Print Inspection: RL004126

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 04/29/25 through 05/02/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity of the citations. 1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area: C0372: OAR 411-054-0070 (5 & 9-10) Training within 30 days: Direct Care Staff. The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. 2. Refer to deficiencies in the report.

C-150 1) The facility implemented an immediate plan of correction for C-372 Training within 30-Days and is collaborating with a consultant to conduct a root cause analysis associated with this violation to evaluate overall system failures. 2) Implementation of an immediate plan of correction with process improvement adjustments as indicated, along with subsequent consultant recommendations. Review progress in daily clinical meetings and monthly Quality Improvement (QAPI) meetings 3) Key quality indicators and operational standards will be evaluated monthly. 4) Executive Director, Milestone Regional Clinical and Operations Specialists

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) received services in a manner that promoted respect and dignity in a homelike environment. Findings include, but are not limited to: Resident 1 moved into the assisted living community in 10/2024 with diagnoses including Type 2 diabetes. During an interview with the resident on 04/30/25 at 1:40 pm, it was reported “[Staff 1 (ED)], the Director yelled at me, well we yelled at each other, twice and he threatened to kick me out. I don’t know why he yells at me in front of other people and doesn’t take me in his office like he does other people. I think he knows it upsets me when he raises his voice at me, like he is trying to talk over me...I told my case worker [caseworker name] and she called him, but then he did it again after that.” A review of a progress note dated 04/10/25 read “Resident has expressed concerns and fears. [S/he] fears [s/he] is going to be kicked out and not have a home to go to...” The need to ensure residents were treated with dignity and respect in a homelike environment was discussed with Staff 1, Staff 2 (Health and Wellness Director/LPN), and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings.

C-200 1) Staff acknowlege the discussions, but not the accuracy of Resident #1's statements. The ED and all staff will follow resident #1’s individualized service plan of, for example, validating feelings even when they are being aggressive or confrontational, acting to keep other residents safe and free from harm, redirection when appropriate, reassure resident that they are not being kicked out, use a calm and reassuring voice. 2) R1 opted to move to a lower level apartment to minimize conflict with a second-story neighbor. The ED has secured transit passes for R1 through his/her Casewoker. ED has secured a behavioral health evaluation for R1 through his/her Caseworker for the purpose of developing a behavior plan to assist R1 with a successful placement. Under the direction of the ED and DHW, staff will develop techniques and strategies to respond to R1s challenging comments and behaviors. The facility will continuously explore new interventions to help reassure and improve R1’s chances of having a successful placement at the facility through quarterly evaluation and service plan updates. 3) This will be evaluated during regularly scheduled facility daily stand up meetings, quarterly, and with a change of condition as indicated. 4) Executive Director, Director of Health and Wellness, Milestone Regional Clinical and Operations Specialists.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report physical injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse, and failed to notify the local SPD office immediately of any incident of suspected abuse, for 3 of 3 sampled residents (#s 1, 3, and 4) with injuries of unknown cause and suspected abuse. Findings include, but are not limited to: 1. Resident 4 moved to the assisted living community in 04/2024 with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, and congestive heart failure. A review of the resident's clinical record between 01/29/25 and 04/29/25 and resident interview identified the following: * A progress note dated 02/03/25 stated: “ALERT for increased pain with bruising to Right arm.”; * A progress note dated 02/10/25 stated: “ Assited [sic] with shower on 2/2/25 and bruise observed on resident’s arm…. Resident did not recall how they got their arm bruise.”; and * A progress note dated 02/13/25 stated “…observed several small cuts on bil [bilateral] feet, legs.” These incidents on 02/02/25 and 02/13/25 represented injuries of unknown cause. There was no documented evidence the facility immediately investigated the injuries to rule out abuse, nor reported them to the local SPD office as suspected abuse. During an interview on 04/30/25, Resident 4 was unable to provide information about the incidents on 02/02/25 and 02/13/25. In an interview on 05/02/25, Staff 2 (Health and Wellness Director/LPN) acknowledged the incidents of injuries of unknown cause were not reported immediately to the local SPD office. On 05/02/25 at 12:32 pm and 12:41 pm, Staff 2 provided documentation the incidents had been self-reported to the local SPD office. The need to ensure injuries of unknown cause were immediately investigated by the facility to reasonably conclude and document the physical injury was not the result of abuse, and reported to the local SPD office as needed was discussed with Staff 1 (ED) and Staff 2 on 05/02/25 at 12:21 pm. They acknowledged the findings. 2. Resident 1 moved into the assisted living community in 10/2024 with diagnoses including Type 2 diabetes. Progress notes and resident incident reports (the document used by the facility to investigate injuries) dated 01/29/25 through 04/29/25 were reviewed during the survey. The following injury of unknown cause was identified: * 01/31/25 - Abrasion 4 x 2.5 cm on the right shin. The resident was unable to remember what caused the injury. This constituted an injury of unknown cause and required reporting unless a prompt investigation ruled out abuse. The following resident-to-resident altercations were identified: * 02/23/25; * 03/18/25; and * 04/08/25. There was no documented evidence the facility reported these altercations to the local SPD office as required. Survey requested the facility report the altercations and the injury of unknown cause. Verification was received on 05/02/25 at 12:54 pm. The need to ensure resident injuries of unknown cause were immediately investigated by the facility to reasonably conclude and document that the physical injury was not the result of abuse, and reported all resident-to-resident altercations to the local SPD office was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings. 3. Resident 3 moved into the assisted living community in 05/2019 with diagnoses including stroke with right-sided paralysis. A review of the resident's clinical record, including progress notes, incident reports, and service plans all dated between 01/29/25 to 04/29/25, and staff interviews identified the following: * 03/26/25 – Unwitnessed fall with right humerus fracture. There was no documented evidence the unwitnessed fall with injury had been investigated promptly to rule out abuse, nor evidence the local SPD was immediately notified of the incident. During an interview on 04/30/25 at 1:28 pm, Resident 3 was unable to recall the fall or the reason why s/he was wearing a sling on his/her right arm. Survey requested the facility report the unwitnessed fall with injury to the SPD office. Confirmation of the reporting was received on 04/30/25 at 2:16 pm. The need to immediately investigate unwitnessed falls with injury to rule out abuse or suspected abuse and to notify the local SPD if abuse could not be ruled out was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:07 pm. They acknowledged the findings.

