Print Inspection: RL002540

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 resident's current health status and needs, and provided clear direction to staff, and were implemented for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 06/2020 with diagnoses including Alzheimer’s disease and had a recent history of falls. Observations of the resident, review of the most recent service plan dated 12/27/24 and incident reports with a review of fall incidents were reviewed. The service plan did not reflect the resident's needs as identified in the evaluation and provide clear direction to staff in the following areas: *One to one feeding assistance, aspiration precautions, and swallow strategies; and *Fall risk and fall prevention interventions. The need to ensure service plans were reflective of resident’s needs, as identified in the evaluation, and included clear direction to staff was discussed with Staff 1 (ED), and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings. 2. Resident 3 moved into the facility in 11/2016 with diagnoses including Alzheimer’s disease. Observations of the resident, and the most recent service plan dated 12/26/24 were reviewed. The service plan did not reflect the resident’s needs as identified in the evaluation and provide clear direction to staff in the following area: *One to one feeding assist. The need to ensure service plans were reflective of resident’s needs, as identified in the evaluation, and included clear direction to staff was discussed with Staff 1 (ED), and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

1.The service plan has been updated to reflect resident #2 with resident specific details with instructions related to aspiration precautions and swallow strategies, including, monitor for pocketing of food, and staying upright for 30 minutes after eating. #2's service plan has been updated with instructions to try and prevent falls. #3's Service plan has been updated to state the resident requires assistance by staff to feed her during meals and snack times. We are reviewing, and updating all resident service plans to ensure servvice plan compliance. 2. The need and the requirement for person centered care being reflective in each resident service plan has been reviewed with the service planning team. 3. The service plans will be reviewed and signed off by the entire service plan team intially, 30 days, quarterly, and when there is a change of condition. 4.The RCC, Executive Director, LN, and Operations Director will be responsible to ensure the corrections have been made, and will be monitoring to ensure the needs and the directions to meet those needs are clear and resident specific on each service plan.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short term changes of condition, communicated actions and interventions to staff on each shift, and monitored the change of condition at least weekly until resolved for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 12/2024 with diagnoses including vascular dementia. The current service plan dated 01/27/25, temporary care plans, and progress notes dated 12/10/24 through 02/03/25 were reviewed. Observations and interviews with staff were completed between 02/03/25 and 02/04/25. The facility failed to determine what action or intervention was needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions: * 12/10/24 – New move in; * 12/27/24 - New behaviors; * 12/31/24 – Hospital visit for behaviors; * 01/04/25 – New medication; * 01/08/25 – Hospital visit for unresponsive event; * 01/14/25 – Medication change; and * 01/27/25 – New medication. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Operations Director) at 1:00 pm on 02/06/25. They acknowledged the findings. 2. Resident 2 moved into the facility in 06/2020 with diagnoses including Alzheimer’s disease. The resident's current service plan dated 12/27/24, progress notes dated 01/11/25 through 02/03/25, interim service plans (ISPs), and incident reports with a review of fall incidents were reviewed. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution: *Incident reports indicated Resident 2 experienced a fall on 01/10/25 resulting in facial bruising, a fall on 01/23/25 resulting in redness to left knee and a fall on 01/30/25 resulting in a skin tear on right elbow. The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings. 3. Resident 3 moved into the facility in 11/2016 with diagnoses including Alzheimer’s disease. The resident's current service plan dated 12/26/24, progress notes dated 01/17/25 through 01/20/25, and an incident report were reviewed. The following short-term change of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution: *A progress noted dated 01/17/25 indicated Resident 3 experienced an abrasion on her/his right arm. The need to ensure actions or interventions for short-term changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

1.Service plans for resident # 1,2, & 3 have been updated with resident specific instructions,and interventions added. Resident specific instructions are now being added, and put into place with each short term change of condition including when a new resident moves in, behaviors, hospital visits, medication changes or new medication. Short term change of conditions are being documented on daily to weekly through resolution. 2.All changes of conditions are reviewed daily during the daily clinical meeting to ensure the resident's needs are being met. 3.A daily clinical meeting to review 24 hours of any resident changes and so we have clear instructions in place to be able to meet the needs of the resident. 4. The Med Techs, RCC, LN, and the ED will ensure corrections are made, and monitored daily.

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

OAR 411-054-0050(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 establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to: a. On 02/03/25 at 11:40 am, Staff 3 (Lead MT) was observed to sneeze into their hand, touch their nose, cough into their hand and then applied a blood pressure cuff to a resident with no hand hygiene observed. b. Lunch service was observed on 02/03/25 and 02/04/25. Staff were observed serving meals and beverages, touching residents, removing dirty dishes and opening the kitchen door without changing their gloves or performing hand washing. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. The findings were acknowledged.

1.On 2/28/2025 we had an all staff meeting on how to prevent the spread of infection. All staff now carry there own hand sanitizer. Hand sanitizer has been placed on the med carts. Hand sanitizer dispenser will be installed in the dining room. All staff have been assigned Oregon Care Partner's handwashing training. Training to be done regarding proper sanitation practices during meals and with cleanup. During scheduled monthly "All staff meetings" there will be additional training related to infection control. 2. Random monitoring staff during medcation passes and during meals that the staff are following infection control protocol. ongoing monthly trainings. 3. Weekly monitoring with monthly ongoing training. 4. The RCC, LN, Executive Director, Operations Director ( Infection specialist) will be responsible for corrections and monitoring to ensure compliance.

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 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 7 and 9) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Review of training records showed Staff 7 (Care Partner, Med Tech), hired on 10/21/24, and Staff 9 (Care Partner), hired on 9/9/24, did not have documented evidence first aid and abdominal thrust training had been completed within 30 days of hire. The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

1.Care staff 7 & 9 have completed the required 30-day training in abdominal thrust & first aid. A audit of staff training records will be completed and any staff without the required demonstrated competencies within 30 days of hire. All employees training records will be reviewed for any trainings that may need completing. b. An audit of staff training records will be completed and any staff without the required training, including First Aid & Abdominal Thrust will be provided the training. 2. To ensure the system is correceted and staff remain in compliance with all training requirements,at the time of hire the employee will be assisgned required training. The employee will be assigned required trainings in Oregon Care Partners online training program. 3. Staff training records will need to be evauated on monthly basis. 4. Administrator/designee will be responsible to see that corrections are completed and monitored.

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Review of fire and life safety records from 08/01/24 through 02/03/25 revealed fire and life safety training for staff was not consistently being provided on alternating months. Between 08/01/24 and 02/03/25 only one documented life safety training was provided for staff (12/02/24). On 02/04/25, the need to ensure the facility staff received required fire and life safety training on alternate months from fire drills was reviewed with Staff 1 (ED) and Staff 5 (Maintenance Director). They acknowledged the findings.

1.Fire life training will be done monthly to correct the missing months of trainings provided. After being back on track with Fire & Life Safety, Fire & Life Trainings will be provided to the staff on opposite months of the fire drils and will be placed in the Fire drill/Fire and Life Safety binder. 2.A monthly schedule with alternating months from the fire drills will be then followed to ensure compliance with Fire drills and Fire & Life Safety. 3. The Fire Drill/Fire & Life Safety binder will be evaluated monthly. 4. The Administrator/Designee will be responsible to ensure correctionsare completed and monitored.

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 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the proper processing of soiled linens. Findings include, but are not limited to: Inspection of the interior environment of the building on 02/03/25 showed laundry rooms on both the north and south side of the building. Both laundry rooms were used for resident clothing and for clothing and linens soiled with bodily fluids. Observations of both laundry rooms and interviews with Staff 6 (Care Partner), Staff 1 (ED), and Staff 5 (Maintenance Director) were conducted on 02/03/25 at 1:00 pm and identified: * There were no separate areas with closed containers to ensure the separate storage and handling of linens soiled with bodily fluids from resident clean laundry; * At 1:00 pm in the south laundry room, wet laundry was observed directly on a counter top; * Soiled linens and soiled clothing were stored in a wire cart next to and above clean resident clothing; and * Washing machines reached only 120 degrees F, and no laundry disinfectant was used for soiled linens. Interview with Staff 1 and Staff 5 on 02/02/25 at 1:00 pm confirmed the washing machines did not reach the minimum rinse temperature of 140 degrees Fahrenheit, and a chemical laundry disinfectant was not used with the soiled linens. The above deficiencies increased the risk that communicable diseases could be spread to residents and staff. The need to ensure the facility developed and implemented proper soiled linen handling procedures was reviewed with Staff 1 and Staff 5 on 02/03/25. They acknowledged the findings.

1. large bins with lids will be labeled for dirty laundry and clean laundry will be placed and labled in separate basket for delivery to rooms. Laundry disinfective is now being used in accordance to the manufactures directions. All staff will be provided with training 2.All staff will be in-servicing on proper use of diinfectant and infection precautions regarding storage of clean and dirty laundry. 3. laundry rooms will be checked during daily inspection walk throughs to ensure compliance with the rule for Housekeeping and Laundry and the community policy. 4. RCC and the Administrator/Designee are responsible for corrections and monitoring. .

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 295, C 372, C 420 and C 530.

Refer to C295, C372, C420 and C530

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#7) completed all required pre-service orientation, 2 of 3 new staff (#s 7 and 9) completed the required pre-service training, and 2 of 3 long term staff (#s 3 and 10) completed the required 16 hours of annual training. Findings include, but are not limited to: Review of staff training records on 02/04/25 revealed the following: a. Staff 7 (Care Partner/Med Tech) was hired 10/21/24. There was no documented evidence they had completed the following elements of the required pre-service orientation prior to performing any job duties: * Resident rights and values of community-based care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Written and signed job description; * Infectious disease prevention 7/1/22 requirement; and * Approved HCBS course. b. There was no documented evidence Staff 7 (Hired on 10/21/24), and Staff 9 (Care Partner), (Hired on 09/09/24), had completed training as required in the following areas: * Dementia disease process; * Techniques for understanding and communicating; * Social needs and activities in dementia, * Dementia care and safety; * Environmental factors important to wellbeing; * Family support and the role family may have in the care of the resident; and * Recognizing behaviors that indicate a change in condition. c. There was no documented evidence Staff 10 (Activities) and Staff 3 (Med Tech), completed the required 10 hours of annual training related to provision of care in community-based care or the required six hours related to dementia care. The facility's failure to ensure staff completed all required training in a timely manner and that training was documented was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

1. Staff #7 & #9 have completed the required the pre-service training. #7 has completed all elements of the preservice orientation, including resident rights and values of community based care, abuse reporting, fire safety and emergency procedures,HCBS, and infection prevention, and has a signed job description in their records. Staff # 7 & 9 will have training completed for Dementia disease process, Techniques for understanding and communicationg, social needs and activities in dementia, dementia care and safety, environmental factors important to well being, faamily support and the role of the family, recognizing behaviors that indicate a change in condition. Staff # 3 & 10 will complete the annual required 10 hours training and the six hours related to dementia. 2. All the staff records will be reviewed and corrected to ensure compliance with all required training. 3.All staff records will be reviewd monthl. 4. The Administrator/Designee will be responsible for corrections are completed and monitored.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260 and C 270.

Refer to C260 and C270

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

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observations and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service plan for 2 of 3 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to: Resident's 2 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) and Staff 2 (Operations Director) on 02/06/25. They acknowledged the findings.

1. Resident's #2 & 3 service plans have been updated regarding their nutrition and hydration status and needs with clear instructions for staff to meet those needs. 2. All resident's service plans are being reviewed and updated to reflect detailed instructions for the staff regarding each residents individualized status and needs. 3. Whenever a resident's service plan is updated it will be updated to the current need of the resident. initial, 30-day, 90-day, and with any change of condition. 4. The Administrator/Designee will be responsible that corrections are completed and monitored.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: