OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 1 of 2 sampled residents (# 1) while performing ADL care. Findings include, but are not limited to: Resident 1 was admitted to the facility in 06/2026 with diagnoses including Alzheimer’s disease. Observations of the resident and interviews with staff from 09/28/26 through 10/01/26 revealed Resident 1 was bedbound and relied on two staff for all ADL needs. On 09/30/26 at 9:45 am, Staff 12 (CG) and Staff 14 (CG) provided incontinence care for Resident 1. Staff 12 and 14 donned gloves before providing care. Staff 14 removed the resident's soiled brief and performed perineal care, then applied barrier cream, placed a clean brief on the resident, dressed the resident, and placed blankets back onto Resident 1 while continuing to wear the same gloves The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (Administrator ALF), Staff 2 (Director of Quality Assurance), Staff 3 (Health Services Quality Coordinator), and Staff 4 (Regional Director of Operations) on 10/01/26 at 10:00 am. They acknowledged the findings.

1. All staff will be instructed on correct infection control hygiene while performing resident care. This was taught in all staff at 11:30am and 3:30pm on 10/7/26. 2. Staff have been trained to infection control guidelines and will continue to receive training at least weekly during shift change. 3. Care staff to be observed weekly while providing cares to ensure appropriate protocol. 4. Administrator or designee

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing Temporary rule language in effect until 02/05/2027 (1) STAFFING REQUIREMENTS. Facilities must consistently have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support. (a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services. (b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule. (c) The following facility employees are ancillary to the caregiver requirements in this section: (A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation. (B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services). (C) Administrators. (d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection. (e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department. (f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents. (g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs. (h) In facilities where residents are housed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times. (i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic. (A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience. (B) Facilities must be able to demonstrate how their staffing system works. (j) All staff will have a written position description that specifies their specific duties and responsibilities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a sufficient number of care staff to meet the minimum required staffing standards based on the acuity, needs of each resident, and the condition placed by the Department. Findings include, but are not limited to: During the acuity interview on 09/28/26, it was identified the facility had two segregated buildings, Fir house (F) and Grove house (G), and was home to 28 residents. The facility had a condition dated 09/08/26 for Acuity-Based Staffing Tool (ABST) indicating the following: * Fir: Day and Evening shift – One med tech and two caregivers; * Fir: Noc shift – Half med tech and two caregivers; * Grove: Day and Evening shift – One med tech and two caregivers; and * Grove: Noc shift – Half med tech and two caregivers. During survey, on 09/30/26, the condition was amended, and the facility posted an updated staffing plan for each building matching the updated condition as follows: * Fir: Half med tech and two caregivers on day, evening and noc; and * Grove: Half med tech and two caregivers on day, evening and noc. The facility’s staffing schedule was reviewed on 09/29/26 and 09/30/26 for the week of 09/21/26 through 09/27/26. The facility had seven out of 21 shifts, or 33%, not staffed according to the facility’s posted staffing plan and the amended ABST condition. On 9/30/26 at 12:15 pm, Staff 3 (Health Services Quality Coordinator) confirmed that the seven identified shifts were not staffed according to the posted staffing plan and the amended ABST condition. On 10/01/26 at 10:15 am, the need to ensure the facility had a sufficient number of care staff to meet the minimum required staffing standards based on the acuity, needs of each resident, and the condition was reviewed with Staff 1 (Administrator ALF), Staff 2 (Director of Quality Assurance), Staff 3, and Staff 4 (Regional Director of Operations). They acknowledged the findings.

1. The community will be staffed in accordance with the condition and mandated staffing. 2. All shifts that are open or otherwise not covered will be filled by on call staff or supervisory staff to maintain substantial compliance. 3. The schedule and open positions will be reviewed daily for open positions or call outs. 4. Administrator or designee

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time for each care element must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident?s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) accurately captured care time for care elements staff were providing to residents for 2 of 2 sampled residents (#s 1 and 2) whose ABST evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 06/2026 with diagnoses including Alzheimer’s disease. Observations of Resident 1, interviews with staff, and review of Resident 1’s ABST data and 09/22/26 service plan were completed. Observations and interviews with staff during the period of the survey confirmed Resident 1 was bedbound and required two-person staff assistance for ADL care, including repositioning and incontinence care. Resident 1 was also dependent upon one staff member for all nutrition and hydration needs. The following ABST areas were not reflective of the time staff spent providing ADL assistance and care to Resident 1: * Time spent supervising, cueing or supporting while eating; and * Time spent helping with bowel and bladder management. On 10/01/26 at 10:00 am, the need to ensure resident ABST evaluations captured care time for care elements that staff were providing to each resident was reviewed with Staff 1 (Administrator ALF), Staff 2 (Director of Quality Assurance), Staff 3 (Health Services Quality Coordinator), and Staff 4 (Regional Director of Operations). They acknowledged the findings. 2. Resident 2 moved into the facility in 12/2023 with diagnoses including dementia. Observations of Resident 2, interviews with staff, and review of Resident 2’s ABST data and 09/14/26 service plan were completed. Observations and interviews with staff during the survey, from 09/28/26 through 10/01/26, confirmed Resident 2 required staff assistance for cueing during meals related to behaviors and ingesting non-food items. The following ABST areas were not reflective of the time staff spent providing ADL assistance and care to Resident 2: * Time spent supervising, cueing or supporting while eating; and * Time spent cueing or redirecting due to cognitive impairment or dementia. On 10/01/26 at 10:15 am, the need to ensure resident ABST evaluations captured care time for care elements that staff were providing to each resident was reviewed with Staff 1 (Administrator ALF), Staff 2 (Director of Quality Assurance), Staff 3 (Health Services Quality Coordinator), and Staff 4 (Regional Director of Operations). They acknowledged the findings.

1. The time for task in the ABST for the selected residents has been reviewed and updated on the ODHS tool. Resident 1 has had their ABST time updated for time spent supervising, cueing, or supporting while eating, and time spent helping with bowel and bladder management. Resident 2 has had their ABST time updated for time spent supervising, cueing, or supporting while eating and time spent cueing or redirecting due to cognitive impairment or dementia. 2. Every resident will have their ABST reviewed by 11/30/26. Going forward every resident's ABST times will be reviewed at their initial, 30-day, quarterly, and significant change of condition evaluations. 3. By 11/30/26, at the initial, 30-day, quarterly, and significant change of condition 4 . Administrator or designee

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: Review of records for Residents 1 and 2 showed no documented evidence the residents had been provided with a key to their units. The service plan for Resident 1, dated 09/21/26, stated, “Resident REFUSED a key.” Resident 2’s service plan, dated 09/14/26, stated, “Resident does not have a key to [his/her] residence.” In an interview with Staff 1 (Administrator ALF) on 10/01/26 at 8:50 am, she stated their system was to have the key hanging inside the closet door of each apartment, “whether they want it or not.” Staff 6 (Staffing Coordinator) and the surveyor went to two apartments in “F” house and did not observe keys and/or hooks in the closets. Two apartments in “G” house were also observed to lack keys and/or hooks. On 10/01/26 at 10:00 am, the need to ensure all residents were provided keys to their units was reviewed with Staff 1, Staff 2 (Director of Quality Assurance), Staff 3 (Health Services Quality Coordinator), and Staff 4 (Regional Director of Operations). They acknowledged the findings.

1. As of 10/16/26, keys have been issued to all residents in Footsteps, placed on hooks in their personal closets. 2. Keys have been issued to all residents and will continue to be issued and documented upon move in. 3. Keys being in dedicated locations within apartments will be audited monthly 4. Administrator or designee

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C295, C360, C362, and H1518.

Refer to plan of correction for C295, C360, C362, and H1518.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 13 and 14) had demonstrated competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 09/29/26 at 1:30 pm with Staff 18 (Business Office Manager), and the following was identified: There was no documented evidence Staff 13 (CG), hired 06/12/26, and Staff 14 (CG), hired 07/26/26, had demonstrated competency within 30 days of hire in one or more of the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and * Conditions that require assessment, treatment, observation and reporting. On 10/01/26 at 10:15 am, the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was reviewed with Staff 1 (Administrator ALF), Staff 2 (Director of Quality Assurance), Staff 3 (Health Services Quality Coordinator), and Staff 4 (Regional Director of Operations). They acknowledged the findings.

1. Audit of training records and compliance with OARs to be completed by 10/16/2026. Staff 13 and 14 have completed new competency cehcklists to include demonstrated competency in role of the service plan, providing assistance with ADLs, changes associated with normal aging, identification of changes in the resident's physical, emotional, and mental functioning and documentation and reporting of resident changes, and conditions that require assessment, treatment, observation, and monitoring. 2. Any deficiency in training records to be corrected by 11/30/26. For new staff: pre-service, 30-day, and competency checklist to be reviewed before being released to work independently on the floor. 3. With every new hire and then audited weekly 4. Administrator or designee