Print Inspection: CHOW006254

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure 3 of 3 sampled residents (#s 1, 2, and 3) and several non-sampled residents were treated with dignity and respect related to ADL care, a homelike environment, and terms of endearment. Findings include, but are not limited to: a. During an ADL observation on 08/18/25 at 1:50 pm the following was noted: Staff 8 (CG) assisted Resident 3 with personal care by removing a soiled brief, and exclaimed, “That’s smelly!” b. During a breakfast meal observation on 08/20/25 at 8:10 am, loud music was playing in the dining room, maintenance was steam cleaning the carpets around the dining room perimeter, and Staff 11 (CG) was banging dishes of old food against the inside of the garbage can. Resident 1 with wide eyes stated, “Wow!” Resident 1, along with two other unsampled residents at the dining table, were turning their heads, looking around to see what was going on. The need to ensure residents were treated with dignity and respect related to their ADL needs and a homelike environment was discussed with Staff 1 (MC Director), Staff 14 (Regional Director of Operations), and Staff 15 (ED in training) on 08/20/25 at 1:10 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s disease, dysphagia, and mood disturbance. Resident 2 relied on two staff for all ADL needs. a. During an observation of care on 08/20/25 at 10:30 am, Staff 6 (CG) and Staff 11 (CG) were heard referring to Resident 2 as “honey” and/or “hon” throughout the process of providing assistance. Staff 11 stated, “Alright hon, I am going to put your pants on,” and Staff 6 stated, “honey, let go honey.” b. Multiple observations were made throughout the period of the survey of multiple staff referring to sampled and unsampled residents using terms of endearment instead of the residents’ names. On 08/20/25 at 1:10 pm, the survey team discussed with Staff 1 (MC Director), Staff 14 (Regional Director of Operations), and Staff 15 (Executive Director in Training) observations made of multiple staff having used terms of endearment rather than the residents’ names throughout the period of the survey. They acknowledged the findings and confirmed the need to ensure residents were treated with dignity and respect and had a safe and homelike environment.

In reference to OAR 411-054-0027 Resident Rights and Protection - General It was observed that three sampled residents 1,2,3 and serveral non sampled residents were not treated with dignity and respect ralted to ADL care and a home like environment. A. During ADL observation Staff removed soiled brief stating That’s stinky. Staff member 8 as well as all staff did retraining on residents rights and digity. One and one wer conducted and Risident rights and digity were gone over. All staff signed off acknowledging they have gone over and understand.This will be kepted in their files B. During breakfast meal time Loud music was playing staff 11 banging dishes against garbage can. and Carpet cleaning was being completed creating a loud and disrubtive to the residents during meal time. Staff member 11 as well as all staff have been retrained on Background music being played at a respectful volume, adjusted based on resident preferences, to maintain a calm and pleasant atmosphere.This includes banging of the dishes OR Carpet cleaning during meal time. A training of kitchen etiquette and creating a home like environment will be completed and all staff will sign off that they understand. A rubber mat will be purchased for the kitchen sink to reduce noise and improve safety. A silicone plate scraper will be added to assist with dishware cleaning, helping to minimize loud or disruptive sounds.Carpet cleaning will be completed during none meal times. This will be overseen by Maintenance Director or designee. All training or retraining will be overseen by Lead MT and Administrator. It will continuee to be monitored by Administator. All training are currently taking place and will be on going. 2. A. It was observed that staff 6 and 11 were heard referring to residents as Honey or Hon. Staff 6 and 11 were spoken to regarding using terms of endearment and to refer to the residents by their names. B. Multiple Observations of multiple staff were observed referring to them with names of endearment and not their names. This is a retraining that all MC staff will need to complete and or have and will sign acknowledging they understand. Resident and Resident family members feedback on music preferences or meal ambiance will be conducted at resident council. All training or retraining will be overseen by Lead MT and Administrator. It will continuee to be monitored by Administator. All training are currently taking place and will be on going.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and record review, it was determined the facility failed to ensure snacks and liquids were offered in between meals, seven days a week for memory care residents. Findings include, but are not limited to: Observations of the MC dining area on 08/18/25 showed a large drink dispenser of water sitting on the kitchen counter and several snack items stocked in the refrigerator. Observations of the MC between 08/18/25 and 08/20/25 showed staff offered no snacks and liquids to the memory care residents between meals. The need to ensure all memory care residents were offered snacks and liquids throughout the day, seven days a week was discussed with Staff 1 (MC Director), Staff 14 (Regional Director of Operations), and Staff 15 (ED in training) on 08/20/25 at 1:10 pm. They acknowledged the findings.

In reference to OAR 411-054-0030 (1)(A) Resident Services Meals, Food Sanitation Rule Snacks and liquids will be offered seven days a week. Resident Refreshment Schedule to be posted in all common areas advising that snacks are available at all times. To ensure comfort and convenience for all residents: * A water station with a bowl of snacks will be available at all times on the counter for easy access in the kitchen. * A snack and beverage cart will make rounds daily at the following times or upon request: * 10:30 AM * 3:30 PM * 7:30 PM The cart will visit resident rooms and all common areas, offering a variety of snacks and drinks. This will be overseen by MT daily and monitored by lead and Administator or disignee.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: Observations during the survey, from 08/18/25 to 08/21/25, showed there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community. An activity calendar was provided which noted scheduled activities for each day of the week. The activities noted for 08/18/25 included the following: * 10:30 am – Daily Chronicle. Observations at 10:30 am were made and this activity did not take place. * 11:30 am – The Price is Right. Observations were made at 11:30 am and this activity did not occur. * 2:00 pm – Monday Movie. Observations were made at 2:00 pm and this activity did not occur. The activities noted for 08/19/25 included the following: * 10:30 am – Daily Chronicle. Observations at 10:30 am were made and this activity did not take place. * 1:30 pm – Arts and Crafts. Observations were made at 1:30 pm and this activity did not take place. During an interview on 08/19/25, at 1:40 pm, Staff 14 (Regional Director of Operations) stated caregivers and the team in memory care were responsible for the programming of activities. Staff 14 stated Staff 1 (MC Director) was responsible for creating the activity calendar. This surveyor advised Staff 14 observations had been made during the survey and the calendar had not been followed. Staff 14 acknowledged the findings. Residents were observed sitting in the dining room at tables and watching TV in the common area. Residents who were in their apartments were not approached for activity invitations during observations. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 1, Staff 14, and Staff 15 (Executive Director in Training) on 08/20/25 at 1:10 pm. They acknowledged the findings.

In reference to OAR 411-054-0030 (1) (C-D) Lack of scheduled and unscheduled activities provided for residents living in Memory Care. Daily programof activities not being completed. (D) Equipment supplies and space to meet individual or in group Shows a lack of schedule and unscheduled activities. We will have Scheduled and unschedule Activities 7 Days a Week 5 of those days activities will be Led by a Activities assistant which will focus activities. Life Stations Strategically placed throughout the community, these interactive stations will offer spontaneous moments of joy, reflection, and stimulation. To ensure our Memory Care Activity Calendar remains dynamic and enriching, a wide variety of supplies and items have been—and will continue to be—purchased. These resources support both planned programming and spontaneous engagement, helping residents connect, create, and thrive. We have hired a Activities assistant that will work 5 days a week 20-25 hours a week. She will be overseeing and conducting activities and one and ones. The Administator or designee will monitor to ensure that activites are taking place.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; 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 implemented for 1 of 2 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 07/2024 with diagnoses including Alzheimer’s disease, dysphagia, and mood disturbance. Resident 2 relied on two staff for all ADL needs. The resident’s service plan, dated 07/17/25, was reviewed, interviews with staff were conducted, and observations of the resident were made. The resident’s service plan was not implemented in the following areas: * Activities; * Nutritional risk: related to offering snacks three times a day between meals; * Dressing/undressing related to the process; and * Behavior patterns related to interventions for wheelchair use. On 08/21/25 at 12:30 pm the need to ensure service plans were implemented was discussed with Staff 1 (MC Director), Staff 14 (Regional Director of Operations), and Staff 15 (Executive Director in Training). They acknowledged the findings.

In reference to OAR 411-054-0036 (1-4) Service Plan : General. (1- Person - Centered Service Plan. Will incoporate all elements identified in the person centered service plan. (2) SERVICE PLAN 1. Resident service plan was not implemented. Residents 2 relied on two staff for all ADLS's. Residents service plan was not implemented in the following Actvitities, Nutritional (snacks) Any changes made to the plan accurately reflect residents needs and preferences. dressing/undressing. Behavior patterns related to interventions for wheelchair use. Resident 2 Service Plan will be updated to refected the correct needs of the resident. A audited will be conducted to all service Plan and and updated. At every shift change, staff will review and discuss any updates to individual Service Plans. All staff will read and sign off that the acknowledge that have read and understand resident service plan. All service plan will be kept in a service plan binder and or in PCC. The updating of th eService plan will be followed and training will be conducted to ensure all staff are aware. This will be conducted by Lead MT and or adminstator All staff members are required to: * Review all current resident Service Plans in full. * Sign an acknowledgment confirming they understand and will follow the care directives outlined for each individual resident. This ensures every team member is aligned in delivering consistent, personalized care and maintaining compliance with our standards. All newly hired staff are required to: * Read all current resident Service Plans thoroughly. * Sign an acknowledgment form confirming they have reviewed and understood each plan prior to training on the floor. This will overseen by Lead and or Administator and will be monitored by Administator.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary environment for 2 of 2 sampled residents (#s 2 and 3) who received incontinence care. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2020 with diagnoses including Alzheimer’s disease. During the acuity interview, it was reported Resident 3 relied on two staff for all ADL needs. During an ADL observation on 08/18/25, at 1:10 pm, the following was noted: Staff 6 (CG) and Staff 8 (CG) donned single use gloves while assisting the resident with transferring from her/his geri chair to the bed. The staff then helped with personal care by removing a soiled brief, cleaning the perineal area, and disposing of the brief and bed pad. Staff 6 opened the closet door, removed a new package of disposable briefs, opened the package, and removed a clean brief, and the two staff then assisted with donning the clean brief on the resident while wearing soiled gloves. Staff 8 opened a cabinet door, removed a new package of disposable bed pads, opened the package and removed two clean bed pads, and placed them on the resident’s mattress while wearing soiled gloves. Both caregivers then doffed their soiled gloves and assisted the resident with her/his blankets. There was no observation of hand hygiene. The need to ensure proper infection control and hand hygiene was utilized during incontinence care was discussed with Staff 1 (MC Director) on 08/21/25. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s disease, dysphagia, and mood disturbance. Observations of the resident and interviews with staff from 08/18/25 through 08/21/25 revealed Resident 2 relied on two staff for all ADL needs. On 08/20/25 at 10:30 am, Staff 6 (CG) and Staff 11 (CG) provided ADL incontinence care for Resident 2. Staff 6 and 11 donned gloves prior to providing incontinence care. Both staff assisted with removing the resident's soiled brief. Staff 6 performed perineal care without doffing soiled gloves. Staff 6 and 11 then placed a clean brief on the resident and assisted with pulling up Resident 2’s pants with the same gloves. The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (MC Director), Staff 14 (Regional Director of Operations), and Staff 15 (Executive Director in Training) on 08/21/25 at 12:30 pm. They acknowledged the findings.

In reference to OAL411-054-0050 (1-5) Infection prevention and control. 1. Staff 6 and Staff 8 were educated on donning and doffing. All staff including staff 6 and staff 8 were retrained on Infection Prevention and Control. Staff will sign and acknowledge they understand proper infection control prevention and hand hygiene. Staff will participate in 1-on-1 competency reviews to ensure understanding and proper application of infection control practices. This will be completed by Lead MT and or Administator. And will be monitored by Administator. Spot training and individual coaching will be provided as needed or when gaps are observed during daily operations.This will be done by Lead MT and or administator/ designee. Small hand sanitizers will be provided to all staff for personal use during shifts. This is has been purchased and will be a daily reminder with posters and at every shift change.Training and competency will be conducted and kept as record. This will be monitored by Administator.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) following a significant change of condition for 2 of 2 sampled residents (#s 2 and 3). Findings include, but are not limited to: Review of the ABST was completed on 08/20/25, and the following was found: Residents 2 and 3 experienced significant changes of condition on 07/16/25 and 07/25/25, respectively, and the ABST data for both residents was last updated on 06/30/25. The need to ensure residents' ABST was updated with significant changes of condition was discussed with Staff 1 (MC Director) on 08/21/25. She acknowledged the findings.

In reference of OAR 411-054-0037 (4-6) Acuity Based Staffing Tool Updates and Staffing Plan. Resident 2 and 3 had significant change of condition and the ABST did not reflect the changes. We will Review and update the ABST (Acuity-Based Staffing Tool), Prior to move-in, Whenever there is a significant change in condition and at least quarterly, in conjunction with the Service Plan. We have made a completion task sheet check off to ensure no steps are missed. New LN has requested access to the ABST tool. To assure multi people are able to complete updates as needed, Adjust staffing ratios as needed to meet resident care requirements per ABST guidelines. This will be done by LN'S,ED, Administator.

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 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 13 (Maintenance Director) on 08/21/25 at 11:50 am. There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and again at least annually. The need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and again annually was discussed with Staff 1 (MC Director), Staff 14 (Regional Director of Operations), and Staff 3 (Executive Director in Training) on 08/21/25 at 12:30 pm. They acknowledged the findings.

In reference to OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents. Fire and Life Safety will be conducted To ensure all residents are informed and prepared for fire safety procedures: The Maintenance Director will meet with new residents within 24 hours of admission to provide fire and Life safety training. Residents will be re-instructed at least annually to reinforce safety protocols. If the Maintenance Director is unavailable to do so, the Executive Director will ensure the Fire and Life Safety is completed. The Maintenance Director will be give the OAR on fire safety and have sign he understands the OAR and the importance of completing them. All residents and their designated family members or POAs will be notified of the annual fire safety training. A notice will be posted to announce the upcoming Annual Fire Safety Training, scheduled for October 12, 2025.

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 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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 08/18/25 at 11:00 am, the facility grounds were toured and identified a paved pathway in the courtyard with an uneven/raised section that created a tripping hazard for residents. On 08/19/25 at 11:38 am, the uneven pathway was observed with Staff 1 (MC Director), and she acknowledged the need to maintain pathways for resident safety. The need to ensure all exterior pathways were maintained in good repair was reviewed with Staff 1, Staff 14 (Regional Director of Operations), and Staff 15 (Executive Director in Training) on 08/22/25 at 12:30 pm. They acknowledged the findings.

In reference of OAR 411-054-0200 (3) General Building Exterior.In Reference to OAR 411-054-0090 (3) Pathways in the courtyard have uneven/raised sections that create a trip hazard for residents. The Maintenance Director is responsible for community ground and pathways. Repairs to be completed by the Maintenance Director or an outside licensed contractor to ensure proper leveling and compliance with safety standards.We will have a contract for repair date prior to resurvey. IRoutine walkthroughts will be conducted quarterly or as needed by Maintance Director,ED and Administator. This will be monitored and overseen by Maintance Director.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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 411-054-0200 (4)(a-b) General Building Interior (4) GENERAL BUILDING INTERIOR. The design of a RCF must emphasize a residential appearance while retaining the features required to support special resident needs as outlined in this rule. (a) RECEPTION AREA. A reception area must be visible and accessible to residents and visitors when entering the doors of the main entrance to the RCF. (b) CORRIDORS. Resident-use areas and units must be connected through temperature controlled common corridors. (A) Resident-use corridors exceeding 20 feet in length to an exit or common-use area, must have a minimum width of 72 inches. A CF may request an exception to this requirement, which shall be reviewed and decided on a case-by-case basis. (B) Corridors shall not exceed 150 feet in length from any resident unit to a seating or other common-use area. A CF may request an exception to this requirement, which shall be reviewed and decided on a case-by-case basis. (C) Handrails must be installed at one or both sides of resident-use corridors. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure resident-use corridors had handrails installed on one or both sides. Findings include, but are not limited to: The interior of the building was toured on 08/18/25 at 11:00 am. The resident-use corridor where the activities calendar was posted, leading to and including the corridor between apartments 9 and 10, was observed to be without a handrail on at least one side. On 08/19/25 at 11:38 am, a walk-through with Staff 1 (MC Director) was completed. Staff 1 confirmed this was a resident-use corridor, which should have a handrail. The need to ensure handrails were installed along resident-use corridors was discussed with Staff 1, Staff 14 (Regional Director of Operations), and Staff 15 (Executive Director in Training) on 08/21/25 at 12:30 pm. They acknowledged the findings.

In reference to OAR 411-054-0200 (4) (a-b) General Building Interior. In reference to OAR 411-054-0200 (4) (a-b) General Building Interior. To enhance resident safety and accessibility within the community: The Maintenance Director will install handrails between Apartments 9 and 10, as well as in the corridor beneath the large activities calendar. This installation ensures that handrails are present along one side of the corridor, providing continuous support for residents navigating common areas. The supplies have been purchased and will be installed by Maintance Director. This will be overseen by Administator and ED.

OAR 411-054-0200 (4)(a-b) General Building Interior (4) GENERAL BUILDING INTERIOR. The design of a RCF must emphasize a residential appearance while retaining the features required to support special resident needs as outlined in this rule. (a) RECEPTION AREA. A reception area must be visible and accessible to residents and visitors when entering the doors of the main entrance to the RCF. (b) CORRIDORS. Resident-use areas and units must be connected through temperature controlled common corridors. (A) Resident-use corridors exceeding 20 feet in length to an exit or common-use area, must have a minimum width of 72 inches. A CF may request an exception to this requirement, which shall be reviewed and decided on a case-by-case basis. (B) Corridors shall not exceed 150 feet in length from any resident unit to a seating or other common-use area. A CF may request an exception to this requirement, which shall be reviewed and decided on a case-by-case basis. (C) Handrails must be installed at one or both sides of resident-use corridors. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 the environment was maintained clean and in good repair. Findings include, but are not limited to: During a tour of the MCC on 08/18/25 at 11:00 am the following was identified: * Carpet throughout the common areas and corridors of the memory care had large stains; * Carpet in apartment 13 had multiple stains throughout; * Walls in the dining room had black smudges on both the right and left side; and * A floor outlet located near rooms 3 and 5 was not flush with the ground and created a trip hazard. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (MC Director) on 08/19/25 at 11:38 am. She acknowledged the findings.

In reference to OAR 411-054-0200 (4) (d-i) Doors, Walls, elevators, odors (d) All common areas and corridors within the Memory Care unit will have flooring replaced with non-porous laminate to improve sanitation and ease of cleaning. A contract for Installation will be obtained by date of resurvey. Carpet Cleaning Staff are to add a work order to the Maintenance Director’s binder when carpet cleaning is needed. Carpets will be cleaned upon request or as needed. Monthly inspections will be conducted to ensure all carpets are clean and free of stains. Administator will do monthly walkthrough to ensure of any carpets need to be cleaned or repaired. The Maintenance Director will repair and paint damaged walls. Repair Completion Date: Will be prior to resurvey. Housekeeping and staff are responsible for maintaining clean, neat, and tidy wall surfaces. A housekeeper has been hired for just Memory Care and has started working. Any issues should be reported via a work order or directly to the Executive Director. Floor Outlet Safety Repair The floor outlet in the common area will be repaired or replaced to prevent tripping hazards. Repair Completion Date: Before resurvey which will be completed by Maintaince Director and oveseen by Administator/ ED.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(2)(j) Individual freedom: Access To Food Any Time (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (j) Each individual has the freedom and support to have access to food at any time. This Rule is not met as evidenced by: Provider owned, controlled, or operated residential settings must have all of the following qualities: Each individual has the freedom and support to have access to food at any time. Refer to: C240.

In reference to OAR 411-004-0020 (2) (j) access to food any timeIn reference to OAR 411-004-0020 (2) (j) Individual freedem: access to food any time. * A Posted signs will be placed around Memory Care stating that Snacks are available at all times and the location. * A refreshment station will be maintained on the kitchen counter, featuring: * A water dispenser * A bowl of assorted snacks * A selection of fresh fruit This setup will be monitored by Administrator and will be maintaned by Med Tech on duty. It will be checked and filled three times a day. I have ordered bowls to places snacks in and they will be placed on the counter top next to the water dispencer.

OAR411-004-0020(2)(j) Individual freedom: Access To Food Any Time (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (j) Each individual has the freedom and support to have access to food at any time. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Administrator Compliance Refer to: C200, C240, C242, C295, C422, C510, C511, C513

In reference to OAR 411-057-0140 (2) Administration Complaince.In reference to OAR 411-057-0140 Administration Compliance. The Administrator will comply with compliance with Oregon Administrative Rules (OAR) Chapter 411, Division 57, which governs Endorsed Memory Care Communities The Administrator will ensure that the community remains in full compliance with all applicable licensing requirements, including those outlined in Oregon Administrative Rules Chapter 411, Division 57. This includes adherence to standards governing endorsed memory care services, staffing qualifications, resident rights, environmental safety, and program implementation. Ongoing monitoring, staff training, and documentation will be maintained to uphold regulatory expectations and promote quality care. This will be overseen by the campus Administrator.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed prior to beginning job duties and demonstrated competency in assigned duties within 30 days of hire for 4 of 4 newly hired direct care staff (#s 3, 4, 6, and 7). Findings include, but are not limited to: Training records were reviewed on 08/21/25. The following deficiencies were identified: 1. Training records for Staff 3 (MT/CG), Staff 4 (MT/CG), Staff 6 (CG), and Staff 7 (CG), hired 04/07/25, 07/08/25, 04/10/25, and 04/28/25, respectively, identified the following: a. There was no documented evidence Staff 3, Staff 6, and Staff 7 completed required pre-service orientation training prior to beginning job duties in one or more of the following areas: * Fire Safety and emergency procedures; * Infectious Disease Preventions; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 3 completed pre-service dementia training prior to independently providing care and services to residents. c. There was no documented evidence Staff 3, Staff 4, Staff 6, and Staff 7 completed additional pre-service dementia training in one or more of the following dementia training topics: * Environmental Factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities. d. There was no documented evidence Staff 3, Staff 4, Staff 6, and Staff 7 had knowledge and performance demonstrated within 30 days of hire in the following required areas: * Changes associated with normal aging. The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (MC Director) on 08/21/25. She acknowledged the findings.

In reference to OAR 411-057-0160 (2b) Staff Training Requirment All staff will receive the training mandated by the State of Oregon within the required timeframes. Training assignments will be issued upon hire via Workday or Oregon Care Partners. All required training must be completed prior to any floor-based duties. Made a live training tracker to update and add to with all new training. Laptop has been provided to staff to complete assigned training. Staff will receive a personalized list of required courses and sign for them acknowledging they know and understand. A binder with CEUS and certifactions will be kept in the ED office. Staff to completed all training by 10/20/20 Staff who do not complete training by the assigned deadline will be removed from scheduled shifts. The administrator or designee will maintain an dupdate the training tracker to monitor updates, and hours.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Compliance with rules/Health Care Refer to: C260, C363

In reference to OAR 411-057-0160 (2b) Complaince with rules Health Care.-In reference to OAR (2b) Compliance with rules Health Care. The Administrator will oversee and ensure that all health care services provided within the community are delivered in full compliance with applicable licensing rules, specifically those outlined in OAR Chapter 411, Division 57, including but not limited to Sections C260 and C363. This includes: • Ensuring that health-related services are coordinated and documented according to residents’ individualized care plans. • Monitoring that services are delivered by qualified personnel in accordance with state regulations. • Maintaining accurate records of health interventions, assessments, and follow-ups. • Responding promptly to changes in residents’ health status and ensuring appropriate medical attention is provided. The Administrator or designee will regularly audit service delivery and documentation to ensure ongoing compliance and quality of care

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: