Print Inspection: CHOW003666

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician's or other legally recognized practitioner’s orders were carried out as prescribed for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2022 with diagnoses including scoliosis, hypertension, and COPD. The resident's current signed physician orders, and 03/01/25 through 04/09/25 MARs, substance disposition logs, and blood pressure readings were reviewed, and the following was identified: a. Resident 1 had a physician’s order, dated 01/16/25, to administer Acetaminophen (Tylenol) with codeine #3 300-30 mg every 4 hours for chronic low back pain. The resident’s narcotic logs revealed the medication was administered with less than four hours between doses on 21 occasions between 03/01/25 and 04/09/25. b. Ciprofloxacin 500 mg 1 tablet every 12 hours for 7 days for a urinary tract infection was ordered on 03/30/25. The MAR revealed on 04/01/25 the medication was administered at 6 am and 8 am, rather than 12 hours between doses as prescribed. c. Lisinopril 25 mg (for high blood pressure) was ordered to be held for systolic blood pressure less than 100 or diastolic less than 60. A blood pressure reading from 03/24/25 revealed Resident’s 1 blood pressure was 102/55 and indicated a diastolic reading less than 60. According to the MAR, Resident 1 received the medication on 03/24/25. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Health Services Administrator), Staff 2 (Assisted Living Manager), Staff 3 (Nursing Supervisor RN), and Staff 4 (Nursing Supervisor LPN) on 4/10/25 at 12:40 pm. They acknowledged the findings, and no additional information was provided.

1. The Nurse Supervisor LPN held an in-service on 4/21/25 reviewing the procedure to give Narcotics and Antibiotics in the appropriate time windows that the medications are prescribed. The Nurse also conducted an in-service going over parameters and when to give a medication according to these parameters. 2. The Nurse Supervisor RN and Nurse Supervisor LPN will assign a Relias training regarding medication pass education to be completed by 6/1/2025. 3. The Nurse Supervisor RN and Nurse Supervisor LPN will do a weekly MAR audit to verify Narcotic and Antibiotic administration times and medications given according to parameters weekly for 3 months. 4. The Nurse Supervisor LPN or designee will conduct the audits. The AL Manager will review the weekly audits for 3 months.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose ABST records were reviewed. Findings include, but are not limited to: Residents’ service plans, Temporary Service Plans (TSPs), and corresponding ABST individual minutes were reviewed. The residents were observed, and interviews were conducted with staff. The residents’ care times and care elements were found to not be reflective in one or more of the following areas: * Assisting with communication, assistive devices for hearing and vision; * Assisting with medication administration; * Assisting with grooming; * Transferring in and out of bed or chair; * Responding to call lights; * Safety checks and fall prevention; * Monitoring physical conditions or symptoms; * Assisting with bowel and bladder management; * Assisting with personal hygiene such as shaving and mouth care; and * Dressing and undressing. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Health Services Administrator), Staff 2 (Assisted Living Manager), Staff 3 (Nurse Supervisor RN), and Staff 4 (Nurse Supervisor LPN) on 04/10/25. They acknowledged the findings

1. On 4/28/2025, the AL Manager updated all 22 ABST questions for sample residents (#1,2,3, and 4) to reflect current care plans. 2. The AL Manager will attend 30 day, Quarterly and change of condition service plan meetings with the Nurse Supervisor RN and Nurse Supervisor LPN to make sure accurate care times and care elements are recorded for each resident in the ABST. If AL Manager is unavailable for the meeting, they will notify the Nurse Supervisor RN and Nurse Supervisor LPN the day before in the morning meeting so that either the RN or LPN can update the ABST. 3. The AL Manager will use and update a service plan audit tool to track the updates of the ABST for residents prior to move in, within the first 30 days of residency, upon change of condition and no later that quarterly for Service Plans and ABST updating. 4. The AL Manager or designee will update the service plan audit tool and will conduct weekly audits for 3 months to verify that ABST updates have been made accordingly.

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to update and review the acuity-based staffing tool (ABST) following a significant change of condition for 3 of 3 sampled residents (#s 1, 2, and 4) who had a significant change of condition. Findings include, but are not limited to: The facility’s ABST was reviewed during the survey and the following was identified: a. Review of Resident 4’s ABST and clinical records during the survey showed the following: * The resident experienced a significant change of condition following a 01/07/24 fall and an increase in ADL needs; and * The resident’s ABST was not updated after the resident’s significant change of condition. b. Review of Resident 1’s ABST and clinical records during the survey showed the following: * The resident experienced a significant change of condition following a decline in health and a 03/20/25 return from a skilled nursing stay; and * The resident’s ABST was not updated after the resident’s significant change of condition until 03/31/25. On 04/10/25 at 12:25 pm, Staff 1 (Health Services Administrator) confirmed Resident 1’s ABST was not updated and/or updated in a timely manner following a significant change of condition. c. Review of Resident 2’s ABST and clinical records during the survey showed the following: * The resident experienced a significant change of condition following a decline in health, increased ADL needs, and a 03/20/25 hospice admission; and * The resident’s ABST was not updated after his/her significant change of condition. On 04/10/25 at 12:40 pm, Staff 1 confirmed Resident 2’s ABST was not updated and/or updated in a timely manner following a significant change of condition. The need to ensure residents' ABSTs were updated with significant changes of condition was discussed with Staff 1, Staff 2 (Assisted Living Manager), Staff 3 (Nurse Supervisor RN), and Staff 4 (Nurse Supervisor LPN) on 04/10/25. They acknowledged the findings.

1.On 4/28/2025, the AL Manager updated all 22 ABST questions for sample residents (#1,2,3, and 4) to reflect current care plans. Resident #1 ABST updated for significant change of condition, #2 ABST was updated for significant change of condition, #3 ABST was updated for significant change of condition and #4 ABST was updated for significant change of condition. The AL manager will conduct weekly ABST meetings with a nurse manager or designee for the first 3 months starting the week of 4/21/2025. 2. The AL Manager will document ABST meetings on a log and obtain signatures of those in attendance: AL Manager, Nurse Supervisor RN and/or Nurse Supervisor LPN or other designee. The log will include if the updates to the ABST are due to significant change in condition, 90 day, pre-move in or an increase/decrease in care. 3. AL Manager will conduct a weekly audit on the ABST tool and service plan audit tool. 4. The AL Manager or designee will keep the ABST up to date through weekly audits and attending service plan meetings.

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 3 of 3 newly hired staff (#s 10, 13, and 14) completed all required pre-service training. Findings include, but are not limited to: Staff training records were reviewed on 04/08/25 and revealed the following: There was no documented evidence Staff 10 (MT), hired on 2/11/25, Staff 13 (CG), hired on 2/4/25, and Staff 14 (CG), hired on 2/25/25, completed Department approved pre-service infection control training that addressed the following: · Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease; · Respiratory hygiene and coughing etiquette; · Standard precautions; · Use of personal protective equipment; · Cleaning of physical environment; · Disinfecting high-touch surfaces and equipment; and · Handling, storing, processing and transporting linens to prevent the spread of infection. In an interview on 04/10/25 at 1:15 pm, staff training records and rule requirements were reviewed and discussed with Staff 6 (Human Resources Generalist). Staff 6 confirmed the required training had not been completed for newly hired Staff 10, 13, and 14. The need for staff to complete all required pre-service training prior to starting job duties and providing care to residents was discussed with Staff 1 (Health Services Administrator), Staff 2 (Assisted Living Manager), Staff 3 (Nursing Supervisor RN), and Staff 4 (Nursing Supervisor LPN) on 4/10/25 at 12:30 pm. They acknowledged the findings.

1. The Health Services Administrator and AL Manager will assign the required infection control courses by 5/1/2025. Staff number #10,#13 and #14 will complete the required courses by 6/1/2025. The courses will be assigned in Relias Learning following the Oregon approved Relias Crosswalk to include the follow courses: Environmental Cleaning 7 step process,Transporting clean linen, all about personal protective equipment, infection control: cohorting, Infection control: Essential Principles . 2. All team members that are required to the have the pre-service infection control trainings will complete the training by 6/1/2025. All new team members will have the pre-service infection control courses assigned to them and completed prior to working with residents. Any team member that would be working in AL including caregivers, nurses, maintenance, dining and housekeeping will take he required courses. 3. The AL Manager will conduct weekly audits to verify progress in completing the required courses by 6/1/2025. 4. The AL Manager will conduct weekly audits and verify team members have completed the required trainings prior to working with residents.

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 411-054-0090 (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 provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire drill and fire and life safety training records dated 10/07/25 through 04/07/25 were requested and reviewed on 04/08/25. The following was identified: * There was no documented evidence the facility provided fire and life safety training to staff on alternating months from fire drills. * There was no system or curriculum to provide trainings on a regular basis, and no system to track if staff had received fire and life safety training as required. The need to ensure staff received fire and life safety instruction on alternating months was discussed with Staff 5 (Director of Building Grounds) on 04/09/25. The requirement for fire and life safety training on alternating months was reviewed with Staff 1 (Health Services Administrator), Staff 2 (Assisted Living Manager), Staff 3 (Nursing Supervisor RN), and Staff 4 (Nursing Supervisor LPN) on 4/10/25 at 12:30 pm. They acknowledged the findings

1. The Director of Buildings and Grounds or designee will add mandatory fire life safety trainings to our All Staff meetings beginning on 5/13/2025.The first topic on 5/13/25 will be a refresher of our emergency operations plan. 2. The Director of Buildings and Grounds or designee will create in-service sign-in sheets for these training courses and they will be stored in HR records. The Director of Buildings and Grounds or designee will continue to do monthly fire drills as required by other jurisdictions. 3. The Director of Buildings and Grounds created a training calendar for Fire Life safety trainings and created recurring work orders for the trainings in the computerized maintenance management system to alert the Building and Grounds team of upcoming required trainings. The AL Manager will keep a log of the dates that the Fire Life safety trainings occur to ensure compliance. 4. The Director of Buildings and Grounds or designee will update the training calendar annually as part of our emergency operations plan update.

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: