Print Inspection: RL003022

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were the foundation used for the development of the resident's service plan, available to staff, and reviewed with documented updates when a resident had a significant change in condition for 3 of 4 sampled residents (#s 2, 3, and 4) whose quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 12/2011 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and unspecified dementia. Resident 3's service plan, available to staff was dated 12/30/24. The evaluation occurred on 01/24/25. Therefore, the evaluation was not the foundation for the resident's service plan. The resident experienced a significant change of condition following the identification of bilateral leg wounds on 02/16/25. The resident's evaluation, dated 01/24/25, was not updated with changes to the resident's care needs. The need to ensure evaluations were the foundation of the resident's service plan, available to staff, and reviewed with documented updates after a resident experiences a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 10:40 am. They acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were the foundation used for the development of the resident's service plan, available to staff, and reviewed with documented updates when a resident had a significant change in condition for 3 of 4 sampled residents (#s 2, 3, and 4) whose quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 12/2011 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and unspecified dementia. Resident 3's service plan, available to staff was dated 12/30/24. The evaluation occurred on 01/24/25. Therefore, the evaluation was not the foundation for the resident's service plan. The resident experienced a significant change of condition following the identification of bilateral leg wounds on 02/16/25. The resident's evaluation, dated 01/24/25, was not updated with changes to the resident's care needs. The need to ensure evaluations were the foundation of the resident's service plan, available to staff, and reviewed with documented updates after a resident experiences a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 10:40 am. They acknowledged the findings. 2. Resident 4 moved into the facility in 04/2021 with diagnoses including congestive heart failure. The resident’s clinical record was reviewed. The most recent quarterly evaluations for Resident 4 were completed on 09/21/24 and 02/09/25. On 03/04/25 at 11:24 am, Staff 6 (Assistant Director of Health Services/LPN) confirmed the quarterly evaluation, due on 12/20/24, was not completed. Resident 4's service plan was dated 12/30/24. The resident’s last two evaluations were dated 09/21/24 and 02/09/25. There was not an evaluation to correspond with the resident’s 12/30/24 service plan; therefore, the evaluation was not the foundation of the service plan and did not correspond with the resident’s quarterly service plan updates. The resident experienced a significant change of condition following the identification of a venous stasis ulcer documented by the facility on 01/17/25. The resident's evaluation, dated 12/30/24, was not reviewed with updates documented following the significant change of condition. The need to ensure evaluations were the foundation of the resident's service plan, were performed at least quarterly, to correspond with the quarterly service plan updates and reviewed with documented updates after a resident experienced a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:00 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2024 with diagnoses including type I diabetes and history of falling. The most current service plan, accessible to staff, was dated 01/06/25. However, the facility provided an evaluation for the resident, completed on 01/24/25 following a change in condition due to weight loss, and another evaluation on 03/03/25 as the quarterly review. The evaluations were not included as the foundation for developing the current service plan. The need to ensure evaluations were the foundation of the resident's service plan and were reviewed with documented updates after a resident experience a change in condition was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 10:00 am. They acknowledged the findings.

C252 - Resident Move In and Evaluation - Resident Evaluation 1. Level of Care evaluations were reviewed and updated to accurately reflect the needs and service plans were updated, printed and reviewed by Health Services Staff for resident 2, 3 and 4. 2. Audited and updated all current residents to verify their required evaluations, assessments and service plans were completed timely and accurately to reflect their needs and all service plans are updated to reflect resident needs. All health Services staff received training on reporting changes in resident care needs and environment concerns to health services timely so resident evaluations are updated appropriately. Training conducted with health services team about the requirements of timely evaluations and assessments. 3. Reviewed weekly during clinical meeting and weekly Regional Team review. 4. Executive Director, Resident Care Coordinator, Director of Health Services

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 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, provided clear direction to staff regarding the delivery of services, and were reviewed and updated when a resident experienced a significant change of condition for 3 of 6 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 04/2021 with diagnoses including congestive heart failure. Observations of the resident, interviews with the resident and staff, and review of the service plan available to staff, dated 12/30/24, revealed the service plan was not reflective of the resident’s current care needs and/or did not provide clear direction to staff in the following areas: * Transfer pole; * Home health services; * Non-pharmacological pain interventions; and * Instructions around how much fluid is safe for a resident with heart failure. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:00 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 07/2024 with diagnoses including type I diabetes and history of falling. Observations of the resident, interviews with staff, and the current service plan, updated 01/06/25, reviewed during the survey, from 03/03/25 through 03/06/25, revealed Resident 2's service plan was not reflective of his/her status and did not provide clear directions regarding the delivery of services in the following: * Transfer status including the use of a Hoyer lift; * Use of a side rail including necessary precautions; * Transfer pole; and * Receiving personal training status. On 03/05/25 at 11:18 am, the service plan was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services). They acknowledged the service plan was not reflective of the resident's status and lacked clear directions. 3. Resident 3 moved into the facility in 12/2011 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and unspecified dementia. a. Observations of the resident, interviews with staff and review of the current service plan, updated 12/30/24, revealed Resident 3's service plan was not reflective of his/her status and did not provide clear directions regarding the delivery of services in the following: * Ability to use call pendant; * Fall history; * Recent weight loss; * History of bilateral leg wounds; * Assistance required with laundry, personal hygiene, oral care, dressing, bathing, toileting, and meals; * Preference of open door to apartment; * Outside provider services, including home health RN, PT, and OT; * History of urinary tract infection; and * Frequency of meal delivery. b. There was no documented evidence the service plan was reviewed and updated when Resident 3 experienced a significant change of condition following the identification of bilateral leg wounds on 02/16/25. On 03/06/25 at 10:40 am, the service plan was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services). They acknowledged the service plan was not reflective of the resident's status, lacked clear directions, and was not updated after a significant change of condition.

C260 - Service Plan General 1. Service plans for resident #2, 3 and 4 were reviewed and updated to reflect resident's current care needs and have clear directions to staff regarding the delivery of services. 2. To prevent recurrance, all current resident service plans will be audited for accuracy. Direct care staff were reeducated regarding the importance of implementing current service plans and reporting any discrepancies. Training with Health Services team completed to ensure service plans are updated for accuracy and they provide clear direction to care team. Monitored during Stand up/Clinical meeting to review upcoming evals/service plan reviews that need to be completed as well as to note when there are changes of condition that could require an update more frequent than quarterly schedule. 3. Service plan schedule and residents with change of conditon and significant change of condition are reviewed during Stand-up and clinical meetings. Service plans will be evaluated and reviewed upon admission, at 30 days, quarterly and with significant change of condition. 4. Executive Director and Health Services

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 ensure residents who had a significant change of condition were evaluated, referred to the RN for assessment and the service plan was updated as needed for 1 of 1 sampled resident (# 3); and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 5 of 6 sampled residents (#s 2, 3, 4, 5 and 7) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility 03/2023 with diagnoses including Parkinson’s disease and cerebrovascular accident (CVA). Review of the resident's clinical record including progress notes from 12/02/24 through 03/03/25, service plan updated on 01/06/25 and interim service plans (ISP’s) were completed during the survey. The facility failed to monitor the changes of condition, at least weekly, until resolved for the following changes of condition: * 01/09/25 and 01/16/25: Falls; and * 02/10/25: New medication. The need to ensure the facility monitored the changes of condition, at least weekly, until resolved was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25. They acknowledged the findings. 2. Resident 7 was admitted to the facility 01/2025 with diagnoses including congestive heart failure (CHF) and history of falls. Review of the resident's clinical record including progress notes from 01/03/25 through 03/03/25, service plan updated on 03/03/25 and interim service plans (ISP’s) were completed during the survey. The facility failed to monitor the changes of condition, at least weekly, until resolved for the following change of condition: * 02/04/25: Multiple new medications. The need to ensure the facility monitored the changes of condition, at least weekly, until resolved was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2024 with diagnoses including type I diabetes and history of falling. Review of the resident's clinical record including progress notes from 12/06/24 through 03/03/25, service plan updated on 01/06/25, and interim service plans (ISP’s) were completed during the survey. The facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and/or to monitor the change of condition, at least weekly, until resolved for the following changes of condition: * 12/08/24: Not receiving multiple medications; * 12/13/24: Emergency visit after a fall and experiencing high blood sugar levels; * 01/14/25: Experiencing weight loss; * 01/29/25: Experiencing episodes of vomiting; * 02/09/25: Signs and symptoms of urinary tract infection; and * 02/12/25: An increase in the dose of insulin and starting a new scheduled dose of Tylenol for pain. The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated resident-specific instructions and interventions to staff on each shift, and/or monitored the change of condition, at least weekly, until resolved was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/05/25 at 11:08 am. They acknowledged the findings. 4. Resident 4 moved into the facility in 04/2021 with diagnoses including congestive heart failure. The resident's current service plan available to staff, dated 12/30/24, progress notes, dated 12/03/24 through 03/02/25, and Interim Service Plans (ISPs) 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/or progress noted at least weekly through resolution: * 12/23/24: Fall; * 12/31/24: Elevated CBG; * 01/03/25: Edema; * 01/05/25: Skin tear to left shin; * 01/05/25: Upper body aches; * 01/07/25: Water blisters; * 01/20/25: Skin tear to left shin; * 02/05/25: Medication change; * 02/12/25: Bruise to right ring finger; and * 02/18/25: Medication changes. The need to ensure the facility determined and documented what resident-specific actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:00 am. They acknowledged the findings. EX #2 EX #3 Laura Tiffany 4. Resident 4 moved into the facility in 04/2021 with diagnoses including congestive heart failure. The resident's current service plan available to staff, dated 12/30/24, progress notes, dated 12/03/24 through 03/02/25, and Interim Service Plans (ISPs) 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/or progress noted at least weekly through resolution: * 12/23/24: Fall; * 12/31/24: Elevated CBG; * 01/03/25: Edema; * 01/05/25: Skin tear to left shin; * 01/05/25: Upper body aches; * 01/07/25: Water blisters; * 01/20/25: Skin tear to left shin; * 02/05/25: Medication change; * 02/12/25: Bruise to right ring finger; and * 02/18/25: Medication changes. The need to ensure the facility determined and documented what resident-specific actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:00 am. They acknowledged the findings. 5. Resident 3 moved into the facility in 12/2011 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and unspecified dementia. The resident's current service plan available to staff, dated 12/30/24, progress notes, dated 12/03/24 through 03/02/25, and Interim Service Plans (ISPs) were reviewed. a. 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/or progress noted at least weekly through resolution: * 12/14/24: Resident “seemed out of it and dazed;” * 01/11/25: Swollen and red left eyelid; * 01/16/25: Abraded area to buttocks; * 01/31/25: Resident found on floor; * 02/01/25: Skin tear to right shin; * 02/16/25: Bilateral lower leg wounds; and * 02/18/25: New sore on left heel. b. The following significant change of condition lacked documentation of a facility evaluation of the resident, referral to the facility nurse, documentation of the change, and service plan updates: * 03/01/25: Resident experienced significant weight loss. The need to ensure the facility determined and documented what resident-specific actions or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, monitored the short-term changes of condition at least weekly through resolution; and the need to evaluate significant changes of condition, refer to the RN for assessment, and the service plan was updated as needed was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 10:45 am. They acknowledged the findings.

C270 - Change of Condition and Monitoring 1. Residents 2, 3, 4, 5, 7 were reviewed, ISPs were updated and all assessments completed and staff direction and updated by RN. Service plans have been updated and interventions have been reviewed for effectiveness. Service plan includes clear direction to direct cares on current interventions. 2. To prevent recurrence, staff will be reeducated on our alert charting guidelines, when to notify the RN and providing resident-specific actions or interventions to staff when a change of condition has been identified. 24 hour summary will be reviewed during stand up clincial meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will then trigger a LN assessement which will include any changes to the care. The change of condition will be monitored until resolved or a new baseline is determined. When a change of condition is determined to be a significant change the RN will be notified to complete a significant change of condition assessment and resident will be monitored until resolved or until a new baseline is determined. Licensed nurses and Resident Care Coordinator reviewed regulations related to monitor of change of condition, including effectiveness of interventions. 3. This system will be evaluated during stand up clincial meeting and as needed when a change of condition occurs. 4. Executive Director and Licensed Nurse will be responsible for maintaining this system.

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 interview and record review, it was determined the facility failed to monitor each resident consistent with his or her evaluated needs and service plan for 1 of 3 sampled residents (#9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 9 moved into the assisted living community in 08/2023 with diagnoses including pressure ulcer of unspecified buttock. The resident’s skin integrity and progress notes from 07/05/25 through 08/18/25 were reviewed and revealed a MT identified a sore on Resident 9’s bottom on 07/14/25. The sore was evaluated by Staff 6 (LPN) on 07/17/25; however, the evaluation was entered as a “late entry.” Staff 6 confirmed the evaluation was entered into the resident’s electronic record on 08/18/25, or after survey’s entrance into the community. On 07/23/25, HH wound care was initiated, and the HH RN and Staff 3 (Regional RN) completed their initial assessment. Staff 3 documented their assessment on 07/24/25 as a “late entry.” On 08/18/25 at 3:45 pm, additional documentation of skin monitoring was requested. On 08/19/25 at 3:00 pm, Staff 3 confirmed there was no documented evidence of monitoring the resident’s wound by the facility between 07/24/25 and 08/18/25. Review of 08/13/25 and 08/18/25 HH RN documentation and the RN’s skin assessment dated 08/20/25 revealed the buttock wound was healing. The need to ensure the facility monitored the resident according to their evaluated needs was discussed with Staff 1 (ED) and Staff 3 on 08/20/25 at 3:41 pm. The findings were acknowledged.

1. Resident Review & Documentation Updates: Residents #9 were reviewed by the RN. Interim Service Plans (ISPs) were updated to reflect current conditions and interventions. Resident Assessment was completed, and staff directions were revised to ensure clarity. Interventions were evaluated for effectiveness and adjusted as needed. 2. Staff Reeducation: All direct care staff and licensed nurses received reeducation on: ? Alert charting protocols. ? Criteria for notifying the RN. ? Providing resident-specific actions/interventions when a change of condition is identified. o Licensed Nurses Training Included Nurse Learn Courses • Module 1 – Identifying, Assessing, and Monitoring Short Term and Significant Changes of Condition • Module 18 – Creating Individualized Care/Service Plans • Module 24 - Nursing Leadership in Community-Based Care Settings • Module 25 – Organization, Prioritization, and Time Management 3. Enhanced Monitoring System reviewed daily in Clinical Stand Up: o Residents with identified changes in condition are placed on alert charting, triggering a Licensed Nurse assessment. o The assessment includes updates to service plans/TSP and interventions. o Monitoring continues until the condition resolves or a new baseline is established. o If the change is determined to be significant, the RN completes a Significant Change of Condition Assessment and initiates ongoing monitoring, timely. 4. Clinical Oversight & Documentation Review are completed by Resident Care Coordinator, Director of Health Services and Executive Director in Clinical Meeting: o Daily stand-up clinical meetings now include review of the 24-hour summary for all residents on alert charting. o On Mondays, the 72-hour summary is reviewed to ensure weekend documentation is complete and accurate.

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 411-054-0045 (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 an RN assessment was completed with documentation of the findings, resident status, and interventions made as a result of this assessment or was completed timely for 2 of 4 sampled residents (#s 3 and 4) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 12/2011 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and unspecified dementia. Review of the clinical record and interviews with staff revealed Resident 3 had two wounds on his/her legs, which were identified on 02/16/25, upon the resident’s return from a hospital visit. The wounds constituted a significant change in condition for which an assessment by the facility RN was required. The resident was admitted to home health nursing services for wound care on 02/21/25. The facility RN assessment was completed on 02/25/25, or nine days following identification of the resident’s wounds. The wounds were still being treated by the outside home health provider and monitored weekly by the facility LPN. The need to ensure the facility conducted an RN assessment timely after a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 10:45 am. The findings were acknowledged. 2. Resident 4 moved into the facility in 04/2021 with diagnoses including congestive heart failure. Review of the resident’s clinical record and interviews with staff revealed Resident 4 had a wound on his/her left leg which was documented by the facility’s RN in an RN Skin Assessment form and the Skin Integrity Weekly RN Monitoring form on 01/17/25. The wound constituted a significant change in condition for which an RN assessment with documentation of findings, resident status, and interventions was required. Although the facility RN completed an assessment on 01/17/25, it failed to include the documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:00 am. They acknowledged the findings.

C280 - Resident Health Services 1. Significant change of condition assessments for resident #3 and #4 were completed and updated by RN. RN conducted audit for all residents to determine if any current change of conditions required an RN assessment. 2. To prevent reoccurence, staff will be reeducated on change of condition reporting and when to notify the RN. An RN has been hired for the Director of Health Services position to provide consistency of resident care. 24 Hour summary will be reviewed during stand up clincial meeting. At the beginning of the week, the 72 hour summary will be reviewed to include documentation over the weekend. When a change of condition is identified, the resident will be placed on alert charting which will then trigger a LN assessment, which will include any changes to the plan of care. The change of condition will be monitored until resolved or a new baseline is determiend. When a change of condition is determined to be a significant change, the RN will be notified to complete a significant change of condition assessment and resident will be monitored until resolved or a new baseline is determined. The health services team have been reeducated on the RN requirements related to significant change of condition. 3. This system will be evaluated during stand up clinical meeting and as needed when a significant change of condition occurs. 4. Executive Director and Licensed Nurses will be responsible for maintaining this system.

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 an RN assessment was completed in a timely manner for 1 of 3 sampled residents (# 9) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 9 moved into the community in 08/2023 with diagnoses including pressure ulcer of unspecified buttock. The resident’s progress notes from 07/05/25 through 08/18/25 were reviewed and revealed a MT identified a sore on Resident 9’s bottom on 07/14/25. On 07/17/25, Staff 6 (LPN) documented the resident had scratched open his/her wound. The wound note was documented as a “late entry.” On 08/19/25 at 2:48 pm, Staff 6 confirmed it was entered into the resident’s electronic record on 08/18/25, or after survey’s entrance. In interviews with Staff 3 (Regional RN) and Staff 6 on 08/19/25, it was confirmed Resident 9 had a recurring gluteal wound that would heal and then re-open because s/he had scratched it. The wound constituted a significant change in condition for which an assessment by the facility RN was required. The resident was admitted to home health nursing services for wound care on 07/23/25. Staff 3 was present for the HH RN assessment and documented agreement with the HH RN’s assessment as a “late entry” on 07/24/25. The facility RN’s assessment was documented ten days following the MT’s identification of the condition. The need to ensure an RN assessment was completed in a timely manner for residents with significant changes of condition was reviewed with Staff 1 (ED) and Staff 3 on 08/20/25 at 3:41 pm. The findings were acknowledged.

• Immediate Resident Review: • Significant Change of Condition Assessments were completed for Residents #9 by the RN. • A comprehensive audit of all residents was conducted to identify any additional changes in condition requiring RN assessment. • All necessary assessments were completed and documented. • Staff Reeducation & Leadership Stabilization: • All care staff and licensed nurses were reeducated on: o Protocols for identifying and reporting changes in condition. Licensed Nurse Specific Training Includes: • Module 2 – Significant Change of Condition: Weight Changes • Module 3 – Significant Change of Condition: Responding to Falls • Module 5 – Significant Change of Condition: Acute Health Status Change • Module 18 o RN responsibilities related to significant change assessments. • Monitoring & Documentation Protocols: • Residents with identified changes in condition are placed on alert charting, which triggers a Licensed Nurse assessment. • The LN assessment includes updates to the resident’s service plan. • The change is monitored until resolved or a new baseline is established. • If the change is deemed significant, the RN completes a Significant Change of Condition Assessment and initiates ongoing monitoring. • Clinical Oversight & Review Process: • The 24-hour summary is reviewed daily during stand-up clinical meetings. • At the start of each week, the 72-hour summary is reviewed to ensure weekend documentation is complete and accurate. • Effectiveness of interventions and service plan updates are discussed and documented by Clinical Health Services team.

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 observation, interview, and record review, it was determined the facility failed to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, and the service plan was adjusted, if necessary, and reporting protocols were in place for 2 of 3 sampled residents (#s 3 and 4) who received outside services. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 04/2021 with diagnoses including congestive heart failure. The resident’s clinical chart including outside provider notes, progress notes, dated 12/03/24 through 03/02/25, and the service plan, dated 12/30/24, was reviewed. Interviews with facility staff and the resident were completed during survey and revealed the following: On 01/17/25, the facility RN documented Resident 4 had a venous stasis ulcer on his/her left leg and HH would be requested for follow-up. In a progress note on 01/23/25, Staff 6 (Assistant Director of Health Services/LPN) documented “home health on board for resident’s wound care.” On 03/06/25 at 11:00 am, Staff 4 (Vice President of Clinical Services) confirmed the facility did not have documentation of the services provided by the resident’s HH wound care RN. Therefore, there was no documented evidence the facility’s management or licensed nurse was notified of the services provided by the HH RN to ensure staff were informed of new interventions, and the service plan was adjusted if necessary. On 03/04/25 at 11:47 am, Staff 6 (Assistant Director of Health Services/LPN) confirmed the resident’s ulcer had healed. The need to ensure the facility management or the licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, the service plan was adjusted, if necessary, and reporting protocols were in place was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:00 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 12/2011 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and unspecified dementia. The resident’s clinical chart including outside provider notes, progress notes, dated 12/03/24 through 03/02/25, and the service plan, dated 12/30/24, was reviewed. Interviews with facility staff and the resident were completed during survey and revealed the following recommendations: * 02/21/25: “Encourage protein rich foods first at meals to aid in wound healing.”; and * 02/27/25: “Please serve all meals in [sic] dinner plates and give real silverware. [Please] explain one step activities prior to performing tasks to improve participation and behaviors.” Resident 3 was observed to be served breakfast meals on 03/03/25 and 03/04/25 in plastic clamshell containers with plastic silverware. There was no documented evidence the facility updated the resident's service plan as necessary after being informed of the new interventions. The need to ensure staff were informed of new interventions and the service plan was updated as necessary after on-site health services were provided was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 10:50 am. They acknowledged the findings.

C290 - Resident On Site and Offsite Health Services 1. All outside provider summary notes for the past 90 days have been reviewed for resident #3 and #4 and service plan has been updated with all recommendations and appropriate interventions. Interim service plan has been printed for all direct care staff to review and sign. 2. To prevent recurrance all outside provider notes to be reviewed through facility triple check process, which includes initiation of ISP by Med tech and reviewed by Licensed Nurse. Coordination of care will be performed by Licensed Nurse with all outside health services to ensure appropriate care and services are provided within the scope of the regulation and practice. 3. This system will be evaluated monthly as part of the facility’s CQI program. 4. Executive Director and RN will be responsible for maintaining this system.

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 provide a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (#3). Findings include, but are not limited to: Resident 3 moved into the facility in 12/2011 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and unspecified dementia. During the acuity interview on 03/03/25 at 9:36 am, it was reported Resident 3 relied on two caregiving staff to provide incontinence care. At 11:21 am on 03/03/25, Staff 14 (CG) and Staff 15 (CG) were observed providing incontinence care for Resident 3. During the observation, both staff donned gloves without performing hand hygiene, assisted the resident in turning side to side and removed his/her soiled brief. Staff 14 provided perineal care and applied barrier cream. Staff 14 failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body and applying a clean brief and clothing for the resident. The above observation was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 10:50 am. They acknowledged the appropriate infection control practices were not implemented.

C295 - Infection Prevention and Control 1. Direct Care Staff have attended training on infection control processes and appropriate glove use during resident care, specifically resident incontinence care. 2. All staff will train on infection control practices prior to working with residents. This training will also be reviewed as part of general orienation to reiterate the importance of infection control and ongoing annually and as needed. 3. This will be evaulated by Licensed Nurses and Resident Care Coordinators as part of weekly spot checks and will further be evaluated quarterly as part of our CQI process. 4. Executive Director and Resident Care Coordinator will be responsible for maintaining this system.

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 interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed; and failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 5 sampled residents (#s 2, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1.Resident 5 was admitted to the facility 03/2023 with a diagnosis including Parkinson’s disease and cerebrovascular accident (CVA). Resident 5's 02/01/25 through 02/28/25 MARs and current physician's orders were reviewed. There were no signed medication orders for the medications and treatments the facility was managing for Resident 5. On 03/06/25 at 10:25 am, Staff 1 (ED) stated the facility was in process of obtaining signed physician orders for Resident 5. The need to ensure signed prescriber orders were maintained in the resident record was reviewed with Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25. They acknowledged the findings. 2. Resident 2 moved into the facility in 07/2024 with diagnoses including type I diabetes and hypertension. The resident’s 02/01/25 – 03/03/25 MARs and physician’s orders were reviewed, and staff interviews were conducted during the survey, revealing the following: a. The physician order, dated 08/19/24, to administer Humalog (a fast-acting form of insulin) “…6 units subcutaneously before breakfast, 6 units before lunch, 6 units before dinner…” The MARs showed the insulin was not administered to the resident on seven occasions without a supporting physician order. b. The 08/19/24 physician order indicated to administer losartan once a day for blood pressure. The MAR showed the medication was not administered to the resident on three occasions, with staff documenting “waiting for delivery.” c. The 08/19/24 physician order indicated to administer the ciclesonide inhaler twice daily for shortness of breath. The MARs showed the medication was not administered to the resident on five occasions, with staff documentation stating the inhaler was empty, and the medication was unavailable. d. The 08/19/24 physician order indicated to apply nystatin topical twice daily for red yeast area. The MARs showed the treatment was not applied to the resident on 21 occasions with staff documentation stating that the medication was unavailable, waiting for delivery or the treatment could not be administered. e. The 08/19/24 physician order indicated to administer atenolol 50 mg twice daily for hypertension. The MARs showed the medication was not administered to the resident on one occasion, with staff documenting the medication was “not available.” On 03/05/25 at 11:22 am, the findings were reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services). They acknowledged the findings. 3. Resident 4 moved into the facility in 04/2021 with diagnoses including congestive heart failure. Resident 4's current physician's orders and the MAR, dated 02/01/25 through 03/02/25, were reviewed. a. The resident had a physician’s order to check blood pressure one time daily and alert the doctor if the reading was 160/90 or greater. The resident had three instances when his/her blood pressure was at or above the physician ordered parameter. On 03/04/25 at 12:43 pm, Staff 3 (Regional RN) confirmed there was no documented evidence the doctor was alerted to the blood pressure readings. Therefore, the order was not carried out as prescribed. b. The facility failed to have signed physician orders in the resident’s record for the following two medications the facility was responsible to administer: * Ozempic 0.25 mg (for diabetes); and * Ketoconazole shampoo (for dermatitis). The need to ensure all medications were carried out as prescribed and written signed physician orders were documented in the resident’s facility record was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:00 am. They acknowledged the findings.

C303 - Treatment Orders 1. Received signed medication orders for Resident #2, 4 and 5. Provided staff training regarding system to request quarterly physician orders and how to process and file new physician orders. 2. Resident Care Coordinator, Licensed Nurse and Medication technicians have received education about processing medication orders, the triple check process, filing new orders and the requirement to have signed physicians orders. 3. This system will be reviewed through weekly Resident Care Coordinator audits to ensure quarterly physician orders are requested and through daily triple check process to ensure new orders are received, processed and filed appropriately. 4. Executive Director and LNs will be responsible for maintaining this system.

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 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order for 1 of 1 sampled resident (# 1) who had documented medications refusals. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2024 with diagnoses including type I diabetes and hypertension. Review of the resident’s 02/01/25 – 03/03/25 MAR and practitioners orders showed the following: * The resident was prescribed acetaminophen 500 mg two tablets three times a day for pain; and * Staff documented on the MARs that the resident refused acetaminophen on 22 occasions. There was no documented evidence the facility notified the prescriber when the resident refused to consent to the orders. On 03/05/25 at 11:27 am, Staff 1 (ED) confirmed that there was no documented evidence the facility notified the prescriber when the resident refused to take the medication. On 03/05/25 at 11:30 am, the refusals were reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services). They acknowledged the findings.

C305 - Resident Right to Refuse 1. Physician for resident #1 was faxed a copy of all refusals for past 30 days. 2. To prevent recurrance, a list of all residents that require physician notification for refusals has been created and posted in the Med Room. All Medication technicians re-educated on the importance of notifying physicians timely regarding refusals, unless we have an order in place stating not to. 3. LN will review the 24/72 hour report during stand up clinical meeting to identify any residents who refused medications, treatments or tasks, and ensure physician is notified by looking for a progress note and then hard copy of fax confirmation located in residents chart. 4. ED, RN/LN & RCC will be responsible for maintaining this process.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potential restraining qualities was assessed thoroughly by an RN, PT or OT prior to use, including attempting less restrictive alternatives and to provide instruction to the caregivers on the correct use and precautions for 1 of 1 sampled resident (# 2) who had a half-length side rail on the bed. Findings include, but are not limited to: Resident 2 moved into the facility in 07/2024 with diagnoses including history of falling and cerebral infarction without residual deficits. Resident 2 was observed on 03/03/25 at 11:55 am to have a half-length side rail on the bed in the down position. On 03/04/25 at 10:58 am, Staff 15 (CG) reported the side rail was in the up position when she entered in the morning to provide morning care which was identified to be a device with potentially restraining qualities. Review of the resident's clinical record showed the following: * No documented evidence of an assessment completed by a RN, Physical Therapist or Occupational Therapist for the use of the side rail. Therefore, there was no documented evidence that other less restrictive alternatives had been attempted prior to their use; and * No instruction on the service plan to caregivers related to use and precaution of the side rail. On 03/04/25 at 2:45 pm, the lack of documented assessment, including attempting less restrictive alternatives and care instructions for the use of the side rail was reviewed with Staff 1 (ED) and Staff 4 (Vice President of Clinical Services). They acknowledged the findings.

C340 - Restraints and Supportive Devices 1. Supportive Device assessment for resident #1 was completed by RN. 2. Staff re-educated on the importance of reporting to RN when a resident has or is requesting a device with restraining qualities. RN received reeducation on the expectation of completing the Supportive Device assessment per regulation. 3. This process will be reviewed during stand-up/Clinical meeting to review progress notes to for documentation that may indicate a resident requesting to add a supportive device. During Stand up/Clinical meeting the LN will review Assistive Device assessment schedule to track who needs an assessment and will complete. 4. Executive Director and Licensed Nurse will be responsible to maintain compliance.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 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 4 of 4 sampled newly hired staff (#s 19, 20, 24, and 26) completed all pre-service orientation topics prior to beginning their job responsibilities, 1 of 3 newly hired direct care staff (#20) completed pre-service dementia training requirements prior to beginning their job responsibilities, and 9 of 11 sampled staff (#s 10, 12, 15, 17, 20, 21, 24, 25, and 27) completed the department approved LGBTQIA2S+ training prior to 12/31/24. Findings include, but are not limited to: Staff records were reviewed on 03/05/25 at 1:30 pm. The following was identified: a. There was no documented evidence Staff 19 (CG), hired on 11/13/24, Staff 20 (CG), hired on 11/13/24, Staff 24 (Server), hired on 07/29/24 and Staff 26 (MT), hired on 12/02/24, completed pre-service orientation topics in one or more of the following areas: *Written job description; and *Home and Community Based Services. b. There was no documented evidence Staff 20 completed the following pre-service dementia training: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. c. There was no documented evidence Staff 10 (MT), hired on 11/12/22, Staff 12 (MT), hired on 07/29/20, Staff 15 (CG), hired on 02/01/23, Staff 17 (Plant Operations Assistant), hired on 12/29/21, Staff 20, Staff 21 (CG), hired 03/19/21, Staff 24, Staff 25 (Cook), hired on 09/17/21, and Staff 27 (Cook), hired on 06/18/22, completed the department approved LGBTQIA2S+ training by 12/31/24. The need to ensure newly hired staff completed all required pre-service orientation topics and pre-service dementia training, and all staff completed the department approved LGBTQIA2S+ training by 12/31/24 was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), and Staff 4 (Vice President of Clinical Services) on 03/06/24 at 11:30 am. They acknowledged the findings.

C370 - Staff Training - Pre-service 1. A complete audit was done of all training records. Staff who were missing components of training were removed from the floor until their training was completed. 2. To prevent recurrence, training grid will be utilized to ensure that all staff have required trainings completed. Staff will not be allowed to work on the floor unsupervised until all of their required trainings are completed. Monthly, as part of facility continuous quality improvement meetings, training grid will be reviewed to identify any staff members whose certifications/trainings are close to expiration and they will be scheduled to complete the required training. 3. Incomplete trainings will be reviewed weekly during Stand up to identify missing training components and to review the status of new hires and where they are at with their trainings. This system will be evaluated monthly as part of the facility continuous quality improvement process and will include a review of the training grid. 4. The Executive Director will be responsible for maintaining this system

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 19, 20, and 26) had documented evidence of demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 03/05/25 at 1:30 pm and revealed the following: There was no documented evidence Staff 19 (CG), hired on 11/13/24, Staff 20 (CG), hired on 11/13/24, and Staff 26 (MT), hired on 12/02/24, demonstrated competency within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Other duties as applicable (Med pass, treatments); and * First Aid/abdominal thrust. In an interview on 03/05/25 at 3:40 pm, Staff 1 (ED) acknowledged Staff 26 did not have documentation of demonstrated competency in medication pass prior to working independently as a MT. Staff 1 agreed to ensure Staff 26 demonstrated competence prior to independently passing medications. The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was reviewed with Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:30 am. They acknowledged the findings.

C372 - Training within 30 days of hire 1. A complete audit was done of all training records. Staff who were missing components of training were removed from the floor until their training was completed. 2. To prevent recurrence, training grid will be utilized to ensure that all staff have required trainings completed. Staff will not be allowed to work on the floor unsupervised until all of their required trainings are completed. Monthly, as part of facility continuous quality improvement meetings, training grid will be reviewed to identify any staff members whose certifications/trainings are close to expiration and they will be scheduled to complete the required training. Incomplete trainings will be reviewed weekly during stand up to identify missing training components and to review the status of new hires and where they are at with their trainings. 3. This system will be evaluated monthly as part of the facility continuous quality improvement process and will include a review of the training grid. 4. The Executive Director will be responsible for maintaining this system

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 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (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. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 4 long-term direct care staff (#s 12 and 15) failed to have a minimum of 12 hours of annual in-service training including six hours related to dementia care training and 5 of 7 long-term direct care and non-direct care staff (#s 10, 12, 15, 17, and 25) failed to have annual HCBS training. Findings include but are not limited to: Training records were reviewed on 03/05/25 at 1:30 pm and revealed the following: a. There was no documented evidence Staff 12 (MT), hired on 07/29/20, time period reviewed 07/29/23 through 07/29/24 and Staff 15 (CG), hired on 02/01/23, time period reviewed 02/01/24 through 02/01/25, completed the required 12 hours of annual training including six hours of topics related to provision of care for persons in a community-based setting and six hours of dementia care. b. There was no documented evidence Staff 10 (MT), hired on 11/12/22, time period reviewed 11/12/23 through 11/12/24, Staff 12, Staff 15 (CG), Staff 17 (Plant Operations Assistant), hired on 12/29/21, time period reviewed 12/29/23 through 12/29/24 and Staff 25 (Cook), hired on 09/17/21, time period reviewed 09/17/23 through 09/17/24, completed the required annual training in Home and Community Based Services. The need to ensure all long-term direct care staff completed a minimum of 12 hours of in-service training annually including six hours on topics related to the provision of care for persons in a community-based setting and six hours of dementia care training, and all long-term care staff completed annual training on the Home and Community-Based Services regulations was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:30 am. They acknowledged the findings.

C374 - Annual and Biennial Inservice for All Staff 1. A complete audit was done of all annual and biennial training records. Staff who were missing components of training were removed from the floor until their training was completed. 2. To prevent recurrence, training grid will be utilized to ensure that all staff have required annual/biennial trainings completed. Staff will not be allowed to work on the floor unsupervised until all of their required trainings are completed. Monthly, as part of facility continuous quality improvement meetings, training grid will be reviewed to identify any staff members whose certifications/trainings are close to expiration and they will be scheduled to complete the required training. Incomplete trainings will be reviewed during standup meeting to identify missing training components and to review the status of new hires and where they are at with their trainings. 3. This system will be evaluated monthly as part of the facility continuous quality improvement process and will include a review of the training grid. 4. The Executive Director will be responsible for maintaining this system

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (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. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. 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 fire drills were conducted according to Oregon Fire Code. Findings include but are not limited to: Fire and life safety records, dated between 09/2024 and 02/2025, were reviewed and revealed the following: a. There was no documented evidence the facility conducted a fire drill every other month between 09/2024 and 02/2025. b. One fire drill, dated 02/26/25, had been conducted during the reviewed time period; however, residents were not evacuated or relocated. The fire drill records failed to include documentation of the following components: * Problems encountered, comments relating to residents who resisted or failed to participate in drills; and * Number of occupants evacuated. The need to ensure fire drills were conducted according to Oregon Fire Code was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 11:30 am. They acknowledged the findings.

C420 - Fire and Life Safety 1. Maintenance Director reeducated on the requirement to accurately document Fire Drills on alternating months to include relocation of residents. The community just had a recent fire drill in February and will conduct another in April. 2. Computer program used for scheduling maintenance tasks has been reviewed to ensure it is populating the drills on alternating months and to ensure staff have received Fire and Life Safety training and have signed training documentation. Staff inservice schedule will be followed to ensure fire and life safety training is provided on alternating shifts and a sign in sheet will be used to document attendance. 3. Fire drills and Inservice schedule will be reviewed monthly at CQI meetings to ensure schedule is being followed and all components are addressed. 4. Executive Director and Maintenance Director are responsible for maintaining this system.

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 270 and C 280.

Refer to C270 and C280

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include but are not limited to: Tour of the facility on 03/03/05 found the following in need of cleaning and repair: a. Interior: * Doors and doorframes in the Caregiver Office, Community bathroom, Craft Room, Room 119, 215, and 322 had smudges, splatters, scrapes, scuffs and/or dings; * Walls in the community bathroom on the first floor; near Rooms 111, 121, and 209; outside the kitchen, near the seating area, within the front foyer, in the resident laundry room, in the craft room, on baseboards in multiple areas and on columns had stains, black smudges, loose wallpaper, splatters, dings, small holes, chips, gouges, scrapes and/or scuffs; * Thresholds between the dining room and patio with debris build- up; * Carpets in Room 110 and 202 had multiple black stains; * Windows in Room 110 were smudged and smeared; and * Light fixture in stairwell with black debris build-up. b. Exterior: * Moss buildup on the roof; * Siding had black and brown smudges, scrapes, holes, gouges, flaking paint, rotting and missing pieces; * Doors and door frames with rotting wood, flaking paint, chipped, scraped, and/or dings; * Gouges to the wood in columns; * Window frames with rotting wood, smudges, rust stains and/or missing screens; * Benches had chipped paint, missing slats and gouges in wood; and * Stairway railings outside of the Bistro had moss and debris build-up. During facility tour on 03/04/25 at 10:35 am, the areas in need of cleaning and repair were discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

C613 - General Building 1. Doorframes in caregiver office, community bathroom, craft room, room 119, 215 and 322 scrapes, smudges, splatters, scuffs and dings were repaired and repainted. Walls in the community bathroom on the first floor, walls near 111, 121 and 209, outside of kitchen, near seating area, within the front foyer, in the resident laundry room, in craft room, on the baseboards, column stains in kitchen, loose wallpaper throughout hallway and splatters, dings, small holes, chips, gouges, scrapes and/or scuffs have been corrected. Thresholds between patio and dining/activity area have been cleaned. Carpets in 110 and 202 cleaned, windows in room 110 were smudged and smeared. Light fixture in stairwell had debris and was cleaned. Moss build-up on roof treated. Siding has been pressure washed and repaired and areas of rot have been repaired. Rust stained areas have been cleaned on exterior of building. Moss build up on starway railings outside of bistro were pressure washed. 2. Weekly Maintenance walkthrough to be completed to identify and address environmental concerns. Direct Care staff and housekeepers to input tasks as identified needing to be completed in the TELs (computer system) to notify maintenance. Maintenance to review TELs on a minimum of weekly basis to ensure all items are being addressed. 3. Maintenance will do a weekly walkthrough and minimum weekly TELs review of work orders. 4. Maintenance Director and Executive Director.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured between 03/03/25 and 03/05/25. The facility was built on a hill with the first floor elevated above ground level in areas. Resident unit windows and resident use common area windows on the elevated portion of the first floor, second, and third floor opened vertically, and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls. On 03/05/25 at 11:30 am, Staff 9 (Plant Operations Director) confirmed there was no system throughout facility for preventing accidental falls from windows above the first floor. The need to ensure a mechanism to prevent accidental falls from windows above the first floor was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/04/25 at 10:35 am. They acknowledged the findings.

C615 - Resident Units 1. Ordered and installed all window locks for all second floor and third floor apartments and for any apartments on the first floor that has a drop off outside the window. 2. Weekly community walk through to spot check resident apartments and semi-annual environmental evaluations completed to make sure locks are still in place. 3. Weekly and semi-annually 4. Maintenance and Executive Director.

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by:

OAR 411-054-0300 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. An ALF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) An ALF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (C) Each unit must have individual thermostatic heating controls. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Effective 01/15/2015 wall heaters are not acceptable in new construction or remodeling. (d) VENTILATION. Ventilation in each unit must occur via an open window to the outside, or with a mechanical venting system capable of providing two air changes per hour with one-fifth of the air supply taken from the outside. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when they were installed in locations that were subject to incidental contact by residents or with combustible material. Findings include, but are not limited to: During the survey between 03/03/25 and 03/05/25, wall-mounted heaters were noted in resident unit bedrooms and community areas where residents could come into incidental contact with the units. On 03/05/25 at 11:30 am, Staff 9 (Plant Operations Director) and this surveyor measured the metal surface of the grate in the first-floor Bistro, and it reached 197 degrees F. The need to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees F was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/06/25 at 9:40 am. They acknowledged the findings. In an interview on 03/06/25 at 11:42 am, with Staff 1, Staff 2, and Staff 9 reported 43 of 74 heaters had been disconnected and the rest would be disconnected by the end of the day.

C640 - Heating and Ventilation 1. All cadet wall heaters have been disabled. 2. To prevent recurrence all cadet heaters will remain disabled. Inservice provided to care staff on safety precautions related to the cadet heaters. 3. Monthly during environmental walk through to ensure all cadet heaters are still disabled. 4. Executive Director will be responsible for maintaining this system

OAR 411-054-0300 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. An ALF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) An ALF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (C) Each unit must have individual thermostatic heating controls. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Effective 01/15/2015 wall heaters are not acceptable in new construction or remodeling. (d) VENTILATION. Ventilation in each unit must occur via an open window to the outside, or with a mechanical venting system capable of providing two air changes per hour with one-fifth of the air supply taken from the outside. This Rule is not met as evidenced by:

OAR 411-054-0300 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction. (a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit. (b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules). (c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents’ units were maintained within the range of 110 to 120 degrees Fahrenheit. Findings include but are not limited to: From 03/03/25 through 03/05/25, the surveyor measured water temperatures in kitchens and bathrooms in three resident rooms, 201, 202, and 223. Water temperatures ranged between 100.3 and 109.4 degrees F, or below the required range of 110 to 120 degrees F. On 03/05/25 at 12:15 pm Staff 9 (Plant Operations Director) explained the low water temperatures on the second floor were due to a broken water heater, and during busy times the remaining two water heaters could not provide enough hot water for the entire building. The need to ensure water temperatures were maintained within the range of 110 to120 degrees F was discussed with Staff 1 (ED), Staff (2) (Regional Director of Operations), Staff 3 (Regional RN) and Staff 4 (Vice President of Clinical Services) on 03/04/25 at 10:35 am. They acknowledged the findings.

C645 - Plumbing Systems 1. One water heater required replacement. Water heater has been replaced. 2. Weekly water temperatures will be taken to identify water temperatures are within regulatory compliance. If water temps do not meet regulation, Maintenance will notify Executive Director and will take necessary steps to correct promptly. 3. Weekly water temps taken 4. Maintenance Director and Executive Director responsible

OAR 411-054-0300 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction. (a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit. (b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules). (c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. 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 9 of 11 sampled staff (#s 10, 12, 15, 17, 20, 21, 24, 25, and 27) completed the department approved LGBTQIA2S+ training prior to 12/31/24. Findings include, but are not limited to: Refer to C 370.

L370 - PreService Training LGBTQIA2S+ Refer to C370

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: