Print Inspection: CHOW010710

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 residents received services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#1) who received two-person assistance for incontinence care. Findings include, but are not limited to: Resident 1 moved into the community in 06/2025 with diagnoses including left hemiparesis. During the acuity interview on 04/13/26, staff reported Resident 1 required two-person assistance for transfers using a mechanical lift and for ADLs. The resident’s need for two-person assistance during incontinence care was confirmed by Staff 9 (CG/Universal Worker) on 04/13/26 at 2:55 pm. On 04/13/26 at 3:08 pm, Staff 5 (Team Lead/MT) and Staff 9 were observed to assist Resident 1 with incontinence care. Both staff members entered the room and closed the door, but left the blinds open. The resident’s window was adjacent to a walkway which surrounded the building. Staff 5 and Staff 9 changed Resident 1’s shirt and completed perineal care, including a full brief change. Resident 1’s blinds remained open for the duration of his/her care. On 04/13/26 at 3:26 pm, Staff 9 acknowledged she hadn’t closed the blinds because there was a fence on the other side of the walkway. She also stated she never considered the walkway when she made the decision to keep the blinds open. On 04/14/26 at 9:18 am, Staff 14 (CG/Universal Worker) and Staff 10 (MT/CG/Universal Worker) were observed to assist Resident 1 with incontinence care and a clothing change. Staff 10 and Staff 14 entered the room and failed to close the resident’s door to the hallway or close the blinds. The staff assisted the resident with a brief change, perineal care, and a shirt change while the blinds and door remained open. On 04/14/26 at 9:35 am, Resident 1 was asked how s/he felt when the door and blinds remained open during his/her care. Resident 1 stated s/he would not be ok with someone walking by and seeing him/her naked. Resident 1’s roommate approached this surveyor on 04/13/26 at 1:20 pm. The unsampled resident asked whether the regulations required a partition between the beds in a shared room. The unsampled resident stated that his/her roommate received care, and s/he did not want to see his/her roommate naked but inadvertently had. The need to ensure residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 12 (Owner) on 04/15/26 at 10:26 am. They acknowledged the findings.

1. Care staff will close doors, blinds and use dividers when providing cares. Care staff sited was immediately educated. 2. Edication will be provided to care staff at next staff meeting. Dividers were ordered and care staff wilbe educaticated on using dividers in shared apartments. 3. Daily walk throughs and boservations by management. 4. To be done by administrator or admin designee.

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 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction for staff for 1 of 2 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 12/2025 and had diagnoses which included diabetes and cancer. During the entrance conference on 04/13/26, staff reported the resident had a side rail, a suprapubic catheter, a colostomy, and was receiving hospice services. Resident 2’s clinical record, interviews with care staff, an interview with the resident, and observations during the survey revealed s/he needed staff assistance as needed with ADLs, was an insulin-dependent diabetic, had a hospital bed with a full side rail raised on the right side of the bed, and had chronic pain. Resident 2's current service plan, updated 01/26/26, was not reflective or did not provide clear directions to staff in the following areas: * Urostomy; * Colostomy; * Hospital bed and side rail use; * Lower leg edema; * Recreational marijuana use; * Pain; * Use of reading glasses; * Dining location preference; and * Continence and toileting. The need to ensure the service plan was reflective of Resident 2's current needs and provided clear directions to staff was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 04/14/26 at 11:00 am. They acknowledged the service plan was not reflective in several areas and needed to be updated.

1. Resident #2 service plan is updated to reflect current needs. 2. Any service plan updates will be communicated usng TSP's and added to permanent service plan with significant change or quarterly update. 3. At least weekly 4. Administrator or administrator designee.

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 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 moved into the facility in 12/2025 and had diagnoses including chronic pain and was receiving hospice services. Resident 2 had orders for oxycodone HCL (narcotic) 20 mg, two tablets every four hours PRN for breakthrough pain, and Morphine Sulfate (narcotic) 0.5ml under the tongue every two hours as needed for pain/discomfort/dyspnea. Resident 2's Controlled Substance Disposition Logs and MARs, reviewed from 03/01/26 through 04/13/26, revealed four occasions when staff signed on the drug disposition log that the medications were given. However, the MAR lacked documentation that the resident received the medications. Inconsistencies between the MARs and Controlled Substance Disposition Logs were reviewed with Staff 1 (Administrator) and Staff 2 (RCC) on 04/14/26 at 11:00 am. They viewed the documentation and stated they were unaware of the discrepancies. They further stated they thought “hospice was auditing the records.” Staff 1 said they would add MAR and narcotic record review to their auditing system.

1. Medication for surveyed resident #2 were reiewed for accuracy and compared with controlled substance documentation on MAR and controlled substance log. 2. MAR to cart to chart audit for controlled substance with immediate follow up and edication with medication techs for any discrepancies. 3. Audits to be done weekly until all med techs are trained and have shown competancy with no documentation mistakes-then monthly. 4. administrator or administrator designee, nursing.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (#1) whose MARs and physician orders were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 06/2021 with diagnoses including hypothyroidism. Review of the resident’s 04/01/26 through 04/13/26 MAR and current physician orders identified the following: a. The resident was prescribed one 112 mcg tablet of levothyroxine sodium daily for hypothyroidism. According to the resident’s April MAR, the medication had been discontinued on 04/03/26. On 04/15/26 at 9:54 am, Staff 4 (Team Lead/MT) confirmed Resident 1 was no longer receiving levothyroxine as it had been discontinued. On 04/15/26 at 10:04 am, Staff 12 (Owner) and Staff 1 (Administrator) acknowledged the levothyroxine was not supposed to be discontinued. Therefore, the resident’s levothyroxine order was not carried out as prescribed for ten days. b. On 01/26/26, the resident was prescribed Systane eye drops four times daily for dry eyes. The resident’s April MAR did not include the Systane eye drops. A discontinuation order was requested on 09/14/26 at 9:43 am but not received. On 04/15/26 at 9:54 am, Staff 4 and the surveyor observed the resident’s medication supply. Staff 4 confirmed the facility did not have and was not administering the resident’s eye drops. On 04/15/26 at 10:04 am, Staff 12 and Staff 1 acknowledged the eye drops were left in the resident’s room by a family member; however, the medication cart did not receive the medication. Therefore, the physician order was not followed for the eye drops between 01/26/26 and 04/13/26. The need to ensure medications and treatments were carried out as prescribed was discussed with Staff 1, Staff 2 (RCC), and Staff 12 on 04/15/26 at 10:04 am. They acknowledged the findings.

1. Resident 1, levothyroxine and systance eye drop orders have been implemented and are on MAR. 2. Three check order process identified. Medication techs will be trained on 3-check process then implemented. Mediation techs will be trained 1:1 as needed until process fully implemented. 3. Daily and Weekly 4. Adminstrator and administrator designee, nursing.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 2 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 12/2025 with diagnoses including insulin-dependent diabetes. Resident 2 had physician orders for the following: * Insulin Glargine (long-acting insulin) 25 units daily in the morning; and * Novolog (rapid acting insulin) 10 units via PEN three times a day. In an interview with the resident on 04/13/26, s/he stated s/he kept the insulin in his/her apartment and self-administered it. According to the resident’s MARs, reviewed from 03/01/26 through 04/13/26, MAs initialed that they were administering the insulin. The MARs did not indicate that the resident self-administered his/her insulin. During interviews with Staff 10 (MT/CG/Universal Worker) on 04/13/26 at 2:00 pm, Staff 5 (Lead MT) on 04/13/26 at 4:50 pm, and Staff 11 (MT/CG/Universal Worker) on 04/14/26 at 9:50 am, they verified the resident self-administered his/her insulin. In an interview on 04/14/26 at 11:50 am, Staff 1 (Administrator), Staff 2 (RCC), and Staff 12 (Owner) reviewed the MARs. They verified that staff did not administer the insulin even though the MAR indicated they did. The need for the facility to ensure MARs were accurate was discussed with Staff 1 on 04/14/26 at 2:15 pm. She acknowledged the findings.

1. Resident 2 MAR updated to reflet current orders, including insulin being self administered by resident. 2. 3-check order process identified. Medication techs will be trained on 3-check process, then system will be implemented, Medicaiton techs will be trained 1:1 as needed until process fully implemented. 3. Daily, Weekly 4. Administrator or administrator designee, nursing.

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications had physician or other legally recognized practitioner orders in place for the self-administration of prescription medications for 1 of 1 sampled resident (#2) who self-administrated insulin. Findings include, but are not limited to: Resident 2 was admitted to the facility in 12/2025 with diagnoses including insulin-dependent diabetes. Resident 2 had physician orders for the following: * Insulin Glargine (long-acting insulin) 25 units daily in the morning; and * Novolog (rapid acting insulin) 10 units via PEN three times a day. During interviews with the resident on 04/14/26, Staff 10 (MT/CG/Universal Worker) on 04/13/26 at 2:00 pm, Staff 5 (Lead MT) on 04/13/26 at 4:50 pm, and Staff 11 (MT/CG/Universal Worker) on 04/14/26 at 9:50 am, all verified that the resident self-administered his/her insulin. A review of the clinical record revealed no signed order from a legally recognized practitioner for the resident to self-administer insulin. Additional information was requested during the survey. In an interview on 04/14/26 at 11:50 am, Staff 1 (Administrator) and Staff 2 (RCC) acknowledged there wasn’t an order from a legally recognized practitioner for the resident to self-administer insulin. The need to ensure residents had physician or other legally recognized practitioner orders in place for the self-administration of prescription medications was discussed during the exit conference with Staff 1 and Staff 2 on 04/15/26. They acknowledged the findings.

1. A self medicaiton administration evaluation was completed for resident # 2 2. An audit of all residents for any self-medication orders or request completed. Administrator or nursing will complete all self medicaiton evaluations. 3. Quarterly or with significant change of condition. 4. Administrator or administrator designee, nursing.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: During the survey, the residential care community consisted of four separate and distinct buildings that housed 23 residents. Manzanita 1 housed six residents, Manzanita 2 housed eight residents, Sage 2 housed nine residents, and Sage 1 was under construction and housed no residents. The current posted staffing plan, the Acuity-Based Staffing Tool (ABST) Facility Entrance Questionnaire, the facility’s ABST, and the facility schedule, dated 04/05/26 through 04/11/26, were reviewed. Interviews with facility staff were conducted, and the following was revealed: * Manzanita 2 had one resident who required two-person assist with transfers; * Sage 2 had two residents who required two-person assist with transfers. One of the two residents also required two-person assist with incontinence care; * All 23 residents required support for cognitive impairments; * According to the facility’s posted staffing plan, the overnight shift included three direct care staff, one scheduled for each house where residents resided. The facility also scheduled one direct care staff to float between the three houses to assist as needed. In addition to floating between houses, the fourth caregiver helped to cover breaks. This left one staff available in each house to assist residents who required two-person assistance while the other staff members were on break; and * Per the schedule, dated 04/05/26 through 04/11/26, the community lacked a scheduled float on five of the seven days reviewed. The remaining two days included a scheduled float for less than the entire shift. During interviews on 04/14/26 at 2:29 pm and 4:12 pm, Staff 1 (Administrator) and the surveyor reviewed the previous week’s schedule. Staff 1 acknowledged the overnight floating caregiver shift had not been fully covered during the week of 04/05/26 through 04/11/26. Staff 1 also noted that she had not considered that during meal breaks only one staff member would be available in each house to assist in the scheduled and unscheduled needs of the residents who required two-person assistance. The need to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs was reviewed with Staff 1, Staff 2 (RCC), and Staff 12 (Owner) on 04/15/26 at 10:26 am. They acknowledged the findings.

1. In the house with 2 person tansfers there are a minimum of 2 care staff on shift plus a float for all houses. 2. ABST reviewed with every change of condition and service plan update, staffing plan updated as needed with ABST updates. 3. At least 3 times a week 4. Administrator or administrator designee

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 7, 8, and 9) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to: Staff training records, reviewed on 04/13/26 at 5:00 pm, identified the following: There was no documented evidence Staff 7 (CG/Universal worker), Staff 8 (MT/CG/Universal Worker), and Staff 9 (CG/Universal Worker), hired 01/12/26, 01/27/26, and 12/12/25, respectively, completed some/or all the following required pre-service orientation training topics: * Resident rights and values of CBC care; * Abuse reporting requirements; * Food handler’s certificate; * Written job description; * Infectious Disease Prevention; * Home and Community Based Services (HCBS) training; * LGBTQIA2S+ training; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach. The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 04/13/26, and with Staff 1 on 04/14/26 at 2:15 pm. The findings were acknowledged.

1. Care staff surveyed 7,8,9 2. Orientation process starts with completing all pre-service training prior to being scheduled. 3. Monthly 4. Administrator or Administrator designee

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 caregiving staff (#s 6, 7, 8, and 9) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records, reviewed on 04/13/26, revealed the following: a. There was no documented evidence Staff 6 (MT/CG/Universal Worker), hired 01/02/26, had completed First Aid certification and abdominal thrust training. b. There was no documented evidence Staff 7 (CG/Universal worker), hired 01/12/26, had demonstrated competency in: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment and observation and reporting; * General food safety, serving and sanitation; and * First Aid certification and abdominal thrust training. c. There was no documented evidence Staff 8 (MT/CG/Universal worker), hired 01/27/26, had demonstrated competency in: * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment and observation and reporting; * General food safety, serving and sanitation; * First Aid certification and abdominal thrust training; and * Medication Administration. d. There was no documented evidence Staff 9 (CG/Universal worker), hired 12/12/25, had demonstrated competency in: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment and observation and reporting; and * General food safety, serving and sanitation. The need for the facility to have a system to ensure staff training was completed and documented within the required time frame was reviewed with Staff 1 (Administrator) and Staff 2 (RCC) on 04/13/26 and 04/14/26. They acknowledged the findings. Staff 1 stated Staff 8 would not administer medications until documented training was completed.

1. One of the staff surveyed quiet, the other 2 are completing the required trainings. 2. Orientation process starts with completing all pre-service training prior to being scheduled. 3.Monthly audits 4. Administrator or administrator designee

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

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 and interview, it was determined the facility failed to provide each individual privacy in his or her own unit for 1 of 1 sampled resident (#1) who resided in a shared unit. Findings include, but are not limited to: Refer to C200.

See C200

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: