Print Inspection: CHOW008184

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure management or the licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, that the service plan was adjusted if necessary, and that reporting protocols were in place for 1 of 1 resident (#2) who received HH services. Findings include, but are not limited to: Resident 2 moved into the MCC in 02/2022 with diagnoses including Alzheimer's disease. Staff reported in the acuity interview on 04/20/26 the resident had a history of falls, including an unwitnessed fall with bilateral knee pain, and was currently receiving HH PT services. The resident’s 01/15/26 to 04/20/26 clinical record was reviewed, including HH PT notes. The following was identified: * 03/11/26—HH PT documented the resident’s heart rate was “consistently high[,] above 90 [beats per minute]”; * 03/18/26—HH PT documented exercises were provided for CGs to implement; and * 03/24/26—HH PT documented the resident was discharged from HH PT services. There was no documented evidence facility management or the licensed nurse reviewed the above HH PT notes. There was no documented evidence that reporting protocols were in place to notify facility management or licensed nurse regarding the HH PT report of the resident’s heart rate, the service plan was adjusted with HH PT exercises/recommendations, or that staff were notified of the HH PT discharge. In an interview at 1:46 pm on 04/20/26, Staff 8 (MT) stated outside providers left notes with the MT on shift and verbally spoke with the MTs regarding services provided. She stated, “as far as I know” Resident 2 was still receiving PT services. The need to ensure management or the licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, that the service plan was adjusted if necessary, and that reporting protocols were in place was discussed with Staff 1 (Administrator/RN) at 11:07 am on 04/22/26. He acknowledged the findings.

OAR 411 054 0045 Resident 1 &2 Service Plan has been evaluated by the RN. Home health noted reviewed and signed service plan now reflective of Outside Provider information. Communication protocol with outside provider reviewed, Nursing/RCC protocols for commnuication reviewed with ED - ED will Audit Quarterly to ensure systems in place ED is responisble to see that corrections are made and monitored

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. 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 follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (#1) whose ADL care was observed and 1 of 1 sampled resident (#2) and multiple unsampled residents whose meal service was observed. Findings include, but are not limited to: 1. Resident 1 moved into the memory care community in 07/2024 with diagnoses including Alzheimer’s disease and dementia. During the acuity interview on 04/20/26, the resident was identified as needing assistance for all ADLs and was “bed bound.” On 04/21/26 at 11:37 am, the surveyor observed Staff 6 (CG) and Staff 13 (MT) assist the resident with incontinence care in his/her bed. Both staff members donned cleaned gloves. Staff prepared for the task by removing a doll, a top sheet, a blanket, and pillows being used to elevate Resident 1’s heels. Staff collected a clean brief and chucks pad, disposable wipes, and barrier cream. Staff unfastened the resident’s briefs and removed the soiled brief while assisting the resident to roll to his/her side on the chucks pad that was under the resident. Staff 13 used wipes to provide perineal care following a small bowel movement. Both staff members assisted Resident 1 to get in the middle of the bed by using the resident’s bottom sheet to slide him/her up. They assisted the resident to roll to the other direction and Staff 6 completed the cleaning task, removed the soiled chucks pad, and threw the soiled brief, chucks pad, and used wipes in the garbage can. Some of the items fell on the floor, so he picked them up and placed those in the garbage as well. Staff 6 changed his soiled gloves at that time. Staff 13 was not observed to change her gloves or perform hand hygiene after the incontinence task had been completed. She was observed to touch a clean sheet, pillows, a blanket, place the doll with the resident, touch the bed remote, and push the bed back against the wall. No hand hygiene had been performed prior to touching the non-soiled items. Staff 6 removed the garbage can liner where the soiled items were put and tied it in a knot. He replaced the liner and doffed his gloves. No hand hygiene was observed prior to Staff 6 and Staff 13 exiting the resident’s room. A housekeeper was observed at approximately 1:30 pm to look inside of Resident 1’s apartment but did not enter the room to clean the area where the soiled items were dropped onto the floor. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (Administrator/RN) and Staff 3 (RCC) on 04/22/26 at 10:45 am. They acknowledged the findings. 2. Observations of meal service conducted on 04/20/26 at 12:00 pm showed the following: Staff 3 (RCC) was observed at the counter of the kitchenette wearing single-use gloves, serving residents, including Resident 2 and unsampled residents, food from large serving pans. While serving, she was observed to eat some of the French fries from one of the pans, as well as drink from a personal beverage located to the left of the serving pans. Wearing the same single-use gloves, she continued to serve residents food. The need to ensure the facility maintained infection prevention and control protocols was discussed with Staff 1 (Administrator/RN) at 11:07 am on 04/22/26. He acknowledged the findings.

OAR 411057 0410 Staff 6&13 giving education regarding Infection Control, Polices and best practice Spot check by Director/RCC weekly Education to be given by Direcor to staff monthly Director/ED to be responsible for ensuring weekly observations and monthly trainings are given

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:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents had privacy in their own units for 1 of 1 sampled resident (#3) and multiple unsampled residents who lived in the MCC. Findings include, but are not limited to: 1. The MCC included three double occupancy units: 168, 171, and 173. Review of the current resident roster on 04/20/26 showed all three units were 100% occupied. Observations of the rooms made on 04/20/26 showed no method to ensure privacy between the residents’ sections of the unit. Review of Resident 3’s service plan, last updated 04/02/26, showed no documented evidence of a system to ensure privacy in his/her unit. In an interview at 9:25 am on 04/21/26, Staff 6 (CG) stated when providing dressing and other ADL assistance to Resident 3, he had to wait for the resident’s roommate to leave the room to ensure privacy. The need to ensure residents had privacy in their own units was discussed with Staff 1 (Administrator/RN) at 11:07 am on 04/22/26. He acknowledged the findings. 2. The memory care unit was located inside of an assisted living facility. One way to access the unit was to go through the Bistro Café. The café overlooked the assisted living courtyard, and multiple apartment windows were visible. An unsampled resident was observed to reside in the memory care unit, in an apartment that was immediately inside the unit by the main door. On 04/21/26 at approximately 9:45 am, the inside of the unsampled resident’s apartment, located in the memory care unit, was observed from the assisted living facility’s Bistro Café. The blinds inside of the apartment were raised. There were no window coverings observed in the café. On 04/21/26 and 04/22/26, multiple observations were made of the resident in his/her unit, including while s/he was laying in bed sleeping. On 04/22/26 at 11:43 am, Staff 1 (Administrator/RN) and Staff 3 (RCC) confirmed that the unsampled resident was independent in ADLs. On 04/22/26 at approximately 12:55 pm, Staff 2 (ED) confirmed that all the memory care unit apartments had windows that either faced the courtyard accessible to the assisted living facility or to the street. The need to ensure each resident had privacy in his or her own unit was reviewed with Staff 1, Staff 2, and Staff 3 on 04/22/26. They acknowledged the findings.

OAR 411-057-0220 Resident Rights – Privacy A privacy divider has been provided in apartment 168,171,and 173 to support the resident’s privacy needs. The resident 3's service plan has been updated to reflect their preferences regarding privacy. Staff have been educated on resident privacy rights and expectations, including maintaining dignity during care and honoring individual preferences. The RCC or Memory Care Director will review resident preferences for privacy during initial and quarterly evaluations to ensure service plans are updated accordingly. The Memory Care Director or Executive Director will conduct periodic audits to ensure compliance and that resident privacy needs continue to be met.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents had a key to their unit for multiple sampled and unsampled residents. Findings include, but are not limited to: Observations made on 04/20/26 and 04/21/26 showed Resident 2’s door was locked on several occasions, both while s/he was inside and outside of the unit. At 10:22 am on 04/21/26, Resident 2 attempted to open his/her door, and it was locked. S/he stated, “my door is locked.” Staff arrived shortly after and unlocked the door. In an interview at 10:32 am on 04/21/26, Staff 6 (CG) stated Resident 2 would frequently lock his/her door when leaving or entering the unit. He stated s/he did not have a key. In an interview at 2:09 pm on 04/21/26, Witness 1 (Family) confirmed the resident was not provided with a key to his/her unit. In an interview at 12:53 pm on 04/21/26, Staff 1 (Administrator/RN) stated Resident 2 had not been evaluated for his/her ability to manage a key, and had not been provided with a key. He stated families/residents were offered keys as part of the move-in process, but if they declined, they were not provided with one. He confirmed multiple residents did not have keys to their units. The need to ensure residents were provided with a key to their units was discussed with Staff 1 at 11:07 am on 04/22/26. He acknowledged the findings.

OAR 411 004 0070 Resident 2 key access was given to resident 2, Service plan updated to reflect to say Resident has a key and her key use and where it is located Upon admission key policy to be reviewed with family, During Initial evaluation by RCC/Nurse - Service plan updated and key given per preferance Reviewed quarterly during resident evaluations by Director/RCC Evaluations to be reviewed quarterly by ED

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

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

OAR 411 057 0140 Education goven to staff regarding infection control polices and best practice - to ensure patient care and cross contaminations is reduced Spot checks by RCC/Director weekly Education to be given monthly by Director to staff monthly Director?ED is responsible for ensuring weekly observation and monthly trainings are given

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 ensure 2 of 2 newly hired staff (#s 9 and 11) completed all pre-service orientation training, all required pre-service dementia trainings, and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 04/21/26 at 1:40 pm. The following was identified: Staff 9 (CG) was hired 02/26/26 and Staff 11 (CG) was hired 02/24/26. a. There was no documented evidence Staff 11 completed orientation in infectious disease prevention. b. There was no documented evidence Staff 9 and Staff 11 completed pre-service dementia training in one or more of the following topics: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicated a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * The use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 11 had demonstrated competency within 30 days of hire in: * Identification, documentation and reporting changes of condition; and * Conditions that require assessment, treatment, observation and reporting. On 04/22/26 at 9:04 am, the need to ensure staff completed all required pre-service orientation and pre-service dementia trainings and demonstrated competency in assigned duties within 30 days of hire was discussed with Staff 1 (Administrator/RN) and Staff 3 (RCC). They acknowledged the findings.

OAR 411 057 0155 staff 9+11 completed all trainings required Staff have received required inservice training in Relias and skills orientation checklist completed Annual training to be completed in Relias Relias to be audited by Diector/RCC quarterly

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: Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C290.

OAR 411 057 0160 (2b) Facility nurse to review all outside provider notes to ensure careplans are updated - reviewed communication and documentation Home health noted reviewed and signed service plan now reflective of Outside Provider information. Communication protocol with outside provider reviewed, Nursing/RCC protocols for commnuication reviewed with ED - ED will Audit Quarterly to ensure systems in place ED is responisble to see that corrections are made and monitored

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: