Print Inspection: RL005015

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, and proper food handling procedures were followed in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 06/16/25 at 11:00 am the main kitchen and walk-in refrigerator and freezer were observed to need cleaning and repair in the following areas: a. Kitchen area: * Pipes and the floor behind multiple appliances had grease, dirt, and debris on them; * The air filters on the window air conditioning units were covered with dust; * Multiple ceiling light fixtures contained dead insects or were missing covers; * The electric fan on the floor next to the serving and plating line was covered with dust; and * Wall under the sink adjacent to the plating area had a large gap around the sink drain pipe. b. Walk-in refrigerator and freezer: * Floor of the walk-in freezer contained debris and dirt; * The rubber seal on the door of the walk-in freezer was worn and not air-tight, allowing airflow into the freezer and build up of frost on the internal freezer door; and * Frost was accumulated on the ceiling and the three fans inside the walk-in freezer. On 06/16/25 at 11:00 am, the following improper food handling practices were noted: * Individual portions of food were plated on trays in the walk-in refrigerator and left uncovered. The findings were discussed with Staff 2 (ED) and Staff 6 (Executive Chef) on 06/17/25 at 9:43 am. Both staff acknowledged the findings.

1. The maintenance department will patch wall around sink drain pipe, replace air conditioning filter & clean any remaining dust, clean light fixtures of any dead bugs/ debris, install light covers or bulb covers for any light fixures with exposed bulbs, and replace the rubber seal to the walk in freezer. 2. The kitchen staff will clean areas behind appliances, clean debris from freezer floor, remove and discontinue use of box fans, and cover food in the walk in. 3. The Executive Chef, Timothy Windslow, and Executive Director, Lydia McIntyre, will be responsible for ensuring the corrections are completed and continue to monitor. 4. The Executive Chef, Timothy Windslow, will monitor the kitchen on a weekly basis. 5. The Maintenance Director, Joshua Farrer, will monitor the kitchen on a monthly basis.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to 1. Resident 4 was admitted to the facility in 05/2023 with diagnoses including insulin-dependent diabetes mellitus type 2, systolic (congestive) heart failure, and chronic obstructive pulmonary disease (COPD). Observations were made of the resident's care on 06/17/25 and 06/18/25, interviews with the resident and facility staff were conducted, and the service plan, dated 06/06/25, was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Instructions for proper maintenance of blood sugar monitor on right upper extremity and how to monitor for malfunctions; * Instructions to staff on blood glucose monitoring protocol when resident skipped meals; * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; * Instructions for aspiration precautions and interventions while choking; * Physician Orders for Life Sustaining Treatment status; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions on to whom to report weight gain or loss, and changes in appetite; * Instructions on edema management; * Instructions on fall prevention; * How nebulizer device was to be used and monitored for safety. * History of dehydration; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * How a person expressed memory loss; * Instructions on to whom to report skin impairments; * Personality, including how the person coped with change or challenging situations; * Instructions on peri and skin care; * Skin monitoring; and * Electric wheelchair equipment precautions and instructions for proper maintenance. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Administrator) and Staff 5 (RCC) on 06/18/25 at 12:43 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2022 with diagnosis including osteoarthritis and hypertension. Review of the resident’s progress notes and service plan, dated 05/03/25, and interviews with staff and resident revealed the service plan was not reflective or did not provide clear instructions to staff in the following areas: *Activities; and * Catheter care. The need to ensure service plans reflected resident’s current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator) on 06/18/25 at 2:15 pm. She acknowledged the findings. 3. Resident 2 was admitted to the facility in 10/2018 with diagnoses of hypertension, cardiac arrhythmia, and mild cognitive impairment. Review of Resident 2’s service plan, dated 05/12/25, progress notes, dated 03/16/25 through 06/16/25, and interviews with staff and the resident revealed the service plan was not reflective, or did not provide clear instruction to staff in the following areas: * Activities; * Dining; * Transfers; * Fall interventions; and * Behaviors. On 06/18/25, the need to ensure service plans were reflective and provided clear instructions to staff was discussed with Staff 1 (Administrator) and Staff 2 (ED). They acknowledged the findings.

1. All resident service plans will be evaluated and changed to ensure that resident specific needs and diagnosis/condition specific services as well as monitoring are added to service plans. 2. Service plans will be monitored regularly and reviewed monthly or at change of condition by the RCF Administrator, Paloma Hernandez and nursing staff, Michelle Collazo 3. Services plans will be spot checked twice per month by the Executive Director, Lydia McIntyre. 4. The Facility Administrator, Paloma Hernandez, and Executive Director, Lydia McIntyre, will be responsible for ensuring corrections are made and continue to monitor.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine 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 for 2 of 3 sampled residents (#s 2 and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 05/2023 with diagnoses including insulin dependent diabetes mellitus type 2, systolic (congestive) heart failure, and chronic obstructive pulmonary disease (COPD). Resident 4's progress notes, dated 03/21/25 through 06/13/25, service plan dated 06/06/25, and post discharge skilled nursing facility 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: 04/15/25: “…[resident] noted that …weight was increased today (145 lbs [pounds]) as compared to previous days (139..), and [resident] has been experiencing shortness of breath w[wild]/mild exertion in the past two weeks…”; 04/18/25: Metolazone (for fluid retention) was discontinued; 04/21/25: “noted hypertension… at the time when resident was noticing increased shortness of breath/work of breathing with mild exertion…”; 05/7/25: “coughing, scratchy throat, feels like [resident] caught a cold.”; 05/8/25: ED visit related to onset of cough; 05/13/25: admitted to hospital; 06/06/25: returned to the facility following hospitalization for exacerbation of congestive heart failure and exacerbation of COPD with multiple medication changes; 06/13/25: “Resident reports continued “mild” burning with urination…”; and 06/13/25: “…resident reported that [medical doctor] verbally instructed [him/her] to discontinue potassium tablets…”. 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 (Administrator) and Staff 5 (RCC) on 06/18/25 at 12:43 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2018 with diagnoses including hypertension, cardiac arrhythmia, and mild cognitive impairment. In an acuity interview on 06/16/25 at approximately 9:30 am, Staff 9 (MT) stated Resident 2 had challenging behaviors, including refusal of care, threatening statements to staff, and physical resistance of hands-on care. The resident was also identified as receiving PRN psychotropic medications to treat behaviors. Review of Resident 2’s progress notes, dated 03/16/25 through 06/16/25, revealed the following documented entries from staff: * 04/11/25: ”Resident showing increased signs of anxiety/agitation over the last several months”; * 04/11/25: ”Behaviors include repeatedly pressing call light but stating [he/she] does not need assistance, slamming [his/her] walker up and down or ramming it into the wall when agitated”; * 04/11/25: ”Resident will become agitated during transfers, has difficulty following directions, and will throw [his/her] body backwards towards bed or chair, buckle [his/her] knees mid-transfer, etc.”; and * 06/12/25: ”Resident was having aggressive behaviors with the staff. [He/she] was spitting at the staff and was trying to hit them”. There was no documented evidence resident-specific interventions were developed or implemented, or monitoring with weekly progress noted occurred for the above changes of condition. On 06/18/25, the need to determine resident-specific actions or interventions needed to manage behaviors, communicate this information to staff on all shifts, and monitor the behaviors to resolution was discussed with Staff 1 (Administrator) and Staff 2 (ED). They acknowledged the findings.

1. For each change of condition, the nurse, Michelle Collazo, will identify the change of condition and document what intervention/service plan change is needed and the commensurate monitoring that will be put in place. This will be communicated with appropriate staff via care staff huddles and changes to service plans. 2. The Facility Adminitrator, Paloma Hernandez, will review all changes in condition. 3. Change of condition will be monitored regularly and reviewed weekly by the RCF Administrator, Paloma Hernandez, and nursing staff, Michelle Collazo. 4. Services plans will be spot checked twice per month by the Executive Director, Lydia McIntyre. 5. The Facility Administrator, Paloma Hernandez, and Executive Director, Lydia McIntyre, will be responsible for ensuring corrections are made and continue to monitor.

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 411-054-0055 (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 residents' MARs included resident-specific parameters and instructions for PRN medications and were kept for all medications that are ordered by a legally recognized prescriber and were administered by the facility for 2 of 3 sampled residents (#s 1 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4's MAR from 05/01/25 through 06/16/25 and physician orders were reviewed and revealed the following: a. The following PRN medications lacked instructions for sequential order of use: * Milk of Magnesia 400mg/5ml (for bowel care); and * Miralax Powder (for bowel care). b. The following PRN medications lacked resident-specific parameters for use: * Albuterol 0.083%/3ml (for wheezing and shortness of breath); * Albuterol HFA 90mcg (for shortness of breath); * Mylanta (for heartburn); * Calcium Antacid 500mg (for upset stomach); * Metolazone 2.5mg (for edema); and * Neosporin (antibiotic ointment). c. The order for continuous oxygen was not documented on the MAR. The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator) and Staff 5 (RCC) on 06/18/25 at 12:43 pm. They acknowledged the findings. 2. Resident 1’s MAR from 05/01/25 through 06/16/25 and physician orders were reviewed and revealed the following: The following PRN medication lacked clear instructions for non-licensed staff: * Diclofenac Gel 1% (apply 4 grams topically to the affected area twice daily as needed for pain). The need to ensure MARs were accurate and provided resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator) and Staff 5 (RCC) on 06/18/25 at 12:43 pm. They acknowledged the findings.

1. All resident MARs will be evaluated and changed accordingly to ensure that resident and medication specific instructions are addressed. 2. The triple check process will include resident specific and medication specific instructions. 3. MARs will be monitored regularly between the RCF Administrator, Paloma Hernandez, and nursing staff Michelle Collazo, as well as a twice monthly spot check by the Executive Director, Lydia McIntyre. 4. The Facility Administrator, Paloma Hernandez, and Executive Director, Lydia McIntyre, will be responsible for ensuring corrections are made and continue to monitor.

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 (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 the ABST evaluation for each resident no less than quarterly, as required. Findings include, but are not limited to: Review of the facility's ABST entries was completed and showed the following: Updates to the ABST were not made at least quarterly (within last 90 days) for 14 of the 26 residents currently residing in the facility. In an interview on 06/17/25 at 12:35, Staff 1 (Administrator) acknowledged the failure to update all residents in the facility ABST. On 06/18/25, the need to ensure all ABST evaluations were updated at least quarterly was discussed with Staff 1 and Staff 2 (ED). They acknowledged the findings.

1. The facility ABST will be updated quarterly and anytime there is a resident admission, resident death or discharge, change of condition, or change in resident level of care. 2. ABST will be added to the RCF Administrator, Paloma Hernandez's weekly status report and discussed in a weekly meeting with the Executive Director, Lydia McIntyre. 3. The facility Administrator, Paloma Hernandez, and Executive Director, Lydia McIntyre, will be responsible for ensuring these corrections are made and continue to monitor.

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics and pre-service dementia training had been completed prior to staff providing direct care to residents for 3 of 3 newly hired staff (#s 7, 12, and 14). Findings include, but are not limited to: The facility's training records were reviewed on 06/17/25 and revealed the following: A. Staff 7 (Life Enrichment), hired 03/11/25 lacked documented evidence s/he had completed the following: * Resident's rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious Disease Prevention (two-hour course); * Approved HCBS course; and * Approved LGBTQIAS+ course. B. Staff 12 (CG), hired 04/17/25, lacked documented evidence s/he had completed the following: * Resident's rights and values of CBC care; * Abuse reporting requirements; and * Fire safety and emergency procedures. C. Staff 14 (CG), hired 05/14/25, lacked documented evidence s/he had completed the following: * Infectious Disease Prevention (two-hour course); * Approved HCBS course; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors: reducing use of antipsychotics; and * Specific aspects of dementia care including pain, proving food/fluids, preventing wandering, use of person-centered approach. On 06/18/25, requirements for pre-service orientation and pre-service dementia training were discussed with Staff 1 (Administrator) and Staff 2 (ED). They acknowledged the findings.

1. All assisted living facility staff will complete required trainings prior to providing direct care to residents. 2. New staff will not be scheduled to train for hands-on caregiving tasks without providing to RCF Administrator, Paloma Hernandez, their certificates of completion for all required trainings. 3. New hire training will be evaluated on a quarterly basis. 4. The RCF Administrator, Paloma Hernandez, and Recruiting Coordinator, Breanna Draney, will be reponsible for ensuring this requirement is met and continue to monitor.

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 2 of 2 newly hired staff (#s 12 and 14) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 06/17/25 at 03:00 pm revealed the following: There was no documented evidence Staff 12 (CG), hired 04/17/25, and Staff 14 (CG), hired 05/14/25, had demonstrated competency in all required areas and within 30 days of hire including: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 06/18/25. They acknowledged the lack of documented evidence the required training had been provided.

1. All RCF staff will complete required trainings prior to achieving 30 days of employment. 2. Status of each new hire's training completion in relative to achieving 30 days of employment will be tracked on a weekly status report. 3. New hire training will be evaluated on a quarterly basis. 4. The RCF Administrator, Paloma Hernandez, and Recruiting Coordinator, Breanna Draney, will be responsible for ensuring this requirement is met and continue to monitor.

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: