Print Inspection: INI008945

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 interview and record review, it was determined the facility failed to ensure residents’ right to be treated with dignity and respect related to 1 of 2 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 10/2025 with diagnoses including stroke, dysphagia (swallowing disorder), anxiety, and adjustment disorder with depressed mood. The resident’s clinical record from 10/23/25 to 01/20/26 was reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The following was identified: On 01/21/26 at 11:14 am, the resident reported staff refused to assist him/her with tasks such as blow drying his/her hair and applying lotion after bathing, placing items within reach while in bed or reclining chair such as the television remote, removing medication bottle caps, and opening and closing various items. The following was documented in the resident’s record: * 11/27/25 – there were two staff on shift, and around 6:00 pm, one staff member was on lunch break. Resident 1’s call light went off and the only staff member on the floor was unable to respond in a reasonable amount of time because they were assisting another resident; * 11/29/25 – staff were not able to apply lotion after showers, because it was not on the resident’s service plan, which irritated the resident; * 11/29/25 - staff documented the resident was upset and stated, s/he “…is in a [sic] assisted living place for a reason because [s/he] needs help…”; * 11/29/25 – the resident requested staff blow dry his/her hair after showers. Staff told the resident they were “…there to do stuff [the resident] can not [sic] do by [him/herself]…” and the resident needed to talk to the Assisted Living Director or someone else to see what they could do; * 12/02/25 – the resident reported frustration with staff not helping with requests, such as moving a remote so the resident could use it; * 12/11/25 – the resident called around dinner time with a request for care. Staff asked if they could come back “…in like half an hour…”, the resident got frustrated and “…was attempting to do it [by him/herself] …”; and * 12/11/25 – around dinner, the resident “…kept pressing [his/her] pendant… and …having staff come… to either open a bag or fruit cup.” When the resident requested assistance with dressing and getting ready for bed, staff said they would “…be back in 30 min [sic] [because] staff were helping out at dinner.” On 01/22/26 at 12:46 pm, Staff 2 (Chief Operating Officer) confirmed the resident had not been treated with dignity and respect regarding requests for staff assistance. The need to ensure residents were treated with dignity and respect was reviewed with Staff 1 (ED), Staff 2, Staff 17 (Licensed Administrator/Sales and Marketing), and Staff 13 (Traveling Health Services) on 01/23/26 at 3:45 pm. They acknowledged the findings.

Resident #1 was re-evaluated to ascertain clarify on what services were needed and service plan updated for staff reference. Remaining residents service plans will be reviewed to assure they are reflective of care and service needs. Inservicing will be conducted with carestaff on how to handle and communicate increased service needs and the utlization of the TSP process when resident is requesting additional care and services not reflected on the service plan. Routine review of resident related documentation (MD orders, charting, TSP's, outside agency visit notes etc.) will be conducted to assure accuracey in care needs on service plans and updates when new cares are needed/identified/requested. Daily/weekly/quarterly ALD with ED oversight

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 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately notify the local Senior and People with Disabilities (SPD) office of incidents of abuse or suspected abuse for 1 of 1 sampled resident (#1) who had incidents of abuse or suspected abuse. Findings include, but are not limited to: Resident 1 moved into the facility in 10/2025 with diagnoses including stroke and dysphagia (swallowing disorder). The resident’s clinical record from 10/23/25 to 01/20/26 was reviewed, and interviews with the resident and staff were conducted. The following was identified: a. On 11/12/25 staff documented, “Found bruise on residents [sic] back during shower…” and the resident reported the bruise was from hitting [his/her] back on the toilet “…a few days ago [when] a caregiver was helping in the restroom…”. There was no documented evidence the incident was immediately reported to the local SPD office as required. b. On 11/19/25, staff documented the resident called for assistance using the bathroom and appeared confused. The resident requested assistance with other ADLs which staff stated they were not able to assist with. Staff left the resident’s room without assisting the resident to the restroom and reported they would be back in 15 minutes. However, documentation indicated staff went back to the resident’s room approximately two hours later and found the resident on the floor in the bathroom, unable to reach the emergency pull cord. There was no documented evidence the incident was immediately reported to the local SPD office as required. On 01/22/26 at 10:17 am, Staff 2 (Chief Operating Officer) confirmed the incidents were not reported to the local SPD office. Survey requested the above events be reported, and confirmation the above events were reported was received on 01/23/26 at 4:35 pm and 4:57 pm, before survey exited. The need to ensure incidents of abuse and suspected abuse were reported to local SPD office was reviewed on 01/23/26 at 3:45 pm with, Staff 1 (ED), Staff 2, Staff 17 (Licensed Administrator/Sales and Marketing), and Staff 13 (Traveling Health Services), on 01/23/26 at 3:45 pm. They acknowledged the findings.

Resident #1-incidents were reported to SPD prior to the conclusion of the survey visit as confirmed in the SOD. Re-education provided on reporting guidelines and the communities occurrence reporting procedure to assure understanding. Audit of last 30 days worth of incidents were reviewed to verify reporting had occurred in accordance with state regulations. ED/Designee will assure incidents are reviewed timely to assure reporting is completed as applicable. Daily ED/Designee

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

OAR 411-054-0036 (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 preferences and provided clear direction regarding the delivery of services, for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 10/2025 with diagnoses including stroke, dysphagia (swallowing disorder), anxiety, and adjustment disorder with depressed mood. The resident’s clinical record, including current service plan, dated 12/15/25, was reviewed, interviews with staff and the resident were conducted, and observations were made. Resident 1's service plan was not reflective of his/her needs, did not provide clear direction regarding the delivery of services, or was not implemented in the following areas: * Behavior interventions related to when the resident exhibited depression, agitation, and was verbally threatening towards staff; * Use of a power and manual wheelchair, including the need to charge the power wheelchair nightly, and how the resident preferred to use the manual wheelchair when s/he was not feeling strong enough to hold up his/her left leg; * Ensure proper positioning while eating and while using wheelchair; * Reminders of activities and meals, including escorts to and from the activity and dining room; * Use of athletic shoes and ankle brace for left ankle; * Bathing assistance, including preferences and skin care after bathing; * Safety check frequency and instruction; and * Grooming assistance, including blow drying hair. The need to ensure service plans were reflective of residents’ needs and preferences, and provided clear direction regarding the delivery of services, was reviewed with Staff 1 (ED), Staff 2 (Chief Operating Officer), Staff 17 (Licensed Administrator/Sales and Marketing), and Staff 13 (Traveling Health Services) on 01/23/26 at 3:45 pm. They acknowledged the findings.

Resident 1-resident has been re-evaluated and SP updated to reflect current care and service needs in all areas including those noted in the survey document. A review of remaining residents service plans will be conducted to verify accuracey. Re-education has been provided for ALD on service plan content and update processes to assure understanding. Routine auditing of MD orders, incident/accidents, various assessments/evals and monitoring documentation will be conducted to assure ongoing compliance. Daily/weekly/quarterly ALD/WD with ED oversight

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 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed for 1 of 1 resident (#1) who experienced a significant change of condition. Findings include, but are not limited to: Resident 1 moved into the facility in 10/2025 with diagnoses including stroke, dysphagia (swallowing disorder), and anxiety. The resident’s clinical record, including “Charting Notes”, dated 10/23/25 through 01/20/26, was reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. The following was identified: The residents 10/23/25 service plan indicated the resident was independent with grooming, personal hygiene, and ambulation (once transferred to his/her wheelchair), and required the assistance from one staff for transfers and bathroom needs. On 12/09/25 staff documented the resident was at the emergency department for pain in his/her left foot and received diagnoses including a fractured left fibula and cellulitis. The emergency department reported the resident received a “very heavy boot” and required assistance with transfers. On 12/10/25 staff documented the resident now “…requires [two] person assist with boot on [his/her] leg…”. Staff also documented the resident required assistance removing the boot after transferring into bed. Additional documentation revealed the resident required assistance with dressing and undressing, grooming and hygiene tasks, bathing, and escorts to and from the dining room and activities. This change to the resident’s function in multiple ADLs constituted a significant change of condition for which a timely RN assessment was required. Documentation of an RN assessment, dated 12/16/25, indicated the assessment was completed six days after the significant change of condition was triggered. Therefore, the RN assessment was not completed timely after a significant change of condition. On 01/22/26 at 12:46 pm, Staff 2 (Chief Operating Officer) confirmed the lack of documentation of a timely RN assessment for the significant change of condition. The need to ensure a timely RN assessment was completed for residents who experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2, Staff 17 (Licensed Administrator/Sales and Marketing), and Staff 13 (Traveling Health Services), on 01/23/26 at 3:45 pm. They acknowledged the findings.

Resident 1-change of conditio was completed just late. A review of residents with changes of condition in the last 7 days have been reviewed to assure RN assessments present as applicable. Re-education provided to community RN and ALD on the associated oversight tasks that will promote more timely assessments for changes of condition. Routine auditing of resident related charting will be conducted to assure timely awareness and completion of change of condition assessments. Daily ALD/RN with ED oversight

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

OAR 411-054-0045(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 staff were informed of new interventions and the resident’s service plan was adjusted if necessary for 1 of 1 sampled resident (#2) with outside service providers. Findings include, but are not limited to: Resident 2 moved into the facility in 12/2025 with diagnoses including Parkinson’s disease. Resident 2’s clinical record from 12/15/25 to 01/20/26 was reviewed during the survey. The following was identified: On 01/13/26, staff documented the resident returned to the facility after being sent to the hospital on 01/08/26 and admitted for aspiration pneumonia. On 01/14/26, the following outside agency visit note from a home health nurse was documented in the resident’s progress notes: “Please encourage patient to use flutter valve and incentive spirometer (devices used to improve lung function) 3x per day. Thank you.” There was no documented evidence the facility adjusted the resident’s service plan to include the home health instructions. In an interview with Staff 2 (Chief Operating Officer) on 01/22/26 she acknowledged the home health instructions were not added to Resident 2’s service plan and therefore, staff were not informed of the new interventions. On 01/22/26, the resident stated when s/he received the flutter valve and incentive spirometer a few days ago, s/he didn’t remember the instructions or how to use them. The need to ensure staff were informed of new interventions, and that the service plan was adjusted for residents with outside service providers was reviewed with Staff 1 (ED), Staff 2, Staff 13 (Traveling Health Services) and Staff 15 (Director of Health Services) on 01/23/26 at 3:20 pm. They acknowledged the findings.

Resident #2- a review of most recent outside agency notes has been conducted and compared to SP to assure accuracy. Review of visit notes conducted of remaining residents using outside agency to assure recommendations are known and executed. Re-training provided to ALD and RN on oversight process to outside agency visit notes to assure understanding. Routine review of outside agency visit notes will occurr to maintain ongoing compliance. Weekly ALD/RN with ED oversight.

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 maintain infection prevention and control protocols to prevent the development and transmission of communicable diseases for multiple sampled and unsampled residents during meal service. Findings include, but are not limited to: Meal service was observed in the ALF dining room on 01/21/26 from approximately 12:00 pm until 12:30 pm. The following was identified: * At 12:28 pm, a staff member was noted to touch her face with her bare hand, put gloves on, plate the desserts, remove one glove, touch the serving tray, put another glove on the ungloved hand and continue plating the desserts. She then left the kitchen to the dining area with the desserts. The staff member failed to perform hand hygiene between glove changes or between dirty and clean tasks. * At 12:29 pm, a staff member with gloved hands entered the kitchen with a tray of dirty dishes. She removed one glove, touched containers of condiments with both hands and put them into the refrigerator. She removed a container of Italian dressing from the refrigerator, poured it into a plastic cup and returned the dressing to the refrigerator. She picked up a tray with dirty dishes, put it into the sink then adjusted her waistband and touched her bare stomach with her ungloved hand. She put another glove on her ungloved hand and plated more desserts. Then she removed one glove, put the desserts on a serving tray with the ungloved hand (same hand she used to touch her stomach), took the cake to the dining area and served the residents. The staff member failed to perform hand hygiene between glove changes or between dirty and clean tasks. * On 01/23/26 at 5:05 pm, Staff 5 (MT) was observed carrying three resident beverages in the dining room without the use of a protective barrier and after assisting with ADL care. Staff 5 held one beverage against her body with her arm and another beverage by the brim of the glass. Staff improperly handled glassware and lacked the use of a protective barrier while serving residents in the dining room and after completing ADL care to ensure proper infection control practices. The need to ensure all staff followed infection control protocols to prevent the development and transmission of communicable diseases during meal service was discussed with Staff 1 (ED) and Staff 2 (Chief Operating Officer), Staff 13 (Traveling Health Services), and Staff 15 (Director of Health Services) on 01/23/26 at 3:20 pm. They acknowledged the findings.

Re-training provided to dining services staff on basic infection control practices including proper use of gloves and hand washing. Observations will be made 3/week rotating through all 3 meals with a focus on infection control practices during meal times. Inservicing on glove use, handwashing and basic meal services infection control will be conducted weekly for 3 weeks to assure understanding. Weekly DSM/Designee with ED oversight

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

OAR 411-054-0055 (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 treatment orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) who were prescribed modified diets. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 12/2025 with diagnoses including Parkinson’s disease. During the acuity interview on 01/20/26, the resident was identified as needing a modified diet. The resident’s clinical record was reviewed, including physician orders, dated 01/13/26, observations of the resident were made, and interviews with the resident and staff were conducted. The following was identified: The resident had a current physician-signed order, dated 01/13/26, to receive a “soft and bite sized” diet. On 01/21/26 at 12:27 pm, Resident 2 was observed to have a large, uncut sandwich. The resident’s spouse offered to cut the sandwich for him/her stating, “It’s pretty big.” In an interview with Resident 2 and his/her spouse on 01/22/26 at 10:30 am, the resident’s spouse stated, “[S/he] needs small pieces (of food)” and the resident said, “Staff will cut it only when I ask them to.” On 01/23/26 at 9:41 am, Staff 6 (MT) confirmed caregiving staff only cut the resident’s food when requested by the resident. On 01/22/26 at 12:20 pm, Resident 2 was observed to have pork stir fry and a whole, uncut egg roll which appeared to have a crispy coating. Neither food item was cut into bite sized pieces per the physician’s order. On 01/22/26 at 2:05pm, Staff 11 (Cook) stated, “The caregivers are supposed to cut up the food at the table, not the servers. If they’re really busy, the kitchen can help. [Resident 2’s] food will go out intact. The caregivers have to cut it up for [him/her].” On 01/22/26 at 4:06 pm, Staff 2 (Chief Operating Officer) was informed that observations of Resident 2’s food were not prepared according to physician’s orders. She acknowledged the findings. On 01/23/26 at 12:30 pm, Resident 2’s meal of corned beef and cabbage with potatoes was noted to be soft and bite sized. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2, Staff 13 (Traveling Health Services) and Staff 15 (Director of Health Services) on 01/23/26 at 3:20 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 10/2025 with diagnoses including stroke and dysphagia (swallowing disorder). The resident’s clinical record was reviewed, including physician orders, dated 11/25/25 and 12/24/25, observations were made, and interviews with the resident and staff were conducted. The following was identified: The resident had a current signed order, dated 11/25/25, to receive an “Easy to chew, cut up diet” and an order, dated 12/24/25, which stated, “…cut [his/her] food into bite size pieces for all meals. [S/he] is an aspiration risk, so fully support this accommodation.” On 01/21/26 at 11:14 am, Resident 1 reported his/her meals were rarely provided cut-up or in bite size pieces and the meat was usually hard to chew. On 01/22/26 at 12:27 pm, the resident was observed to have a whole egg roll, which was uncut and appeared to have a crispy exterior. At 12:42 pm, Staff 5 (MT) was observed serving in the dining room and reported she was unaware of the kitchen’s system to ensure residents who had modified diets received the accurate texture. The need to ensure physician orders were followed was reviewed with Staff 1 (ED), Staff 2 (Chief Operating Officer), Staff 17 (Licensed Administrator/Sales and Marketing), and Staff 13 (Traveling Health Services) on 01/23/26 at 3:45 pm. They acknowledged the findings.

Resident #1 & Resident #2: Documentation has been provided to the kitchen re the need for "cut up" food for all meals. Service plans have been reviewed to assure dietary needs are included for staff reference. An audit of residents on modified diets has been conducted to assure documentation of such is available to the kitchen/server staff and reflected on residents service plans. Re-training provided to the kitchen staff on proper procedure for cutting up of food prior to serving food to the resident to assure understanding. Routine auditing will be provided for new dietary orders and ongoing dietary needs assuring information is available to kitchen/serving staff and on service plans for carestaff reference. Observations of meals 3/week for 30 days then randomly thereafter will be conducted to verify modified diets are provided. DSM/ALD/Designee with ED oversight

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 (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 were evaluated upon move-in and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 2 sampled residents (# 2) who were reviewed for self-administration of medications. Findings include, but are not limited to: Resident 2 moved into the facility in 12/2025 with diagnoses including Parkinson’s disease. Resident 2's signed physician orders, dated 12/09/25 through 01/13/26, and MAR, dated 12/15/25 through 01/20/26, were reviewed during the survey and the following was identified: During the MAR review, it was discovered the resident was prescribed the following medications and was administering them him/herself from 12/15/25 through 12/23/25 as indicated by “**SUSPENDED 09 Dec 2025 TO 23 Dec 2025: Med given by outside agent during this time.**” noted on MAR. - Aspirin 81mg oral capsule (for heart health); - Carbidopa-levodopa 25-100mg oral tabs (for Parkinson’s disease); - Ezetimibe-simvastatin 10-20mg oral tabs (for elevated cholesterol levels); - Levothyroxine oral tabs (for regulating thyroid levels); - Trandolapril 4mg oral tabs (for regulating blood pressure); and - Vitamin D 25mcg oral tabs (a dietary supplement). There was no documented evidence the facility had performed an evaluation upon move-in to assure the resident’s ability to safely self-administer medications. There was no documented evidence the facility had obtained a physician’s or other legally recognized prescriber’s written order of approval for the resident to self-administer the prescription medications. During an interview on 01/23/26 at 9:25 am, Staff 2 (Chief Operating Officer) confirmed there was no documented evidence a self-medication evaluation had been completed, nor had a physician’s written order been obtained for Resident 2. The need to ensure residents who chose to self-administer their medications were evaluated upon move in and had a physician's or other legally recognized practitioner's written order of approval for self -administration of prescription medication was discussed with Staff 1 (ED), Staff 2, Staff 13 (Traveling Health Services), and Staff 15 (Director of Health Services) on 01/23/26 at 3:20 pm. They acknowledged the findings.

Resident #2-request sent out for updated MD order for self administration of medications. Audit conducted of remaining residents who self administer some/all meds to verify presence of current MD order. Re-training provided to MT and CG staff for ongoing observations during routine cares for instances of new meds in apts and need for MD orders. Routine audits and evals will be conducted to assure ongoing compliance. Monthly & quarterly ALD/RN with ED oversight

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 observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The facility was an assisted living facility with the capacity of 60 residents. There were 25 residents at the time of the re-visit survey. The facility used the Department ABST to document resident care needs and develop its staffing plan. The data in the ABST was reviewed on 04/06/26 at 02:00 pm. The facility provided a copy of the staff schedule, which included the dates and times that all staff worked for the week of 03/29/26 – 04/04/26. The following deficiencies were identified: * The ABST indicated the facility needed four direct care staff during the day shift (6:00 am - 2:00 pm) to meet the scheduled and unscheduled needs of the residents across the three units. The facility failed to provide the required number of staff from 03/29/26 through 04/04/26. * The ABST indicated the facility needed three direct care staff during the swing shift (2:00 pm -10:00 pm) to meet the scheduled and unscheduled needs of the residents across the three units. The facility failed to provide the required number of staff on five of seven shifts between 03/29/26 and 04/04/26. In an interview with Staff 19 (Assisted Living Director) on 04/06/26 at 11:40 am, she stated the facility recently received approval to staff 1.5 caregivers and one med tech on day and swing shifts, but the facility was not always able to find someone to fill in on the schedule. In interview with Staff 20 (CG) on 04/06/26 at 4:00 pm, it was noted that the CG had been unable to provide a shower for a resident on at least one occasion as the resident required two staff members for assistance and there was only one CG available. Witness 1 (Spouse) stated in an interview on 04/07/26 at 9:40 am, that swing shift was very understaffed and, even though the caregivers worked hard, there just weren’t enough of them. The need to ensure the facility provided a sufficient number of staff on each shift to meet the needs of the residents was discussed with Staff 19 and Staff 15 (Director of Health Services) on 04/07/26. No additional information was provided.

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved-in or with a significant change of condition for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents. Findings include, but are not limited to: On 01/20/26 after survey entered the community, the facility’s ABST data, including individual resident evaluations, were downloaded for review. Interviews with staff were conducted, and the following was identified: On 01/23/26, Staff 2 (Chief Operating Officer) reported the facility had not been entered into the ODHS ABST system until 12/01/25. Therefore, residents who moved in prior to 12/01/25 would not have been entered until around 12/01/25. a. The community ABST noted 17 current residents; however, only ten resident evaluations had been completed. Therefore, seven resident ABST evaluations, including Residents 1 and 2, were not completed before the residents each moved in. b. Resident 1 experienced a significant change of condition 12/09/25; however, the resident’s ABST evaluation was not updated with his/her significant change of condition. On 01/23/26 at 8:46 am, the “ABST Facility Entrance Questionnaire” and ABST documentation, including the above noted areas, were reviewed with Staff 18 (Memory Care Administrator), Staff 4 (Traveling Health Services), Staff 17 (Licensed Administrator/Sales and Marketing), and Staff 1 (ED). The need to ensure the ABST evaluations were reviewed and updated before a resident moved in and with a significant change of condition, was reviewed with Staff 1, Staff 2, Staff 17, and Staff 13 (Traveling Health Services), on 01/23/26 at 3:45 pm. They acknowledged the findings.

ABST tool has been updated for current residents and their individual care needs. Retraining has been provided to the ALD on the ongoing maintenance routine of this required tool. Routine review of the ABST tool will be conducted to assure ongoing compliance Weekly and quarterly ALD/Designee with ED oversight

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all newly hired employees completed pre-service orientation training prior to beginning their job responsibilities, and newly hired direct care staff completed pre-service dementia training prior to providing care to residents for 3 of 4 newly hired staff (#s 7, 8, and 16) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 01/21/26 at 11:04 am. a. There was no documented evidence Staff 7 (MT), hired 10/06/25, Staff 8 (MT), hired 12/07/25, and Staff 16 (Activities), hired 01/06/26, had completed pre-service orientation training in one or more of the following required topics prior to beginning job their responsibilities: * Infectious Disease Prevention; * Approved Home and Community Based Services (HCBS) course; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 7 completed the required pre-service dementia training prior to providing care to residents. The need to ensure all newly hired employees had completed pre-service orientation training prior to beginning job responsibilities and newly hired direct care staff completed pre-service dementia training prior to providing care to residents was reviewed with Staff 2 (Chief Operating Officer) and Staff 15 (Director of Health Services) on 01/23/26 at 2:26 pm, and with Staff 1 (ED), Staff 2, Staff 13 (Traveling Health Services), and Staff 15 on 01/23/26 at 3:45 pm. They acknowledged the findings.

Pre-service training is now completed for sampled staff. Audits have been conducted of remaining staff to verify completion of required trainings. Re-education provided to ED/Designee to assure understanding of training requirements and applicable timing of each item. Routine auditing of employee training records will be conducted to assure ongoing compliance Upon completion of the new hire process and at least twice monthly thereafter ED/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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) with all required elements documented, and fire and life instruction was provided to staff on alternating months from the drills. Findings include, but are not limited to: Four months of facility fire drill and fire and life safety records from 09/2025 to 12/2025 were reviewed on 01/21/2026 and revealed the following: * There was no documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills; * There was no documented evidence that unannounced fire drills were conducted every other month at different times of the day, evening and night shifts; and * The 12/2025 fire drill lacked documented evidence of escape route used, problems encountered or comments relating to residents who resisted or failed to participate in the drills, evacuation time period needed, and number of occupants evacuated. The need to ensure unannounced fire drills were conducted every other month at different times of the day, evening and night shifts, staff were instructed in fire and life safety procedures on alternating months from fire drills and fire drill records included all required elements was reviewed with Staff 1 (ED), Staff 2 (Chief Operating Officer), Staff 13 (Traveling Health Services) and Staff 15 (Director of Health Services) on 01/23/26 at 3:20 pm. They acknowledged the findings.

Calendar of alternating rotation of fire drills and fire life safety instruction has been put together for the balance of 2026 for the community to follow. Re-education and review of regulations has been provideded to community ED and Maintenance Director to assure understanding. Fire drill records will be audited routinely each month to assure completion and associated documentation. Twice monthly ED/Designee and Maintenance Director

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

OAR 411-054-0070 (3)(b)(A)(B)(C) 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: (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) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation, including the Department-approved LGBTQIA2S+ course, was completed prior to beginning job responsibilities for 2 of 4 newly hired staff (#s 8 and 16) whose training records were reviewed. Findings include, but are not limited to: Refer to C 370.

Pre-service LGBTQIA2S+ training is now completed for sampled staff. Audits have been conducted of remaining staff to verify completion of required training. Re-education provided to ED/Designee to assure understanding of training requirements and applicable timing of each item. Routine auditing of employee training records will be conducted to assure ongoing compliance Upon completion of the new hire process and at least twice monthly thereafter ED/Designee

OAR 411-054-0070 (3)(b)(A)(B)(C) 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: (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) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: