Print Inspection: CHOW004899

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately report abuse relating to resident to resident altercations, ensure incidents were immediately investigated to rule out abuse or suspected abuse, and report to the local SPD (Seniors and People with Disabilities) office when abuse could not be reasonably ruled out for 3 of 4 sampled residents (#s 1, 3, and 4) who had documented incidents. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 03/2025 with diagnoses including paralysis in lower extremities and generalized weakness. The resident’s facility medical record including an Incident Form, dated 05/26/25, and progress notes, dated 03/14/25 through 05/29/25, were reviewed and staff were interviewed. The following incidents were identified: * 03/31/25: Two "penny sized wounds"; * 05/02/25: Skin tear to the resident's nose; and * 05/04/25: Bruising to upper left thigh. Facility documentation confirmed that Resident 1 was unable to recall how the above incidents occurred. On 06/11/25 at 1:04 pm, Staff 1 (ED) confirmed the incidents had not been investigated in order to rule out abuse. On 06/11/25 at 6:02 pm, documentation was provided that the above injuries of unknown cause were reported to the local SPD office. The need to ensure all incidents of abuse or suspected abuse were immediately investigated to rule out abuse, and if abuse could not be ruled out, reported to the local SPD office was discussed with Staff 1 on 06/11/25. She acknowledged the findings. 2. Resident 3 moved into the facility in 07/2024 with diagnoses including dementia and chronic kidney disease and Resident 4 moved into the facility in 05/2024 with diagnoses including macular degeneration and dysphasia. On 06/10/25, it was reported that Resident 3 and Resident 4 had a physical altercation. The resident’s records were reviewed, including each resident’s current service plan, progress notes, dated 05/30/25 through 06/07/25, temporary service plans, dated 05/30/25, and an Incident Form dated 05/30/25. Interviews with staff were conducted and the following was identified: On 05/30/25, when Resident 3 “…was being seated at the dinner table…[s/he] ended up yelling at [Resident 4] that [his/her] legs were in the wrong place and needed to be moved…” and “…Instead of waiting the resident decided to kick [Resident 4’s] legs…” Documentation provided for Resident 3 and Resident 4 lacked a determined follow-up action and/or interventions to limit the potential for reoccurrence. On 06/12/25 at 9:01 am, Staff 2 (Director of Wellness) stated he was unaware if the incident was reported to local SPD office and at that time, survey requested the facility to report the incident if it had not been already. On 06/12/25 at 11:36 am, confirmation was received the resident-to-resident altercation was not previously reported to the local SPD office and was reported that day. The need to ensure all incidents of abuse were reported to the local SPD office was discussed with Staff 2, Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings.

1. The incidents that occured with residents 1,3 and 4 were reported while the survey team was in the building. 2. Investigate all incidents to see if community is able to rule out abuse and if unable to rule out abuse or neglect, report to APS immediately. 3. At Each Incident. 4. Executive Director and Drector of Wellness.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 3) whose move-in evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 07/2024 with diagnoses including dementia and chronic kidney disease. On 06/10/25 the residents new move-in evaluation was requested for review and the following was revealed: At 2:49 pm, Staff 2 (Director of Wellness) stated he was unaware a move-in evaluation was needed when a resident moved from the memory care to the assisted living in the same community and did not complete a move-in evaluation. The need to ensure residents were evaluated prior to move-in with all required components was reviewed with Staff 2, Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 03/2025 with diagnoses including paralysis in lower extremities and generalized weakness. The resident’s move-in evaluation was reviewed. The following required elements were not addressed: * Physical health status including vital signs if indicated by diagnosis, health problems, or medications; * Mental health issues including history of treatment and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Ability to use call system; * Pharmaceutical and non-pharmaceutical interventions for pain; * Nutrition habits and weight if indicated; * Recent losses; * Environmental factors that impact the resident's behavior including noise, lighting, room temperature; * Preferred name; and * Preferred pronouns. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 06/12/25. They acknowledged the findings.

1. Resident 1 and 3 evaluation was corrected while survey was in the building. 2. During an initial evaluation, ensure that all information is applied to the evaluation and service plan. 3. At the time of initial evaluation and every three months or as needed. 4. Executive Director or Director of Wellness.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, were implemented, were updated quarterly, and handwritten updates were initialed and dated when the changes were made for 3 of 3 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 07/2024 with diagnoses including dementia and chronic kidney disease. The resident’s record was reviewed, including the service plan available to staff, dated 12/03/24, and Interim and Temporary Service Plans, dated 03/14/25 through 06/09/25. The following was identified: The service plan available to staff was reviewed and revealed the service plan was not reflective of the resident’s current status, lacked clear instruction regarding the delivery of services, and was not implemented in the following areas: * Fall potential and prevention and fall history; * Behaviors that included aggression and agitation at other residents during meals related to having enough leg space; * Resistance to care that included assistance after falls and recent desire to complete everything independently; * Use of mobility and ambulation devices; * Grooming assistance needed that included brushing the residents hair; * Transfer assist that included the need for hands on assist; * Dressing and undressing ability; * Toileting assistance needed that included assistive devices used; * Incontinent assistance needed that included bowel care; * Frequency of safety checks during the day and overnight hours; * Ability to use the emergency response system that included a pull cord and pendant call system; * Level of assistance required for an evacuation that included mobility devices; * Preference to have a male direct-care staff provide groin skin treatment; and * Resident preferred pronouns. The need to ensure the current service plan was available to staff and was reflective of the resident’s current status, provided clear instruction regarding the delivery of services, and was implemented was reviewed with Staff 2 (Director of Wellness), Staff 3, and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 2. Resident 4 moved into the facility in 05/2024 with diagnoses including macular degeneration and dysphasia. The residents current service plan, dated 01/31/25, and Interim Service Plans (ISP) dated 05/30/25, were reviewed, and interviews with staff were conducted. The following was identified: a. The resident’s service plan was not updated at least quarterly. b. There were handwritten updates that were not initialed or dated when the changes were made on ISPs. The need to ensure service plans were reviewed and updated at least quarterly and handwritten updates were initialed and dated when the changes were made was reviewed with Staff 2, Staff 3, and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2021 with diagnoses including vascular dementia. The resident’s service plan available to staff, dated 02/22/25, Interim Service Plans, dated 03/07/25 through 05/21/25, Caregiver Task Sheets, and progress notes, dated 03/01/25 through 06/09/25, were reviewed and staff were interviewed. The service plan was not reflective of the resident’s current needs and/or did not provide clear caregiving instruction in the following areas: * Information and interventions relating to being an elopement risk; * Triggers that cause anxiety and interventions to help to calm the resident; * Instruction relating to a right wrist brace and non-drug interventions for pain; * Collaboration with family in deciding who will be assisting the resident with showers; * The use of a gait belt; * Dining routine including staff providing reminders for meal times; * Underwear versus brief use; and * Staff getting laundry done on shower days. In addition, the service plan had not been updated quarterly, and hand-written updates were not dated and initialed. The need to ensure service plans were reflective of the resident’s needs, provided clear caregiving instruction, was updated quarterly, and hand-written updates were dated and initialed was discussed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25. They acknowledged the findings.

1. ISP/TSP were implemented for residents 2, 3 and 4 while survey was in the building. 2. Communicate changes with the caregivers, RCC and Director of Wellness as needed for changes using ISP/TSP and 24-hour communication book. Update all service plans to ensure accuracy and notifiy all parites involved in any changes. 3. After complete review all assessments and services plans every 3 months, as needed and with significant change of condition. 4. Director of Wellness, Administrator

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition had resident specific interventions developed and communicated to staff on each shift with weekly progress noted until resolution, for 3 of 4 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Findings include but are not limited to: 1. Resident 3 moved into the facility in 07/2024 with diagnoses including dementia and chronic kidney disease. The resident was observed to independently use a manual wheelchair throughout survey. The resident’s record including Incident Accident Report Forms, dated 04/03/25 through 06/09/25, progress notes, dated 03/01/25 through 06/10/25, and Interim and Temporary Service Plans, dated 03/14/25 through 06/09/25, were reviewed and staff were interviewed. a. The resident was identified to have a history of falls when attempting to self-transfer. Documentation revealed the following falls that lacked documented evidence resident specific interventions were developed and communicated staff on each shift, and were monitored through resolution: * 03/10/25: “Recent Fall”; * 03/14/25: “Recent Fall” and “possible head injury”; * 03/20/25: “Recent Fall” with “head contact”; * 03/29/25: “Recent Fall”; * 04/03/25: Unwitnessed Fall; * 04/04/25: “Fall in public bathroom”; * 04/08/25: Unwitnessed fall at 3:30 am; * 04/09/25: “late entry” dated 04/18/25 noted “4/9 at 9:09 pm…fall occurred”; * 04/13/25: “had a fall 4.13.25 at 5:00 am”; * 04/28/25: “found on floor next to bed”; * 04/29/25: “unwitnessed fall in room, 11am”; * 05/02/25: “fell out of bed self transferring”; * 05/03/25: Fall “attempting to use bathroom”; * 05/05/25: “fall…this morning”; * 05/20/25: “Fall” and “found on floor 7:40 am”; * 05/25/25: “resident on the floor” around “2am” and “stated [s/he] hit [his/her] head”; * 05/26/25: “fall in room” and “attempt to self transfer”; * 06/08/25: “possible fall”; and * 06/09/25: “Recent Fall” and “self transfer fall 1:45 am”. b. On 03/10/25, documentation revealed “Redness and superficial indentations” to left knee, however there was no documented evidence the change of condition had resident specific interventions developed and communicated staff on each shift, and monitored through resolution. c. On 05/30/25, the resident was identified to be involved in a resident-to-resident altercation, “Kicking [another resident’s] feet”. There was no documented evidence the change of condition had resident specific interventions developed and communicated staff on each shift and monitored through resolution. The need to ensure resident changes of condition had documented resident specific interventions, the determined interventions were communicated to staff on each shift, and were monitored weekly through resolution was reviewed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 03/2025 with diagnoses including paralysis in lower extremities and generalized weakness. The resident’s facility medical record including an Incident Form, dated 05/26/25, progress notes, dated 03/14/25 through 05/29/25, and Interim Service Plans, dated 03/14/25 through 05/19/25, were reviewed and staff were interviewed. The following changes of condition lacked documentation of actions or interventions needed, communication of the determined actions or interventions to staff on each shift, and/or monitoring through resolution: * 03/13/25: Moving into the facility; * 03/31/25: Two "penny sized wounds"; * 05/02/25: Skin tear to the resident's nose; and * 05/04/25: Bruising to upper left thigh. The need to ensure the facility determined and documented interventions or actions for the resident’s changes of condition, communicated those interventions or actions to staff on each shift, and monitored weekly progress through resolution was discussed with Staff 1 (ED) on 06/12/25 and Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2021 with diagnoses including vascular dementia. The resident’s facility medical record including Incident and Accident Report Forms, dated 04/24/25 through 05/11/25, progress notes, dated 03/01/25 through 06/09/25, and Interim Service Plans, dated 03/07/25 through 05/21/25, were reviewed and staff were interviewed. The following changes of condition lacked documentation of actions or interventions needed, communication of the determined actions or interventions to staff on each shift, and/or monitoring through resolution: * 03/06/25: Fall; * 03/13/25: Burned finger trying to light a candle; * 04/11/25: Experienced chest pain; * 04/21/25: Fall; * 04/24/25: Fall with fracture; and * 05/21/25: Sent to the Emergency Room relating to a low blood pressure. The need to ensure the facility determined and documented interventions or actions for the resident’s changes of condition, communicated those interventions or actions to staff on each shift, and monitored weekly progress through resolution was discussed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25. They acknowledged the findings.

1. Resident 1- skin issues healed and resolved, Resident 2 – continuing to monitor, and resident 3 we implemented ISP and continue to look closely at the shower log to monitor. 2. The staff will use a 24HR book and alert charting / ISP to communicate diviations from the normal observed behaviors, physical, emotional and cognitive or any acute accident. An incident to be filled out when there is an injury to the resident, for the RN to review. 3. Weekly monitoring 4. The RN will be responsible if the change in a residents condition requires further action and corrections are made or referrals related to the change of condition and Wellness Nurse and Administrator or Healthcare providerto be made aware of residents condition to make further recommendations requiring proper and time sensitive documentaion and action. The RN to complete and follow through until situation is resolved, RN also must educate staff, if education is required to perform any tasks related to change of condition.

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

OAR 411-054-0045 (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 a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions for 1 of 1 sampled resident (# 2) who experienced a significant change of condition. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2021 with diagnoses including vascular dementia. The resident was observed wearing a black wrist brace and his/her walker had a platform to rest his/her right arm. Resident 2’s facility medical record including Incident and Accident Report Forms, dated 04/24/25 through 05/11/25, progress notes, dated 03/01/25 through 06/09/25, and Interim Service Plans, dated 03/07/25 through 05/21/25, were reviewed and staff were interviewed. On 04/24/25 the resident fell which resulted in a right wrist fracture. The new diagnosis represented a significant change of condition for the Resident 2. The resident returned to the facility from the hospital on 04/24/25 with increased care needs and equipment following the fracture. On 06/11/25 at 4:47 pm, Staff 4 (RN) acknowledged there was no documented evidence of an RN assessment of Resident 2’s significant change in condition, including documentation of findings, resident status, and interventions made as a result of the assessment. The failure to conduct an RN assessment following a significant change in condition was discussed with Staff 1 (ED) and Staff 4 on 06/11/25, and with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25. They acknowledged the findings.

1. Resident 2 was assessed on 6/18/2025. 2. If the RN is not in the building, the Director of Wellness will complete a full evaluation that the RN can sign off on when she returns. Education for RN and Wellness Department have been scheduled for 8/5/2025 to understand the role of the RN in CBC setting. 3. Must review the service plan and signiture within 48HRS. Evaluation should be weekly or specific or specific to the residents condition or needs. 4. The RN will be responsible for completion of the assessment and the ED and DOW will review any significant changes of condition within 48 hours to ensure the RN has completed the assessment in a timely manner.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication administration systems. Findings include, but are not limited to: Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: C 301: Systems: Medication Administration; C 303: Systems: Treatment Orders; C 305: Systems: Resident Right to Refuse; C 310: Systems: Medication Administration; and C 372: Training within 30 days: Direct Care Staff. The unsafe medication system and lack of adequate professional oversight was discussed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25. They acknowledged the findings.

1. Facility will implement, monitor and ensure a safe medication system for each resident. 2. Facility will provide adequate and effective oversite to ensure a safe medication program using a system that is approved by our Pharmicist Consultant, RN and the Resident’s Physician. 3. Facility will complete daily audits at shift change for holes and PRN follow up. Facility will complete weekly med room audits to ensure oversight. Rcc and Director of Wellness will complete weekly acuity meetings and audits to ensure all systems are in place and implemented. 4. Administrator and Director of Wellness

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medications administered by the facility were set-up or poured and documented by the same person who administered the medications for 1 of 1 sampled resident (# 5) whose orders were reviewed and noted the resident to receive catheter care by another person. Findings include, but are not limited to: Resident 5 moved into the facility in 11/2020 with diagnosis including ataxia (a condition that creates problems with coordination, causing uncertain movement that can appear awkward or clumsy). The resident’s physician orders and MARs dated 05/01/25 through 06/11/25 were reviewed. The following was identified: Resident 5 had an order for staff to prepare 0.25% Acetic Acid solution in 250mL bottles (for catheter care to flush the resident’s catheter tubing), every day. The resident’s MAR documented Staff 12 (MT) had prepared/administered the 0.25% Acetic Acid solution on 13 occasions, however on nine of those occasions, Staff 12 noted the task was “done by [Staff 2 (Director of Wellness)].” On 06/12/25 at 3:15 pm, while reviewing the documentation, Staff 2 stated he did not prepare or administer the solution to flush Resident 5’s catheter. Staff 2 then stated Staff 4 (RN) was responsible for completing that task. On 06/13/25 at 9:41 am, Staff 4 confirmed she did not prepare or administer the solution for the resident’s catheter care. The need to ensure medications administered by the facility were set-up or poured and documented by the same person who administered the medication was reviewed with Staff 2, Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings.

1. Facility will implement a Safe Medication System. Ensure that Med Tech have training and systems available for a safe Medication Administration. 2. Facility will provide In services, training and compentency check lists for all Med Techs that include but are not limited to implementing orders, medication administration and set up by the same person, coordination of care abd follow through. 3. Daily MAR and order audits during shift change. Weekly Med Room audits to ensure adequate oversight and as needed. 4. Executive Director, Director of Wellness and Business Office Manager for all updates to the training tracker.

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. This Rule is not met as evidenced by:

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, the facility failed to ensure medication and treatment orders were carried out as prescribed and had written, signed physician orders documented in the resident’s facility record for all medications and treatments the facility was responsible to administer for 3 of 3 sampled residents (#s 2, 3, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 07/2024 with diagnoses including dementia and chronic kidney disease. The resident’s physician orders and MARs dated 05/01/25 through 06/10/25 were reviewed and staff interviews were conducted. The following was identified: a. The resident’s record lacked signed physician orders for the following orders: * Bupropion (for depression); * Levothyroxine (for thyroid); * Acetaminophen (for pain); * Loperamide (for lose stool); * Polyethylene glycol (for constipation); * Senna (for stomach cramps); * Ketoconazole 2% cream (for anti fungal); and * Multiple vitamins with mineral tabs (for supplement). b. The following orders were not carried out as prescribed: * Sennosides (for stomach cramps) on three occasions; * Simvastatin (for cholesterol) on 11 occasions; * Bupropion (for depression) on three occasions; * Nystatin (for rash) on seven occasions; and * Polyethylene Glycol (for constipation) two occasions. The need to ensure written, signed physician orders were documented in the resident’s record for all medications and treatments the facility was responsible to administer and physician's orders were carried out as prescribed was reviewed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 2. Resident 5 moved into the facility in 11/2020 with diagnosis including ataxia (a condition that creates problems with coordination, causing uncertain movement that can appear awkward or clumsy). The resident’s physician orders and MARs dated 05/01/25 through 06/11/25 were reviewed and the following was identified: a. The facility lacked signed physician orders for all of the resident’s regularly scheduled medication that the facility was responsible to administer and on 06/12/25 at 1:02 pm, Staff 3 (RCC) provided signed physician orders that were signed and dated on 06/12/25. b. The following physician orders were not carried out as prescribed: * Ciprofloxacin (for infection) on eight occasions; * Acetic Acid 0.25% (for catheter care) on two occasions; * Methylphenidate (for ADHD) on one occasion; * Metamucil orange fiber powder (for supplement) on one occasion; * Nystatin (for constipation) on eight occasions; * Polyethylene Glycol (for yeast infection) on four occasions; * Clotrimazole 1% cream (for rash) on 21 occasions; * Digestive advantage capsule (for supplement) on four occasions; and * Vitamin B complex capsule (for supplement) on one occasion. On 06/12/25 at 2:51 pm, Staff 3 reviewed the documentation and acknowledged the above orders were not administered as prescribed. The need to ensure written, signed physician orders were documented in the resident’s record for all medications and treatments the facility was responsible to administer and physician's orders were carried out as prescribed was reviewed with Staff 2 (Director of Wellness), Staff 3, and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2021 with diagnoses including vascular dementia, hypertension, and heart disease. The resident's 05/01/25 through 06/10/25 MARs, physician's orders, dated 06/01/25, and weight records, dated 02/08/25 through 06/10/25, were reviewed. The following orders were not carried out as prescribed: * Don compression socks in the morning and doff them at night: Not completed twice; * Apply ice to right hip three times a day: Not completed three times; and * Daily weights: Not completed 43 times. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25. They acknowledged the findings.

1. MD was faxed while survey was in the building for signed updated orders for residnet 3. Some medications were DC’d and staff were trained on the importance on following doctors orders for resident 2 and 5. 2. Facility will provide In services, training and compentency check lists for all Med Techs that include but are not limited to implementing orders, coordination of care and follow through. 3. Daily MAR and order audits during shift change. Weekly Med Room audits to ensure adequate oversight and as needed. 4. Executive Director and Director of Wellness

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 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 3 of 3 sampled residents (#s 2, 3, and 5) who had documented medication and/or treatment refusals. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 07/2021 with diagnoses including vascular dementia, hypertension, and heart disease. The resident's 05/01/25 through 06/10/25 MARs, and physician's orders, dated 06/01/25, were reviewed and revealed Resident 2 refused to consent to the following orders: * Compression socks: 13 occasions; and * Ice to right hip: 31 occasions. There was no documented evidence the facility notified the prescriber each time the resident refused to consent to orders. The need to notify the physician of the resident’s refusals to consent to orders was discussed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25. They acknowledged the findings. 2. Resident 3 moved into the facility in 07/2024 with diagnoses including dementia and chronic kidney disease. The resident’s physician orders and MARs, dated 05/01/25 through 06/10/25, were reviewed and identified the resident refused to consent to the following orders: * Ketoconazole 2% cream (for antifungal): 19 occasions; * Nystatin (for rash): 56 occasions; and * Polyethylene Glycol (for constipation): four occasions. There was no documented evidence the facility notified the prescriber each time the resident refused to consent to the prescribers’ orders. The need ensure the physician was notified of the resident’s refusal to consent to orders was reviewed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 3. Resident 5 moved into the facility in 11/2020 with diagnosis including ataxia (a condition that creates problems with coordination, causing uncertain movement that can appear awkward or clumsy). The resident’s physician orders and MARs, dated 05/01/25 through 06/10/25, were reviewed and identified the resident refused to consent to the following orders: * Nystatin (for yeast infection): 17 occasions; and * Polyethylene Glycol 3350 (for constipation): three occasions. There was no documented evidence the facility notified the prescriber each time the resident refused to consent to the prescribers’ orders. The need ensure the physician was notified of the resident’s refusal to consent to orders was reviewed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings.

1. The facility updated the MAR per dificiency for resident 2, 3 and 5 2. In services and training for all med techs to include dosage volumes, tracking, administering instructions, parameters and implementation of the system to keep accurate records. 3. Daily MAR audits at shift change, Monthly medication administration record checks and as needed. 4. Executive Director, Director of Wellness, and RCC.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for all medications that were ordered by a legally recognized prescriber and were administered by the facility for 3 of 3 sampled residents (#s 2, 3, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 07/2024 with diagnoses including dementia and chronic kidney disease. The resident’s physician orders and MARs, dated 05/01/25 through 06/10/25, were reviewed and interviews with staff were conducted, the following was identified: a. The MAR documented the following medications as administered, however the MAR also noted “not here” due to the “pharmacy account suspension” or “med not here”: * Simvastatin (for cholesterol) on 11 occasions; * Nystatin (for rash) on seven occasions; * Bupropion (for depression) on two occasions; * Polyethylene Glycol (for constipation) on two occasions; * Sennosides (for stomach cramps) on three occasions; and * Ketoconazole 2% cream (for antifungal) on one occasion. On 06/11/25 at 11:07 am, Staff 3 (RCC) reviewed the documentation and confirmed the above orders were documented as administered and were not administered. b. The MAR lacked dosage or volume to administer for the following: * Ketoconazole 2% cream (for antifungal); and * Nystatin powder (for rash). The need to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized prescriber and were administered by the facility was reviewed with Staff 2, Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 2. Resident 5 moved into the facility in 11/2020 with diagnosis including ataxia (a condition that creates problems with coordination, causing uncertain movement that can appear awkward or clumsy). On 06/11/25 at 11:59 am, Resident 5 stated s/he had several “issues” with the facility “keeping track of [his/her] medications” and that “[s/he] shouldn’t have to count [his/her] pills to see if [s/he] is getting all of them”. The resident’s physician orders and MARs, dated 05/01/25 through 06/11/25, were reviewed and interviews with staff were conducted. The following was identified: a. The resident had physician orders dated 05/12/25 and 05/23/25, for Ciprofloxacin HCl 500mg (for infection) to be administered twice daily (14 tablets). The orders contained a total of 28 tablets for administration. There were no additional orders for this medication provided. From 05/13/25 through 05/31/25, the MAR indicated the medication was administered on 33 occasions. On 06/12/25 at 1:02 pm, the discrepancies above were reviewed with Staff 2 (Director of Wellness) and he acknowledged the documentation errors. b. The MAR had documented ranges for administration for the following: * Gabapentin (for catheter changes) administer “1 – 3 capsules…”; and * Ipratropium Bromide 0.03% spray (for rhinorrhea) administer “1 – 2 sprays”. On 06/12/25 at 1:02 pm, the lack of direction to instruct non-licensed staff on what to administer was reviewed with Staff 2. The need to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized prescriber and were administered by the facility was reviewed with Staff 2, Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2021 with diagnoses including vascular dementia and pain. The resident's MARs, dated 05/01/25 through 06/10/25, and prescriber orders were reviewed. The following PRN pain medications lacked resident specific parameters for the sequential order of use: * Acetaminophen liquid; * Camphor-menthol-methyl salicylate patch; * Diclofenac sodium gel; * Lidocaine cream; * Salonpas deep relief gel; and * Tramadol. In addition, the tramadol was prescribed for PRN administration, every six to eight hours, making unlicensed staff responsible to determine how many hours the resident would need in between doses. The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must 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 hosed 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 systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: The facility consisted of a single four-story building that housed 32 residents at the time of the survey. The current facility staffing plan and Acuity Based Staffing Tool (ABST) were reviewed, and interviews with facility staff were conducted. The following was revealed: * The third floor had three residents who required two-person assist for transfers; * Staff went between the third and the fourth floors to provide assistance to residents; and * According to the facility’s posted staffing plan, one MT and one CG was scheduled to cover the night shift, leaving only one staff available to assist those who required two-person assist while the other staff was on break. The need to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 06/11/25 at 2:53 pm. They acknowledged the findings.

1. We altered the schedule to make it so there was enough staff on the 3rd floor. 2. The facility will have a minimum of two direct care staff sccheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs. 3. Daily for monitoring and weekly or as needed when we are adjusting the schedule. 4. RCC, Staffing coordinator and Administrator.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must 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 hosed 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 systems work. 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 have an accurate number of care minutes included on the acuity-based staffing tool (ABST) for each of the 22 care areas, for 2 of 3 sampled residents (#s 2 and 3). Findings include but are not limited to: Review of Resident 2 and 3’s ABST records revealed the residents’ allotted care minutes were not reflective of current needs in one or more of the 22 care areas of ABST. On 06/13/25, the need to ensure the ABST accurately captured the care minutes for all residents, in each of the 22 ADL areas was discussed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator). They acknowledged the findings.

1. We compared and updated the ABST with the service plan and corrected it for resident 2, 3. 2. Will monitor the ABST during all changes of condition, before move in and at the quarterly service plan review. 3. Weekly during clinical review, at move in or any change of condition. 4. Administrator and Director of wellness.

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 2 of 4 sampled residents (#s 1 and 2) and 16 unsampled residents. Findings include, but are not limited to: The facility’s ABST was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 06/11/25 at 2:53 pm. The following was identified: a. Resident 1, who moved into the facility on 03/13/25, did not have an ABST evaluation completed until 03/25/25, or 12 days following the resident’s move to the facility. Six unsampled residents did not have an ABST evaluation completed before they moved into the facility. b. Resident 2 experienced a significant change of condition related to a wrist fracture on 04/24/25, and the resident needed additional assistance with his/her ADLs. The ABST was updated on 04/30/25, or six days after the significant change of condition. c. Eleven unsampled residents’ ABST evaluation had not been updated quarterly at the same time as the service plan update. The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly with the service plan was discussed with Staff 1 and Staff 2 on 06/11/25. They acknowledged the findings.

1. Facility will complete, update and review the ABST evaluation for each resident before a resident moves in, for any change of condition, and no less than quarterly. 2. Facility will keep documentation of the updated ABST as evidence of the accuracy of the changes before move in, during a significant change and no less than quarterly. 3. Daily discussion during stand-up and weekly audits at clinical. 4. Administrator and Director of Wellness.

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 4 newly hired staff (#s 12, 17, and 18) completed all required pre-service orientation training and pre-service dementia training prior to beginning their job responsibilities. Findings include, but are not limited to: On 06/11/25, staff training records were reviewed for Staff 17 (CG), Staff 18 (CG), and Staff 12 (MT), hired 04/01/25, 03/17/25, and 04/07/25, respectively, and identified the following: a. Staff 17 lacked documented evidence pre-service orientation and pre-service dementia training was completed prior to beginning job responsibilities in the areas of: * Resident rights and values of CBC care; * Approved Home and Community-Based Services (HCBS) course; * Approved LGBTQIA2S+ course; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understating, communicating and responding to behaviors, reducing use of antipsychotics; * Strategies for addressing social needs & engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing flood/fluids, preventing wandering, use of person-centered approach. b. Staff 18 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of: * Resident right and values of CBC care; * Fire safety and emergency preparedness; * Approved HCBS course; and * Approved LGBTQIA2S+ course. c. Staff 12 lacked documented evidence pre-service orientation and pre-service dementia training was completed prior to beginning job responsibilities in the areas of: * Resident right and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency preparedness; * Infectious disease prevention * Approved HCBS course; * Approved LGBTQIA2S+ course; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understating, communicating and responding to behaviors, reducing use of antipsychotics; * Strategies for addressing social needs & engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing flood/fluids, preventing wandering, use of person-centered approach. On 06/11/25 at 1:30 pm, Staff 6 (Business Office Manager) confirmed the need to update the system to track all the required training for newly hired staff. The need to ensure staff completed the required pre-service orientation and pre-dementia training prior to starting their job duties was reviewed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings.

1. Facility will implement pre-service orientation for all employees, prior to beginning their job responsibilities. 2. Training will include but not be limited to, a review of their job description, Resident rights and values of CBC care, abuse reporting, fire safety, emergency procedures, infection prevention and dementia training. 3. Facility will review new hires daily at Stand-up and will audit the ongoing training tracker weekly for updates. 4. Business office Manager to audit the training spreadsheet and Administrator for implemetation.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 11, 12, 17, and 18) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: On 06/11/25, staff training records were reviewed for Staff 17 (CG), Staff 18 (CG), Staff 12 (MT), and Staff 11 (MT), hired 04/01/25, 03/17/25, 04/07/25, and 11/25/24, respectively, and identified the following: There was no documented evidence Staff 11 and 18 demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; * Conditions which require assessment, treatment, observation, and reporting; and * General food safety, serving and sanitation. Additionally, there was no documented evidence Staff 11, Staff 17, Staff 18, and Staff 12 had completed competency in first aid/abdominal thrust within 30 days of hire. On 06/11/25 at 1:30 pm, the above was reviewed with Staff 6 (Business Office Manager) confirmed the need to update the system to track all of the required competency areas. The need to ensure staff demonstrated competency in their assigned job duties within 30 days of hire was reviewed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings.

1. Get access to online trainings. Have all current staff complete any trainings needed. New hires to complete the pre-Service training prior to starting the floor. Have all 30 day trainings and skill competencies completed within the 30 day timeframe. 2. Utilize spreadsheets to ensure all the trainings are done. 3. At hire, weekly than monthly, and then as needed, business office manager will do biweekly audits of all training trainings. 4. Executive director, director of wellness, business office manager.

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

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place to ensure all direct care staff completed the required annual and biannual training in Home and Community-Based Services (HCBS) and LGBTQIA2S+. Findings include, but are not limited to: On 06/11/25 at 1:30 pm, annual training records were reviewed with Staff 6 (Business Office Manager) for Staff 12 (CG), Staff 14 (CG), Staff 10 (MT/CG), and Staff 9 (MT/CG), hired 09/19/23, 09/19/23, 09/21/23, and 09/21/23, respectively, and the following was identified: * There was no documented evidence Staff 12 completed the approved HCBS course and LGBTQIA2S+ courses. * There was no documented evidence Staff 14 completed the approved HCBS course. * There was no documented evidence Staff 10 completed the approved HCBS course and LGBTQIA2S+ courses. * There was no documented evidence Staff 9 completed the approved HCBS course. The need to ensure staff completed the required annual and biannual trainings was reviewed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings.

1. Facility will implement annual and bi-annual inservice and training progeram for all employees. We reviewed and audited all employeed to make sure they had all required trainings completed. 2. Training will include but not be limited to12 hours of direct care training to include, 6 hours of dementia training, infectious disease outbreak and infection control, LGBTQIA2S+ protections and care trainings with a designated facility point of contact. 3. Weekly audits will be completed to monitor all employees and ensure the training tracker is updated. 4. Business office Manager to audit the training spreadsheet and Administrator to ensure completion of trainings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. 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 document all required elements for fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: On 06/10/25, fire and life safety records, dated 12/2024 through 06/2025, were reviewed. The fire drill records lacked the following components: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. Due to the escape route not being documented, there was no evidence alternative routes were used during fire drills. Any problems encountered with residents being resistive to participate in drill was not documented, thus the facility was unable to determine if the evacuation standard had been met. There was no documented evidence the facility provided fire and life safety instruction to staff on alternating months from fire drills. The need to ensure fire drills included documentation of all required components was discussed with Staff 1 (ED) and Staff 7 (Maintenance Director) on 06/11/25. They acknowledged the findings.

1. Fire drills will be completed and documented according to the OFC every other month. Fire and life safety instruction will be completed and documented during alternating months. If full evacuation will be completed at least once annually. 2. Unannounced fire drills will be implemented and documented every other month with written evidence that we provided evacuation assistance to a point of safety. We will document a.) problems encountered. B.) evacuation time. C.) staff members on duty participating in the drill and occupants evacuated. 3. Every other month or six times a year. 4. Executive director will monitor with Maintenance Director each time for the first six months then Executive Director will review quarterly.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct residents, at least annually, on the facility's fire and life safety procedures according to the Oregon Fire Code (OFC). Findings include, but are not limited to: There was no documented evidence that residents were instructed on the facility’s fire and life safety procedures within 24 hours of admission or re-instruction at least annually. On 06/11/25 at 11:19 am, Staff 7 (Maintenance Director) confirmed that newly admitted residents were not instructed on fire and life safety procedures within 24 hours of admission or were re-instructed on the procedures at least annually. The need to ensure residents were instructed on the facility's fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, per the OFC was discussed with Staff 1 (ED) and Staff 7 on 06/11/25. They acknowledged the findings.

1. Ensure all residents are instructed on the fire and life safety procedures upon admit and then yearly. 2. Ensure all current residents are instructed on the fire and life, safety procedures, as soon as possible and yearly. New admits our instructed on fire and safety procedures upon admission and yearly. 3. After initial completion, yearly. 4. Executive Director and Maintenance Director.

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

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to: On 06/11/25 at 9:50 am, the exterior of the facility was toured and the following was identified: There were multiple drop-offs, measuring greater than one inch from the concrete to the ground, identified around the exterior perimeter pathway located in courtyard at the front of the facility. This created potential fall hazards to the residents. The need to ensure all exterior pathways were maintained in good repair was reviewed with Staff 1 (ED) and Staff 7 (Maintenance Director) on 06/11/25 at 11:01 am. They acknowledged the findings.

1. Facility will ensure general building exterior is maintained and in good repair. 2. Maintain and repair all exterior pathways that have a greater than one inch drop off as identified around the exterior perimeter pathway in the courtyard. 3. Weekly monitoring around the exterior. 4. Maintenance Director and Administrator.

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

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 06/11/24 at 9:50 am and the following was identified: First Floor: * The entrance and exit doors, door jambs, and/or door frames of the kitchen, located in the resident’s dining room, were in disrepair, had scrapes, and chipped paint present; * Multiple interior doors, door jambs, and door frames including the Service Entrance door, Roof Access door, and Administration door were in disrepair, had exposed wood, and/or chipped paint observed; * The outside of the elevator doors and casing had chipped paint observed; * Common use restroom door and door jamb had chipped paint on both the exterior and interior sides; * Baseboards throughout the first floor, including the dining room and reception area, had an accumulation of dust, gray marks, drips, were separating from the wall, and/or chipped paint present; and * Multiple corners of pillars located on the first floor had gouged and exposed wood, and the paint was chipped. Third Floor: * There was chipped paint, black and/or gray marks, and/or gouges in the door frames and jambs, on the following doors: 302, 306, 314, 315, 316, 317, 319, 320, 321, fire doors, common use restroom, Recreation Room leading to the patio, and the Medication Room; * Baseboards throughout the third floor had chipped paint present and multiple corners were gouged with exposed wood; * Multiple handrails had chipped paint observed; * There were light gray streaks along the walls throughout the third floor including the sitting area outside of the Salon; * The outside of the elevator doors and casing had chipped paint observed; * The laundry room flooring had dark gray and rust colored stains located around the washers and dryers; * The cupboard underneath the eye washing station in the laundry room had brown matter inside; and * Drips, scuffs, and gray marks were observed in the laundry room. Fourth Floor: * There was chipped paint, black and/or gray marks, and/or gouges in the door frames and jambs, on the following doors: 407, 411, exit door leading to the stairwell, common use restroom, laundry room, and storage rooms; * The outside of the elevator doors and casing had chipped paint observed; * There were gray marks on the walls in multiple areas including the corridors and laundry room; * There was an accumulation of lint behind the washer and dryers in the laundry room; and * Baseboards throughout the fourth floor had chipped paint present and multiple corners were gouged with exposed wood; The need to ensure the interior of the facility was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 7 (Maintenance Director) on 06/11/25 at 11:01 am. They acknowledged the findings.

1. Facility will ensure that the general building, doors and walls are maintained and cleanable. 2. Facility will repair and maintain entrance and exit doors, wall chips, door frames, baseboards and common areas to ensure the building interior is in clean and good repair. 3. Weekly audits during walk-through. 4. Maintenance Director and Administrator

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0300 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction. (a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit. (b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules). (c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. Findings include, but are not limited to: On 06/11/25, the surveyor measured water temperatures in multiple resident units and two common use restrooms on the third and fourth floors. The water temperature ranged from 122.2 to 132.4 degrees Fahrenheit. In an interview on 06/11/25 at 11:19 am, Staff 7 (Maintenance Director) confirmed the facility was aware of the water temperature issue and was continuing to come up with ideas to adjust the water temperatures to be within the range of 110 and 120 degrees Fahrenheit. The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 (ED) and Staff 7 on 06/11/25. They acknowledged the findings.

1. Hot water temperatures in residents’ units must be maintained within a range of 110-120 degrees fahrenheit. 2. Water temperatures will be adjusted and maintained by weekly spotchecks and audits. 3. Weekly and as needed. 4. Maintenance Director and Administrator.

OAR 411-054-0300 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction. (a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit. (b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules). (c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by:

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system for security purposes and to alert staff when residents exited the building. Findings include, but are not limited to: The facility was toured on 06/11/25. There were four exit doors on the first floor and one door that led out to a patio area on the third floor. Staff confirmed that when the doors opened, their pagers would alert them as well as the front desk Concierge. Three out of the four exit doors on the fourth floor did not alert staff of residents exiting the building. Staff 6 (Business Office Manager) and Staff 8 (Concierge) replaced the batteries for alarm system to alert staff on 06/11/25. After the batteries were replaced, the exit door alarms were operable. There was no alarming device installed on the third floor’s doors, which exited on to a patio area. The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (ED) and Staff 7 (Maintenance Director) on 06/11/25. They acknowledged the findings.

1. Facility switched out the batteries on the 1st floor exit. 2. Front desk concierge will monitor the effectivenes of the batteries quarterly. Facility will ensure exit doors are equipped with an alarming device for security purposes and will alert staff when residents exit the building including the patio area on the 3rd floor. 3. Weekly audits and as needed. 4. Maintenance Director and Administrator.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR411-004-0020(1)(f) Individual Choice Setting Services&Support (1) Residential and non-residential HCB settings must have all of the following qualities: (f) The setting facilitates individual choice regarding services and supports, and who provides the services and supports. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure individual choice regarding who provided services and supports for 1 of 1 sampled resident (# 3) who had voiced an individual choice. Findings include, but are not limited to: Resident 3 moved into the facility in 07/2024 with diagnoses including dementia and chronic kidney disease. The resident’s record was reviewed, including the service plan and MARs, dated 05/01/25 through 06/10/25. Interviews with staff were conducted and the following was identified: The residents MAR indicated Ketoconazole 2% cream (for antifungal) was to be administered daily to the affected area (groin) and the MAR noted the treatment was refused on 15 occasions in May. On 06/11/25 at 11:07 am, the documented refusals were reviewed with Staff 3 (RCC) and revealed 13 of the 15 refusals noted the resident “preferred males” to administer the treatment. On 06/11/25 at 4:38 pm, Staff 1 (ED) stated when residents had a preference related to services and support, she would do her best to accommodate the request. Staff 1 stated she was unaware Resident 3 voiced a preferred way to receive a service. The need to ensure residents who had an individual choice regarding who provided services and supports was reviewed with Staff 2 (Director of Wellness), Staff 3 (RCC), and Staff 5 (Memory Care Administrator) on 06/13/25 at 11:35 am. They acknowledged the findings.

1. ISP was implemented relating to resident 3’s choices. 2. The facility will implement a system to gather information from residents regarding preference and individual choice to ensure that care and needs are met and document in residents’ care plan. 3. Weekly MAR audits, change of condition and new move in interviews and as needed or upon the request of the resident. 4. Director of Wellness, RCC, RN and Administrator.

OAR411-004-0020(1)(f) Individual Choice Setting Services&Support (1) Residential and non-residential HCB settings must have all of the following qualities: (f) The setting facilitates individual choice regarding services and supports, and who provides the services and supports. This Rule is not met as evidenced by:

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements, including pronouns and gender identity, for 2 of 2 sampled residents (#s 1 and 3) whose move-in evaluations were reviewed. Findings include, but are not limited to: Refer to: C252.

1. Update all assessments and service plans with any missing information. 2. During an initial assessment, ensure that all information is applied to the assessment and service plan. 3. At the time of initial evaluation/assessment and every three months or as needed. 4. Executive Director or Director of Wellness.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: