documented nursing review that includes current status, findings, risks, interventions, provider/hospice notification when applicable, and whether the service plan requires revision. 3. How often it will be evaluated: Weekly for four weeks, then monthly for three months. Findings will be reviewed with Health Services and Resident Services, and corrections/retraining will be completed as identified. 4. Responsible party: Executive Director or designee.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure an RN, PT, or OT conducted a thorough assessment of a supportive device with restraining qualities, document other less restrictive alternatives were evaluated prior to the use of the device, instruct caregivers on the correct use and precautions related to the use of the device, and include the use of the supportive device in the service plan for 1 of 3 sampled residents (# 3) who was observed with side rails. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2026 with diagnoses including depression and heart failure. On 09/08/26 at 1:00 pm, Resident 3’s room was observed with bilateral half siderails on the bed. The right siderail was lowered and in a lateral position. The left siderail was raised in a vertical position with a knob that was loose. a. A current assessment for the siderails was requested from Staff 3 (Resident Services Director) on 09/08/26, and a copy of an assessment, completed on 09/08/26, was provided on 09/09/26. An initial assessment was requested on 09/09/26 and Staff 3 provided an assessment dated 04/01/26. During an interview with Staff 2 (Health Services Director/RN) on 09/10/26 at 1:30 pm, Staff 2 acknowledged the side rail assessment dated 04/01/26 had been completed during survey. Refer to C155, example 1. b. The resident’s service plan, dated 08/31/26, did not include any instructions for staff as to how the side rails were to be used and monitored for safety or to whom any malfunctions should be reported. The need to ensure the facility had an RN, PT, or OT conduct a thorough assessment of a supportive device with restraining qualities, document other less restrictive alternatives evaluated prior to the use of the device and provide instruction to caregivers on the correct use and precautions related to use of the device was reviewed with Staff 1 (ED), Staff 2 and Staff 3 on 09/11/26 at 11:25 am. They acknowledged the findings.

1. Correction for each example/resident: Resident 3’s Supportive Device Safety Evaluation for side rails was completed on 09/08/2026. The evaluation documented purpose, risks and benefits, less restrictive alternatives, resident ability to use the device safely, restraining qualities, device condition, and resident agreement. The service plan was updated with device use, monitoring, and reporting instructions. 2. System correction to prevent recurrence: A DME/supportive device tracker was completed on 09/15/2026. Devices will be identified at move-in and during ongoing reviews. Supportive devices with restraining qualities will be reviewed initially by an RN and then ongoing by a qualified reviewer, documented, and reflected in the service plan. 3. How often it will be evaluated: Monthly for three months, then quarterly. 4. Responsible party: Executive Director or designee.

OAR 411-054-0037 (4-7) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete, update, review, and document 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 and corresponding with resident service plan updates, updating 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 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. (a) The posted staffing plan must incorporate: (A) The total ABST care time in minutes per shift, per day. If a proprietary ABST does not have this functionality, at a minimum the ABST total time must be shown in daily minutes as referenced in paragraph (2) of this rule. (B) The unscheduled care needs of residents. (C) The staffing requirements outlined in OAR 411-054- 0070(1). (D) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (E) The 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. (F) The facility’s distinct and 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. Each distinct and segregated area must have a posted staffing plan. (G) The staffing needs required under the Specific Needs Contracts, if applicable. (b) The facility must maintain staffing documentation to show consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (c) The facility must maintain historical posted staffing plans. The posted staffing plan must contain the date(s) it was effective. Records must be kept for a minimum of three years. (6) CONSISTENTLY MEETING NEEDS. The facility must consistently meet the scheduled and unscheduled needs of all residents, 24 hours a day, seven days a week. (7) 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 a 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 numbers as indicated in the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated before a resident moved in for 1 of 1 sampled resident (#3) and whenever there was a significant change of condition for 1 of 2 sampled residents (#3), and no less than quarterly at the same time the resident’s service plan was updated for 1 of 3 sampled residents (#3) and multiple unsampled residents whose ABST data was reviewed. Findings include; but are not limited to: The facility’s ABST data was reviewed with Staff 1 (ED), Staff 2 (Health Services Director/RN) and Staff 3 (Resident Services Director) on 09/11/26 at 11:08 am and revealed the following: a. Resident 3 moved into the facility in 04/2026, and the ABST evaluation was created seven days following move-in, not prior to move-in. b. The ABST data for sixteen unsampled residents and one sampled resident (#3) was not updated quarterly. c. Resident #3 experienced two significant changes of condition related to weight changes on 05/03/26 and 09/02/26, and the ABST data had not been updated. The need to ensure residents’ ABST was updated before a resident moved in, whenever there was a significant change of condition, and no less than quarterly at the same time the resident’s service plan was updated was discussed with Staff 1, Staff 2 and Staff 3 on 09/11/26 at 11:08 am. They acknowledged the findings.

1. Correction for each example/resident: Resident 3’s ABST was updated. ABST evaluations for current residents were reviewed and updated by 09/18/2026 and compared with current service plans. The Executive Director reviewed the staffing plan, and no direct-care staffing change was needed based on the ABST review. ABSTs for residents moving in the week of 09/28/2026 were completed before move-in by 09/25/2026. 2. System correction to prevent recurrence: ABST completion was added to the pre-move-in process. ABSTs will be completed before move-in, after significant change of condition/care needs, and quarterly with the service plan review. Results will be compared with the service plan and staffing plan. 3. How often it will be evaluated: Monthly for three months. 4. Responsible party: Executive Director or designee.

OAR 411-054-0070 (3-4) Staffing Requirements and Training ? Pre-service Temporary rule language in effect until 02/05/2027 (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 per OAR 411-054-0090 and 411-054-0093. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility?s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident?s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled newly hired staff (#s 7, 8, and 17) completed all required pre-service orientation training and direct care staff completed required pre-service dementia training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were reviewed with Staff 3 (Resident Services Director) on 09/09/26, and the following was identified: a. There was no documented evidence Staff 8 (MT), hired 06/05/26, completed the following required pre-service orientation topics prior to beginning job responsibilities: * Abuse reporting requirements; and * Infectious disease prevention. b. There was no documented evidence Staff 17 (Care Partner), hired 07/02/26, completed the following required pre-service orientation topics prior to beginning job responsibilities: * Resident rights; * Abuse reporting requirements; * Fire safety and emergency procedures; and * Pre-service dementia training. c. There was no documented evidence Staff 7 (Cook), hired 02/26/26, completed the following required pre-service orientation topics prior to beginning job responsibilities: * Resident rights and values of CBC care; and * Food handler’s certification. The need to ensure all newly hired staff completed all required pre-service orientation training and direct care staff completed required pre-service dementia training prior to beginning job responsibilities was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN) and Staff 3 on 09/11/26 at 11:25 am. They acknowledged the findings, and no additional documentation was provided.

1. Correction for each example/resident: Missing pre-service training documentation for Staff 7, Staff 8, and Staff 17 was reviewed and completed by 09/12/2026 as applicable to each position and assigned duties. 2. System correction to prevent recurrence: A new-hire training checklist will be used before staff begin job responsibilities. The Resident Services Director will verify required pre-service orientation, dementia training for direct-care staff, food handler certification when applicable, and required training documentation before independent assignment. 3. How often it will be evaluated: The Resident Services Director will review open new-hire checklists weekly. The Executive Director or designee will audit new-hire training records at 30 days of employment, monthly for three months. 4. Responsible party: Resident Services Director; Executive Director or designee for monitoring.

OAR 411-054-0070 (5, 9-10) Training Within 30 Days of Hire ? Direct Care Staff Temporary rule language in effect until 02/05/2027 (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible for verifying 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. (b) Exempt from this training requirement are contractors who contract directly with the resident or the resident’s representative, and contractors who do not generally provide services or supports directly to residents, including, but not limited to, contractors for landscaping, pest control, deliveries and building repairs. (c) By December 31, 2024, facilities shall ensure that all contracts entered into with entities described in paragraph (a) of this section shall include language requiring contractors provide Department-approved LGBTQIA2S+ training to their employees within 12 months of entering into the contract with the facility and every two years thereafter. (d) For existing contracts in effect January 1, 2025, facilities shall require the contractor provide Department-approved LGBTQIA2s+ training to employees by December 31, 2025, and every two years thereafter. (e) For new contracts created after January 1, 2025, facilities shall require contractors provide the Department-approved LGBTQIA2S+ training to employees within 12 months of entering into the contract with the facility, and every two years thereafter. (f) Facilities must inform contractors that the cost of all LGBTQIA2S+ trainings for contracted employees shall be paid by the contractor. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to verify 2 of 3 sampled newly hired direct care staff (#s 16 and 17) 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 3 (Resident Services Director) on 09/09/26, and the following were identified: a. There was no documented evidence Staff 16 (Care Partner), hired 04/17/26, had demonstrated competency within 30 days of hire in one or more of the following areas: * First aid and abdominal thrust. b. There was no documented evidence Staff 17 (Care Partner), hired 07/02/26, had demonstrated competency within 30 days of hire in 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; and * General food safety, serving, and sanitation. The need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN) and Staff 3 on 09/11/26 at 11:25 am. They acknowledged the findings, and no additional documentation was provided.

1. Correction for each example/resident: Missing direct-care competency documentation for Staff 16 and Staff 17 was reviewed and completed by 09/12/2026 as applicable to assigned duties. Until competency was verified, affected duties were limited to training, competency review, or directly supervised practice. 2. System correction to prevent recurrence: Direct-care staff will not work assigned duties independently until competency is verified and documented. A 30-day competency checklist will be used for each new direct-care staff member, with a named evaluator and due date. 3. How often it will be evaluated: The Resident Services Director will review open competency checklists weekly. The Executive Director or designee will audit direct-care new-hire competency records at 30 days of employment, monthly for three months. 4. Responsible party: Resident Services Director; Executive Director or designee for monitoring.

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 take measures in the prevention of the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to: Observations of the facility exterior on 09/09/26 at 9:15 am identified multiple open windows throughout the facility that lacked screens to prevent the entry of rodents, flies, mosquitoes, and other insects. An interview with Staff 4 on 09/08/26 at 2:20 pm confirmed multiple windows were without screens. The need to ensure the facility took measures to prevent the entry of rodents, flies, mosquitoes, and other insects was discussed with Staff 4 on 09/10/26 at 9:50 am and Staff 1 (ED), Staff 2 (Health Services Director/RN), and Staff 3 (Resident Services Director) on 09/11/26 at 10:45 am. They acknowledged the findings.

1. Correction for each example/resident: Missing window screens identified during survey were replaced by 09/16/2026. Window screens in apartments and common areas were checked on 09/16/2026 and corrected as needed. 2. System correction to prevent recurrence: Window screen review was added to routine apartment inspections. Missing or damaged screens will be documented and repaired or replaced when identified. 3. How often it will be evaluated: Quarterly. The Executive Director will review quarterly inspection results and follow up on outstanding repairs. 4. Responsible party: Maintenance Director; Executive Director for oversight.