C-231 1) Each unreported incident that was noted for residents #1, 3, and 4 was reported to Adult Protective Services during survey. The facility began reviewing all new incidents in daily clinical meeting immediately to evaluate the potential need for APS notification. ED and DHW are now ensuring that reportable events are being transmitted to APS. 2) Med Techs will receive training for thoroughly completing incident reports in the community’s new electonic system. The ED and DHW will receive training for completing incident investigations and making timely self-reports to Adult Protective Services. Training to include use of the "Abuse Reporting and Investigation Guide for Providers", from the ODHS, which will be used as a guidance for future reporting. Future investigations will each contain documentation of the incident’s root cause, interventions implemented, investigation of potential abuse, investigation of potential neglect, and the administrator’s review. The Community to develop a system for self-reporting on weekends and holidays to ensure timely response. All APS reports will be reviewed and kept on file by the ED. 3) Incident reports for the previous 24-72 hours will be reviewed during daily clinical meetings. Potentially reportable incidents will be reviewed at that time to ensure APS was notified, or will be by the end of business day. The ED and DHW will ensure weekends and holidays are covered to make timely APS notifications of reportable events. 4) Executive Director, Director of Health and Wellness, Resident Care Directors, Milestone Regional Clinical and Operations Specialists.

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

OAR 411-054-0034 (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 observation, interview and record review, it was determined the facility failed to ensure evaluations accurately described the resident’s health status and environmental factors that helped the individual function at their optimal level and were reviewed with updates documented each time a resident had a significant change of condition for 1 of 1 sampled resident (#3) whose evaluation was reviewed. Findings include, but are not limited to: Resident 3 moved into the assisted living community in 05/2019 with diagnoses including stroke with right-sided paralysis and abnormal weight loss. The quarterly evaluation, dated 02/18/25, was reviewed, observations of the resident were made, and interviews with the staff and resident were conducted during the survey. a. The resident was observed to have a bed cane with a protective net cover on the left side of his/her bed throughout the survey. Interviews with the resident and the staff indicated the bed rail was used to increase the resident’s independence with bed mobility. The quarterly evaluation failed to accurately describe the resident’s status and condition in the following areas: * Transferring enabling devices and methods, including presence of the bed cane and how it was being used; and * History of unexplained weight loss. b. On 03/26/25, the resident experienced a significant change of condition related to a humerus fracture. There was no documented evidence the evaluation was reviewed with updates documented. The need to ensure evaluations accurately described the resident's health status, including environmental factors that helped the individual function at their optimal level and were reviewed with updates documented whenever a resident experienced a significant change of condition was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:07 pm. They acknowledged the findings.

C-252 1) Resident 3 has been re-evaluated and their service plan updated using a checklist of Oregon required elements provided by a consultant and a supplemental assistive device evaluation. 2) Content of evaluation and service plans will now be compared to the Oregon required elements checklist prior to finalization. The facility’s Director of Health and Wellness (DHW) is enrolled in the June 3-5, 2025, session of, "Nursing Practice in Community-Based Care: A Training for Nurses in ALF's, RCF's, Memory Care (CBC)". The ED, DHW and RCCs are now reading resident 24-72 hour progress notes each day during clinical meeting. The Chief of Clinical Operations for Milestone will be solicited for input when necessary. Clinical reviews and QAPI audits will ensure that all evaluations are completed and accurate. 3) Evaluations and service plans will be created prior to admission and reviewed quarterly and with a change in condition. Monthly QAPI audits will monitor compliance with timeliness and content. 4) Executive Director, Director of Health and Wellnes, Milestone Regional Clinical and Operations Specialists.

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 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who was familiar with, or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 3, and 4). Findings include, but are not limited to: Resident 1, 3 and 4's records were reviewed and their most recent service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:21 pm. They acknowledged the findings.

C-262 1) Service plan team meetings, also know as care conferences, have been implemented to occur in conjunction with each evaluation and service plan update. The Resident Directors and the Director of Health and Wellness, solicit resident and family input during the development of each service plan prior to the meeting and document evidence of their involvement, along with the involvement of the facility administrator or a designee and at least one other staff who is familiar with or who is going to provide services to the resident. Involved family members and case managers are now notified and invited in advance of service plan meetings. 2) Care conferences will be scheduled in sync with resident admission, quarterly, or change of condition evaluation and service plan updates. The electronic medical record dashboard will alert the ED and clinical staff to approaching due dates for 90--day reviews and meeting notifications to pertinent individuals will be made. Service plans will be finalized during the meeting and the signature page completed to indicate each individual’s attendance and participation. If attendance is done remotely, this will be documented on the SP signature page. Following the SP Team meeting, a progress note will be made indicating who was in attendance, what was discussed and any follow-up required after the meeting. 3) A monthly QAPi audit will confirm service plan team meetings are occurring in conjunction with evaluation and service plan updates by reviewing signatures on updated service plans and corresponding progress notes. 4) Executive Director, Director of Health and Wellness, Resident Care Directors.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. 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 interview and record review, it was determined the facility failed to monitor each resident consistent with his or her evaluated needs and service plan, determine what actions or interventions were needed for changes of condition, communicate these instructions to staff on each shift, and document on the progress of the conditions at least weekly until resolved, for 3 of 3 sampled residents (#s 1, 3 and 4) whose records were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living community in 10/2024 with diagnoses including type 2 diabetes. a. Resident 1 was evaluated and service planned with behavioral conditions and symptoms that required monitoring. The following resident-to-resident altercations lacked communication to staff regarding the altercations and any actions or interventions needed, monitoring through resolution and a review of the service-planned interventions for effectiveness: * 02/23/25; * 03/18/25; and * 04/08/25. b. The following changes of condition lacked determined actions or interventions needed, the action or intervention communicated to staff on each shift and/or weekly progress documented in the residents’ record until the condition resolved: * 01/31/25 - Abrasion on the right shin; * 02/16/25 - “vomiting most of the night”; and * 03/17/25 - Candidal lesions (a type of yeast infection). The need to ensure the facility monitored each resident consistent with his or her evaluated needs and service plan; determined what actions or interventions were needed for changes of condition, communicated these instructions to staff on each shift, and documented on the progress of the conditions at least weekly until resolved was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings. 2. Resident 4 moved to the assisted living community in 04/2024 with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, and congestive heart failure. Resident 4's progress notes, dated 01/29/25 through 04/29/25, service plan, dated 02/26/25, and post discharge hospital orders were reviewed. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: * 02/03/25 - “increased pain with bruising to Right arm”; * 02/03/25 - “LLE [lower left extremity] red, hot, infection ongoing”; * 02/13/25 - “ …a visual skin inspection was observed several small cuts on bil [bilateral] feet, legs. Bil [bilateral] rash on the groin…”; * 02/20/25 - new order for triamcinolone 0.1% topical cream, “Resident has an allergy to prednisone. Triamcinolone is also a steroid like prednisone and can cause similar reaction”; * 02/25/25 - “on 2/12 and 2/13 in the am given an EXTRA dose of torsemide 50mg”; * 03/02/25 - “ Resident stated to staff that s/he didn’t know where s/he was. Staff attempted or [sic] orient resident but [resident] still stated that s/he did not recognize the building.”; * 04/15/25 - return to the facility after hospitalization and admission to skilled nursing facility related to urinary tract infection from 03/12/25 through 04/15/25; * 04/24/25 - unwitnessed fall; * 04/25/25 - “Resident had concerns regarding his abnormal breathing s/he was experiencing this morning.”; and * 04/26/25 - “Resident had complaints of pain through out the day.” The need to ensure the facility had a system in place 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, and document weekly progress until the condition resolved was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 5/02/25 at 12:21 pm. They acknowledged the findings. 3. Resident 3 moved into the assisted living community in 05/2019 with diagnoses including stroke with right-sided paralysis, dysphagia (difficulty swallowing), and abnormal weight loss. Resident 3's progress notes, dated 01/29/25 through 04/29/25, and service plan, dated 02/18/25, were reviewed and interviews were completed with staff throughout the survey. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communication of the determined action or intervention to staff on each shift, and/or weekly progress noted until the condition resolved: * 01/29/25 – Chest pain; * 01/29/25 – Return from the hospital; * 02/03/25 – Dog bite (from his/her own dog); * 02/04/25 – Dog bite (from his/her own dog); * 02/28/25 – Choking episode; * 03/10/25 – Dog bite (from his/her own dog); * 03/10/25 – Increased confusion; * 03/13/25 – Missed dose of cyclobenzaprine (for muscle spasms); * 03/14/25 – Diarrhea; * 03/26/25 – Fall; * 03/30/25 – Red, swollen legs; * 04/03/25 – Increased confusion; and * 04/17/25 – Dog bite (from another resident’s dog). The need to ensure the facility determined what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicated the determined action or intervention to staff on each shift, and documented weekly progress until the condition resolved was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:07 pm. They acknowledged the findings, and no additional documentation was provided.

C 270 Change of Condition 1) Residents 1, 3, and 4 have all been reassessed with alert monitoring and temporary service plans containing specific care instructions initiated as applicable. 2) The Director of Health and Wellness and RCDs will conduct a daily clinical meeting to review potential resident changes in condition and ensure that ,when a resident does experience a change of condition, alert monitoring and a temporary service plan are initiated. For a significant change of condition, an RN will initiate an assessment within 48 hours. The Health and Wellness Director will attend, “Nursing Practice in Community Based Care: A Training for Nurses in ALFs, RCFs, Memory Care (CBC), in June, 2025. Med Techs will receive additional training on creating alert charting and temporary service plans. Caregivers will be trained regarding what constitues a change of condition and expectations for reporting to an RCC or nurse. 3) Monitoring will occcur during daily clinical meeting, where 24 to 72 hours of progress notes, caregiver communication notes, and daily alert charting will be reviewed and followed up on as needed. Weekly monitoring by Regional company support team. 4) Director of Health and Wellness, Resident Care Directors, Executive Director. Milestone Regional Clinical and Operations Specialists.

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 and included documented findings, resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#3) who experienced significant changes of condition. Findings include, but are not limited to: Resident 3 moved into the assisted living community in 05/2019 with diagnoses including stroke with right-sided paralysis, dysphagia (difficulty swallowing), and abnormal weight loss. a. Review of the clinical record and interviews with staff revealed Resident 3 had a humerus fracture following an unwitnessed fall on 03/26/25. The fracture constituted a significant change of condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. During an interview on 05/01/23 at 9:45 am, Staff 6 (RN) acknowledged an RN assessment had not been completed for the fracture. b. During the acuity interview on 04/29/25, Resident 3 was identified to have a recent history of weight loss. Resident 3's weight records were reviewed and revealed the following: * 11/01/24 – 116 pounds; * 12/01/24 – 110 pounds; * 01/01/25 – 104 pounds; * 02/01/25 – 101.5 pounds; and * 04/30/25 – 110 pounds (requested during survey). Throughout the survey, Resident 3 was observed drinking protein shakes with and between meals and was provided with protein enhanced soups to increase the caloric density of his/her pureed food items. From 11/01/24 to 02/01/25, Resident 3 had a weight loss of 14.5 pounds or 12.5% of his/her body weight in three months. This severe weight loss indicated a significant change of condition and required an RN assessment. During an interview on 05/01/23 at 9:45 am, Staff 6 (RN) acknowledged an RN assessment had not been completed for the severe weight loss. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:07 pm. They acknowledged the findings.

C-280 Resident Health Services 1) Resident #3 has been re-evaluated by an RN, their service plan updated, monitoring initiated and specific staff instructions provided. 2) The Director of Health and Wellness and RCD's will conduct a daily clinical meeting to review potential resident changes in condition and ensure that, when a resident experiences a significant change of condition, alert monitoring and a temporary service plan are initiated and the RN is notified. An RN will initiate an assessment within 48 hours. The Director of Health and Wellness will attend, “Nursing Practice in Community Based Care: A Training for Nurses in ALFs, RCFs, Memory Care (CBC), in June, 2025. The community RN(s) will complete NurseLearn training modules #1 Identifying and Assessing Changes of Condition and #2 Weight Changes, at a minimum. Med Techs will receive additional training on creating alert charting and temporary service plans. Caregivers will be trained regarding what constitues a change of condition and expectations for reporting to an RCD or nurse. 3) Monitoring will occcur during daily clinical meeting, where 24 to 72 hours of progress notes, caregiver communication notes, and daily alert charting will be reviewed and followed up on as needed. Weekly monitoring by Regional company support team. Director of Health and Wellness, Resident Care Directors, Executive Director. Milestone Regional Clinical and Operations Specialists.

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 411-054-0050(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 for 1 of 1 sampled resident (#3) whose ADL care was observed, and for multiple unsampled residents who received meal service. Findings include, but are not limited to: a. Resident 3 moved into the assisted living community in 05/2019 with diagnoses including stroke with right-sided paralysis. At 10:35 am on 05/01/25, Staff 14 (Care Partner) was observed providing ADL assistance for Resident 3. During the observation, Staff 14 provided perineal care for the resident while wearing disposable gloves. Without performing hand hygiene or changing gloves, Staff 14 proceeded to assist the resident in donning a new incontinence brief and pants. Staff 14 then discarded the soiled incontinence pad, touched a cabinet, obtained a clean blanket, and assisted the resident in a transfer from the toilet to his/her wheelchair. This surveyor requested Staff 14 perform hand hygiene prior to continuing with Resident 3’s ADL assistance. Staff 14 proceeded to doff the soiled gloves and to gather the resident’s glasses and additional adaptive equipment prior to performing hand hygiene. b. Observations of meal service were completed on 04/30/25 and revealed the following: * Servers were observed using bare hands to touch clean coffee mugs by the lip of the mug and unwrapped straws by the part placed in the resident’s mouth. The mugs and the straws were then provided to residents. * Multiple servers were observed serving meals and beverages, touching residents, leaning on walkers, leaning on furniture, touching their faces or clothing, clearing dirty dishes, or touching resident napkins without performing hand hygiene between dirty and clean tasks. The need to establish and maintain effective infection prevention and control protocols while performing ADL care and during meal service was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:07 pm. They acknowledged the findings.

C 295 Infection Prevention & Control 1) Staff #14 was re-trainied on proper hand hygiene on May 5th. 2) An inservice for direct care staff on proper hand hygeine and infection control & prevention will be conducted on June 3rd and 4th. An inservice for kitchen servicers was conducted on hand hygiene and infection control & prevention on May 12th and 13th. An infection prevention and control topic will be added to the agenda of each all-staff meeting going forward, the first being on June 10th. Faclility requires annual infection prevention training for all staff. 3) Department supervisors will monitor effectiveness of training through observantion and routine comptency verification. 4) ED, Department Managers and supervisors

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 written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible to administer for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 moved into the assisted living community in 10/2024 with diagnoses including Type 2 diabetes. The resident's 04/01/25 to 04/29/25 MAR and prescriber orders were reviewed. The following medications lacked written signed orders: * Lantus, give 30 units twice per day for diabetic management; * Cetirizine 10 mg tablet, give one tablet per day, as needed for allergies; and * Tylenol extra strength 500 mg as needed every four hours for pain. The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible to administer was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings.

C 303 Treatment Orders 1) Resident 1’s orders have been reviewed and signed by their primary care provider (PCP). 2) All orders will be audited to ensure all have been written and signed by a physician or other legally recognized practioner and documented in resident records for each medication that the facility is reponsible for administering. 3) The system will be evaluated through the facility’s triple-check system. First, upon receipt of a new order, a med tech will review for accuracy and signature then fax to the pharmacy. Second, when the medication is received from the pharmacy, another med tech will review and check for accuracy. Finally, the order will be reviewed by a licensed nurse. Physician orders will be sent to PCPs via email or fax every 90 days for review and signature, then filed in resident records upon return. 4) Med techs, Director of Health and Wellness, Resident Care Directors, RNs, and ED are responsible for ensuring corrections are completed and monitored.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for all medications ordered by a legally recognized prescriber and were administered by the facility for 3 of 3 sampled residents (#s 1, 3, and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living community in 04/2024 with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, and congestive heart failure. Resident 4's MAR from 04/01/25 through 04/29/25 and physician orders were reviewed and revealed the following: a. The following PRN medications lacked instructions for sequential order of use: * Acetaminophen 325mg (for pain); and * Oxycodone 5mg (for pain). b. The following PRN medications lacked resident specific parameters for use: * Naloxone 4mg/0.1ml (for drug overdose); and * Triamcinolone 0.1% cream (for skin conditions). c. The following PRN medications were not recorded in the MAR; however, they were recorded as being administered in the narcotic log book: * Oxycodone 5mg on 04/16/25 at 08:42 am and 08:05 pm; * Oxycodone 5mg on 04/18/25 at 11:16 am; * Oxycodone 5mg on 04/21/25 at 07:01 pm; * Oxycodone 5mg on 04/22/25 at 01:17 am; and * Oxycodone 5mg on 04/27/25 at 06:10 am. The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:21 pm. They acknowledged the findings. 2. Resident 3 moved into the assisted living community in 05/2019 with diagnoses including stroke with right-sided paralysis. Resident 3's MAR, dated 04/01/25 through 04/28/25, and physician orders were reviewed during survey. The following PRN medications and treatments lacked resident-specific parameters or instructions to staff: * Acetaminophen 325 mg (for pain); * Albuterol (for wheezing or shortness of breath); * Aquaphor Healing Ointment (for skin care); * Cyclobenzaprine 5 mg (for muscle spasms); * Diclofenac Sodium 1% gel (for pain); * Guaifenesin (for cough); * Mucinex (for cough); * Preparation H Ointment (for pain); * Senna (for constipation); and * Tramadol 50 mg (for pain). During an interview on 04/30/25 at 9:05 am, Staff 13 (MA) confirmed the PRN medications lacked resident-specific parameters or instructions for unlicensed staff. The need to ensure PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:07 pm. They acknowledged the findings. 3. Resident 1 moved into the assisted living community in 10/2024 with diagnoses including type 2 diabetes. a. Resident 1's 04/01/25 through 04/29/25 MAR was reviewed. The following PRN bowel medications lacked resident-specific parameters and clear instructions for unlicensed staff: * Metamucil powder; * Milk of magnesia; * Polyethylene glycol; and * Senna tablets. b. The MAR lacked initials of the person administering medications on the following dates: * Carvedilol 6.25 mg (for hypertension) on 04/07/25 and 04/08/25; * Lantus 30 units subcutaneous injection (for diabetic management) on 04/11/25, 04/18/25, and 04/22/25; * Metformin ER 500 mg tablet (for diabetic management) on 04/08/25; * Trulicity injection 4.5 mg weekly (for diabetic management) on 04/04/25; * Compression stockings (for edema) on 04/10/25, 04/18/25, 04/19/25, and 04/20/25; and * Wound care on 04/10/25, 04/23/25, 04/24/25, and 04/25/25. During an interview on 04/30/25 at 1:40 pm, Resident 1 reported s/he had no concerns with receiving medications from MA’s. During an interview on 04/30/25 at 3:38 pm, Staff 2 (Health and Wellness Director/LPN) reported the facility was having issues with the electronic health system (Yardi) not saving information MAs entered after they administered medications. c. The resident was prescribed a Dexcom (continuous blood glucose monitoring device). The device had a sensor and transmitter that was changed and re-inserted into the resident's upper arm every 10 days. The Dexcom was not transcribed onto the MAR; therefore, staff were not initialing the MAR every 10 days when the sensor and transmitter was replaced. The need to ensure medications had resident-specific parameters for PRN medications and clear instructions to staff, the MAR included initials for all medications and treatments being administered by the facility and all treatments administered by the facility were transcribed onto the MAR was reviewed with Staff 1 (ED), Staff 2 and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings.

C 310 Medication Administration 1) Resident #1, 3, and 4’s PRN medications have been reviewed by a licensed nurse to ensure resident-specific parameters, with clear instructions for staff regarding their use, are readily available. 2) All Medication Administration Records will be audited and reviewed for resident-specific parameters associated with PRN medications. Med techs will receive training for requesting order clarifications if needed, from the MD or RN overseeing the resident’s care. 3) Monitoring will be conducted during daily clinical meeting when new medication orders are reviewed. Any new or changed PRN order will be reviewed for resident-specific parameters and clear staff instructions. The Director of Health and Wellness will follow up as needed. 4) Director of Health and Wellnes, Resident Care Directors, Med Techs, and ED are responsible for ensuring corrections are completed and monitored.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements staff were providing to each resident as outlined in each individual service plan for 2 of 3 sampled residents (#s 1 and 3) whose ABST and service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living community in 10/2024 with diagnoses including type 2 diabetes and heart failure. Resident 1’s quarterly ABST, updated on 03/17/24, inaccurately captured care time and care elements in the following areas: * Assisting with communication; * Monitoring behavioral conditions or symptoms; * Monitoring physical conditions or symptoms; and * Non-drug interventions for behaviors. The need to ensure the facility's ABST accurately captured care time and care elements staff were providing to each resident was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings. 2. Resident 3 moved into the assisted living community in 05/2019 with diagnoses including stroke with right-sided paralysis and dysphagia (swallowing disorder). Resident 3’s quarterly ABST, updated on 03/28/25, and service plan, dated 02/26/25, were reviewed. The ABST inaccurately captured care time in the following areas: * Personal hygiene; * Call lights; * Communication; * Assistance with leisure activities; * Medication administration; and * Pet care. The need to ensure the facility's ABST accurately captured care time staff were providing to each resident was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/02/25 at 12:07 pm. They acknowledged the findings.

C-362 ABST Time 1) Care information for residents 1 and 3 was updated in the ABST on 5/22/2025. 2) Resident ABST data will be entered prior to admission and with each quarterly or change of condition evaluation. Resident care coordinators will communicate care changes to the ED who will update the ABST data to correspond with each review and update. 3) ABST updates will be monitored for alignment with resident admission and service plan update dates by the monthly QAPI meeting. 4) Executive Director, Director o Health and Wellness, Resident Care Directors

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete or update and review the acuity-based staffing tool (ABST) evaluation for each resident before a resident moved in and no less than quarterly at the same time the resident's service plan was updated for 2 of 4 sampled residents (#s 1 and 2) whose ABST records were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living community in 10/2024 with diagnoses including type 2 diabetes and heart failure. Resident 1’s ABST, updated on 03/17/25, and service plan, updated on 04/24/25, were reviewed during the survey and identified the facility failed to update and review the ABST no less than quarterly at the same time the resident’s service plan was updated. The above findings were discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings. 2. Resident 2 moved into the assisted living community on 01/23/25 with diagnoses including diabetes. The facility’s ABST data was retrieved on 04/30/25 at 8:37 am and reviewed during the survey from 04/29/25 through 05/02/25. Resident 2’s ABST evaluation was completed on 02/07/25, indicating an ABST evaluation was not completed prior to moving in, as required. The need to ensure residents’ ABST evaluations were completed prior to move-in was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings.

C 363 ABST Updates, Staffing Plan 1) The ABST for each resident in the survey sample was reviewed and updated to ensure accuracy. 2) The facility will follow its policy to enter resident data into the ABST tool prior to admission and with each quarterly or change of condition evaluation thereafter. Resident care coordinators will communicate care changes to the ED who will update the ABST data to correspond with each review and update. The ED will conduct an ABST analysis to ensure that scheduled/planned staffing exceeds the ABST recommendation to account for the unplanned needs of residents. 3) ABST updates will be monitored for alignment with resident admission and service plan update dates by the monthly QAPI meeting. ABST analysis will occur at least weekly, more frequently as admissions and discharges occur and impact potential staffing needs. 4) Executive Director, Director of Health and Wellness, Resident Care Directors

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia care training had been completed prior to staff performing any job duties and before providing direct care to residents, for 8 of 8 newly hired direct care staff (#s 7, 8, 9, 10, 11, 12, 14, and 23). Findings include, but are not limited to: Review of the facility's training records on 04/30/25 at 8:20 am and 05/01/25 at 11:17 am identified the following: Staff 7 (MA) hired 09/27/24; Staff 8 (MA) hired 02/15/24; Staff 9 (MA) hired 02/08/25; Staff 10 (Care Partner) hired 03/10/25; Staff 11 (Care Partner) hired 03/14/25; Staff 12 (MA) hired 07/05/24; Staff 14 (Care Partner) hired 08/03/23; and Staff 23 (MA) hired 04/26/24; lacked documented evidence they had completed all or some of the following training requirements: * Pre-service orientation; * Pre-service dementia training; * Infectious disease prevention; * Home and Community Based Care (HCBS); and * Department-approved LGBTQIA2S+ trainings. The training program and requirements were discussed with Staff 1 (ED) on 05/01/25 at 8:07 am, Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings.

C-370 Staffing Requirements & Training: CG Requirements 1) Staff 7, 8, 9, 10, 11, 12, 14, and 23 have been assigned missing pre-service training requirements, due immediately. 2) The community's pre-service training plan will be revised to include all required topics. A pre-service training audit for every employee will be conducted and assignments for any missing training courses will be made and monitored through completion. New employees are now required to complete pre-service training assignments prior to performing any job duties or providing direct care to residents. 3) Supervisors will monitor their staff completion rates weekly through completion and may not schedule new staff for job duties or resident care until completion. Daily leadership team stand-up meetings will discuss completion rates and need for follow-up. Training completion compliance rates will be monitored via monthly QAPI meeting ongoing. 4) Executive Director, Department Directors, Supervisors and Business Office Manager

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 8 of 8 sampled direct care staff (#s 7, 8, 9, 10, 11, 12, 14, and 23) had demonstrated knowledge and performance in any duty they were assigned within 30 days of hire. Five of the eight care staff were identified as MAs who were working independently passing medications and treatments. The MAs lacked documentation of competency in medication and treatment administration which put residents at risk for serious harm. Findings include, but are not limited to: Employee training records were reviewed on 04/30/25 at 8:20 am and on 05/01/25 at 11:17 am. a. The following MAs’ training records were reviewed and identified the following: * Staff 7 (MA) was hired 09/27/24; Staff 8 (MA) was hired 02/15/24; Staff 9 (MA) was hired 02/08/25; Staff 12 (MA) was hired 07/05/24; and Staff 23 (MA) was hired 04/26/24. Each of these staff had been working in the facility independently as MAs which included administering medications and treatments to residents. The facility was unable to provide documentation that their knowledge and performance in administering medications and treatments had been reviewed and each had been determined competent to administer medications and treatments unsupervised. On 05/01/25 at 2:17 pm, the survey team requested an immediate plan of correction (POC) to ensure MAs, whose job it was to administer medications to residents, were trained by appropriate facility staff and there was documentation to show they had observed and evaluated the MAs’ ability to perform safe medication administration unsupervised. On 05/01/25 at approximately 5:17 pm, the facility submitted a POC that was accepted by the survey team. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. b. Staff 7, 8, 9, Staff 10 (Care Partner) hired 03/10/25; Staff 11 (Care Partner) hired 03/14/25; Staff 12, Staff 14 (Care Partner) hired 08/03/23 and Staff 23 lacked one or more of the following competency training requirements within 30 days of hire: * Role of the service plan in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First aid and abdominal thrust. The need to ensure the facility had a process to ensure all direct care staff had documentation of demonstrated competency in any duty they were assigned, including additional medication training for MAs was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/01/25 at 2:17 pm and on 05/02/25 at 9:10 am. They acknowledged the findings.

C-372 Training within 30-days 1) During the survey, Flagstone nurses immediately began retraining all Med Techs and verifying competency using a newly created checklist approved by surveyors. The Executive Director (ED) confirmed that training and competency check offs were being completed, but not properly documented or filed. 2) No Med Tech will work on the med cart until the competency check-off is complete with a nurse. A new Business Office Manager (BOM) is to being recruited and will be trained in how to properly maintain employee files. They will work collaboratively with the Director of Health and Wellness (DHW) to ensure proper Med Tech training is being completed, documented, and filed within 30 days of hire. An additional copy will be maintained by DHW. 3) Proper Med Tech training will be monitored throughout the onboarding process. New hires will receive the required pre-service training and 30-day competency training prior to working independently on the floor. Current staff will be supervised daily and receive additional training as needed. Continued training for all staff will occur in weekly Med Tech meetings and through monthly Relias courses which will include OAR required dementia training and other applicable courses which will be assigned by Corporate Leadership. A monthly QAPI audit will ensure all staff are up to date with competency and training. 4) Executive Director, Director of Health and Wellness, Regional Director of Operations, Chief Clinical Officer.

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 1 of 3 long-term direct care staff (#24) completed 12 hours of annual in-service training, including at least six hours of dementia care topics, annual infectious disease training based on their anniversary date of hire, and HCBS training by 04/01/24, as required. Findings include, but are not limited to: Staff training records were reviewed on 04/29/25 at 8:20 am and 05/01/25 at 11:17 am and the following was identified: There was no documented evidence Staff 24 (Care Partner), hired 04/01/15, completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including 6 hours of dementia care topics, annual infectious disease prevention training and HCBS training by 04/01/24, as required. The need to ensure long-term direct care staff completed and documented the required number of hours of annual in-service training which included a minimum of six hours in dementia care topics, annual infectious disease training and HCBS training was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN), and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings.

C-374 Annual and Bienial Training 1) Staff #24 was assigned annual trainings to meet the minimum requirement of at least 12 hours related to the provision of care including infectious disease prevention and HCBS training. Staff #2 was assigned annual trainings to meet minimum requirement of at least 6 hours in dementia care topics, annual infectious disease prevention and HCBS. 2) The faclity’s annual training plan was audited by the consultant and recommended revisions will be made to include missing required topics. A training tracker spreadsheet will be developed to monitor required training completions. Direct care staff will have provision of care and dementia care topics assigned monthly via online training programs. Supervisors will schedule training shifts for their staff who are not compliant with their training requirements. The Business Office Manager will monitor and report compliance to supervisors. 3) Annual training monitoring will begin at each employee’s first work anniversary. The BOM will update the training tracker each time an employee provides evidence of course completion. The BOM will provide completion data to department managers and supervisors during daily stand-up meetings. A monthly QAPI audit will ensure all staff are up to date with annual training. 4) 4) Executive Director, Department Managers, Supervisors. Milestone Regional Clinical and Operations Specialists.

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 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety procedures at least annually, with a written record of the content of the training sessions and the residents attending per the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drill and fire and life safety records from 11/2024 to 04/2025 were requested and reviewed with Staff 3 (Maintenance Director) on 04/30/25 at 10:48 am. During the review of the fire drill records, Staff 3 reported the facility did not have documentation residents were instructed on general fire safety procedures within 24 hours of admission and annual re-instruction. The need to instruct residents of general fire safety procedures within 24 hours of admission and re-instruct residents at least annually per the OFC requirements was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 6 (RN) on 05/02/25 at 9:10 am. They acknowledged the findings.

C-422 Admission and annual resident training 1) A document has been made that will be a part of every new residents 'move in packet'. The document will instruct the new resident on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places, and a signed acknowledgement will be placed in the resident’s file. 2) Residents will sign this acknowledgement when they have been oriented to their apartment upon move in, and annually thereafter. There will be a update reminder placed in the electronic system to trigger an annnual review. 3) Training will be completed and documented within 24 hours of move in and yearly thereafter. 4) The document will be introduced to the resident by the Transition Specialist TS, with Maintenance Director (MD) responsible for the orientation and yearly documentation. RCDs, DHW and ED will ensure that this is completed.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: