Print Inspection: RL005119

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 ensure incidents, and/or injuries of unknown cause were promptly investigated to rule out abuse, and reported to the local SPD office when required, for 2 of 4 sampled residents (#s 1 and 3). Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 10/2024 with diagnoses including dementia. Resident 3 was observed to be independent with transfers and ambulation without an assistive device, often carrying or following his/her dog throughout the common areas of the facility. Interviews with staff, observations of the resident, and review of the resident's 03/23/25 through 06/23/25 service plans, temporary service plans, progress notes, and accident/incident reports were completed and identified the following: * On 04/23/25 progress notes indicated two bruises located by the resident’s left elbow were observed; *On 06/03/25 the progress notes indicated the resident had a fall with an abrasion to the right elbow and bruising to the left elbow. On 06/24/25 Staff 2 (Memory Care Director) reported there were no investigations completed for the incidents to reasonably rule out abuse, and the incidents were not reported to the local SPD. The need to immediately report incidents with injury, and injuries of unknown cause to the local SPD office unless an immediate investigation reasonably concluded that the incident and/or injury was not the result of abuse was discussed with Staff 1 (ED), Staff 2, and Staff 3 (LPN) on 06/24/25. They acknowledged the findings. The facility was instructed to report the injury of unknown cause to the local SPD office on 06/24/25, and confirmation of report sent was received from the facility by 3:30 pm on 06/24/25. 2. Resident 1 was admitted to the facility in 04/2025 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the resident's 06/11/25 service plan, 04/14/25 through 06/23/25 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident was able to communicate needs to staff, complete some ADL care on his/her own, walked with a walker and had a vision impairment. The resident was not consistently compliant with requesting assistance from staff. Review of the resident's records showed the following: * A progress note dated 05/02/25 at 2:49 am, indicated the resident experienced a non-injury fall. An investigation was not completed at the time of the incident. * A progress note dated 05/02/25 at 8:32 pm, indicated the resident tripped in his/her apartment and fell. The resident sustained a skin tear to the elbow and an abrasion to the back and knee. An investigation was not completed at the time of the incident. * A hospice visit note dated 06/09/25 indicated the resident had a small skin tear to the left arm. There was no other information regarding the skin tear or the cause. The resident did not offer any information on what might have happened. No investigation was completed regarding the injury of unknown cause. The facility was asked to report the injury of unknown cause to the local SPD office. A confirmation of the report was provided to the surveyor. The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (LPN) on 06/24/25. The staff acknowledged the findings.

Items referenced to be out of compliance with OAR 411-054-0028 (1-3) will be addressed, corrected and facility will be in compliance by 8/23/25 by completing the following: 1. Incident investigation will be completed on survery referenced residents including ruling out abuse/neglect by 7/15/25. 2. Clinical team will review the last 2 weeks of incidents/investigations to ensure thoroughness/completeness of investigation, including ruling out abuse and neglect. 3. ED, AHSD, EED and RCC received training on requirement to complete investigation reviews within 24 hours to rule in/out abuse/neglect. 4. AHSD will reivew incident investigations for timeliness compliance weekly x 3 weeks 5. EED received training on Incident Investigations, documentation and followup. 6. EED and/or AHSD will review incidents daily for followup and investigation as necessary during daily Clinical meetings.

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 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, 06/23/25 through 06/24/25, observations of the Memory Care unit showed minimal group activities. The television was on throughout the day. A small group of residents participated in a music activity one afternoon, and one to two individual residents were observed to paint or color after staff set up. Additional residents were observed sleeping in their chairs, in their rooms or wandering the common area, dining room and halls, throughout the rest of the day. Care staff were not observed to initiate any additional large or small group activities or offer the residents other things to do. Staff 10 and Staff 12 (CGs) indicated they did not have a specific activity director for the Memory Care unit. Staff 12 indicated there were supplies in the cupboard and they tried to do the things on the activity calendar but were not always successful. The staff indicated the television, or music was usually kept on, some residents were happy watching TV. Staff 12 indicated they recently did some pot painting and planting with several residents. The need to ensure a daily activity program was provided for residents to address their mental, physical and psychosocial needs was reviewed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (LPN) on 06/24/25. The staff acknowledged the findings.

Items referenced to be out of compliance with OAR-411-054-0030 (1)(c-d) will be addressed, corrected and facility will be in compliance by 8/23/25 by completing the following: 1. Memory care staff will receive training on the purpose and importance of activities, 30 second activity training, how to implement an activity, how engage a resident and orientation to location/contents of activity cart and supplies. 2. EED will hold daily huddles at shift change to discuss scheduled activities and designate person to lead activity. 3. EED will monitor activities via staff/resident interviews and observations to ensure compliance weekly x3 weeks.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; 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 ensure residents who had short term changes of condition had resident-specific instructions or interventions developed and communicated to staff and weekly progress documented until resolution for 2 of 4 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2025 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the resident's 06/11/25 service plan, 04/14/25 through 06/23/25 temporary service plans, progress notes, physician communications, and incident investigations were completed. Multiple daily observations were made of the resident between 06/23/25 and 06/24/25. The resident was observed while in his/her bedroom as well as common areas. The resident spent the majority of his/her time in bed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Behaviors including anxiety and restlessness; * Skin tear, bruises and skin injuries; * Medication changes; * Nausea and vomiting; * Non-injury fall; and * Low blood pressure and dizziness. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were reevaluated for effectiveness and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (LPN) on 06/24/25. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2025 with diagnoses including senile dementia. Observations of the resident, interviews with staff, and review of the resident's 05/13/25 service plan, 03/23/25 through 06/23/25 temporary service plans, progress notes, physician communications, and incident investigations were completed. Multiple daily observations were made of the resident between 06/23/25 and 06/24/25. The resident was observed while in his/her bedroom as well as common areas. The resident spent a majority of his/her day in the common areas and walking the halls. The resident had a four wheeled walker that s/he intermittently used while walking the unit. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Thigh rash, itchy bumps and skin injuries; * Behaviors including restlessness and wandering; * Skin tear, bruises and skin injuries; * Medication changes; * Emergency room visit and hospital return; * Shortness of breath and chest pains; * New roommate; * Compression stockings on extended period; and * Nausea, vomiting and diarrhea; The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were reevaluated for effectiveness and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Memory Care Director) and Staff 3 (LPN) on 06/24/25. The staff acknowledged the findings.

Items referrenced by tag C270 and out of compliance with OAR 411-054-0040 (1-2) will be addressed and correct by 8.23.25 by implementation of the following: 1. AHSD will re-educate medication technicians on importance of routine documentation on SPA's. 2. AHSD, will receive re-education on nursing review and documentation requirement before items are closed. 3. AHSD will audit SPA's for documentation weekly x 3 weeks. 4. SPA documentation and alert charting will be reviewed daily during clinical meeting. AHSD will followup daily with RN as needed for coordination of care or significant change of condition assessments needed.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure staff utilized proper infection control while serving in the dining room. Findings include, but are not limited to: Observations of the dining room during lunch and dinner meal on 06/23/25 and breakfast meal on 06/24/25 showed the following: * One care staff served the food onto plates for delivery. One to two additional staff served the plates and fluids to residents in the dining room. The staff were not wearing aprons or other clothing covers when serving food on 06/23/25. Staff on 06/24/25 had aprons in place but were wearing the aprons out of the dining room and into resident rooms and/or common areas. * Staff were observed with gloves on. Multiple staff were touching other surfaces including doors, wheelchair handles, and dirty dishes without a change of gloves. * Staff were exiting and entering the dining room without consistently changing gloves or washing hands. * Staff were reminded to only use aprons in the dining room/kitchen area and remove prior to leaving the area. One staff was asked to remove the apron she had worn into a resident room and put on a fresh apron. Staff were also asked to change gloves between clean and dirty tasks. The need to ensure staff consistently used proper infection control, hand hygiene and glove use was discussed with Staff 1 (ED) and Staff 2 (Memory Care Director) on 06/24/25. The staff acknowledged the findings.

Items referenced to be out of compliance with OAR 411-054-0050 (1-5) will be addressed and corrected by 8/23/25 by implementation of the following: 1. Staff completed online training course via Oregon Care Partners: Keeping Food Safe & Nourishing for Older Adults 2. Staff inservice to be held 7/29/25 re-educating staff on proper glove, apron, hair restraint usage and meal dining policies and procedures. 3. Signage placed in kitchen area as visual reminder for staff to utilize proper PPE for dining-Gloves, Aprons, Hairnets 4. EED will conduct weekly audits/observations of staff during meals to ensure ongoing compliance

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 13, and 16) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed, with Staff 1 (ED) on 06/24/25 and the following was identified: There was no documented evidence that Staff 9 (CG), Staff 13 (CG), and Staff 16 (CG), hired 02/20/25, 03/05/25, and 03/20/25, respectively, had demonstrated competency in one or more of the following areas: * First aid; and * Abdominal thrust. The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 on 06/24/25. She acknowledged the findings

Items referenced to be out of compliance with OAR 411-054-0070 (5 & 9-10) will be addressed and corrected by 8/23/25 by implementation of the following: 1. All Employees that do not have documented completion per regulation for LGBTQ1A2s+ and Home and Community Based Services btraining will complete this training via Oregon Care Partners by 7/31/25. 2. All Employees will receive Abdominal Thrust Training by 8/15/25. 3. Employee training records will be audited for any first aid training needed and employees will complete training via Oregon Care Partners by 8/15/25. 4. New Competency checklists have been created for direct care staff including the items found to be lacking: Normal Againg and changes associated with aging, Dietary Food Sanitation Standards, The use of Supportive Devices with restraintive qualities. New competency checklist will be completed with all staff by 8/15/25. New competency checklist will be used for any new direct care staff moving forward. 5. Employee training records will be audited for staff training within 30 days and will address any concerns or missing items. 6. ED will audit new employee records for first 30 days training compliance weekly and utilize staff training tracker tool to ensure ongoing compliance. 7. All Training Records and All Staff Inservice Sign-Ins and Documentation will be stored in ED office.

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 01/2025 and 06/2025, showed: * One fire drill was documented as completed in the last six months for the Memory Care unit; * Fire drills were not conducted on alternating months with fire life safety training; and * Drills were not conducted on alternating shifts to include all three shifts. Fire drill documentation was missing the following components: * Escape route used; * Problems encountered; * Evacuation time period needed; * Staff who participated in the drill; * Number of occupants evacuated; and * Evidence alternate routes were used. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training, was discussed with Staff 1 (ED) on 06/23/25 and 06/24/25. She acknowledged the findings.

Items referenced by tag C420 and out of compliance with OAR 411-054-0090 (1-2) will be addressed and corrected by 8/23/25 by implementation of the following: 1. Fire drill for Memory Care took place on 6/27/25 and will be conducted on an alternating rotation with the assisted living portion of the community to ensure compliance in both areas. 2. Maintenance director has received education on the requirement to ensure memory care fire drills are happening per regulation and necessary documentation and details are included in all fire and life safety drills and training. 3. All staff will receive training on fire and life safety on 7/17/25 4. ED will review fire drills and fire & life safety training for compliance with Maintenance Directory monthly to ensure ongoing compliance.

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

OAR 411-054-0090 (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 in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) on 06/24/25. There was no documentation that residents were provided fire training within 24 hours of admission and again at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 06/24/25, Staff 1 indicated she discovered the facility had not been fully documenting specific training on admission or annually with residents. Staff 1 acknowledged the need to provide the residents fire and life safety training.

Items referenced to be out of compliance with OAR 411-054-0090 (5) will be addressed and corrected by 8/23/25 with the implementation of the following: 1. EED and Maintenance Director will complete Resident Orientation and Fire Life Safety training with all memory care residents and/or applicable responsible parties. 2. EED will audit any newly moved in residents files for fire and life safety instruction weekly. 3. Management Team received re-education on requirements for fire/life safety resident orientation upon admission and ongoing annually.

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:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 06/23/25 and 06/24/25 showed the following areas in need of cleaning or repair: * Multiple carpet stains were noted in the tv room. The stains varied in size and included black and red stains; * Multiple scuffs, gouges and deep scratches were noted to the laminate flooring in the dining room, tv room and sitting area. Scratches were several inches in length at the minimum; * Ceiling lights in the dining room had numerous dead insects and debris gathered in the lights; * Spills, scrapes, splatters and debris were noted in the drawers, cupboards, walls and windowsills in the dining room. The curtains in the dining room had multiple spills and splatters with black/brown/white discolorations; * Furniture in the tv room and sitting area had rips, stains, spills and/or debris on seats, arms and sides; * Multiple dining room chairs had debris in seat crevices, spills and/or stains along fabric seat backs and on the sides of the furniture. The chairs had significant scrapes and gouges along chair legs and arms; * Room 11 had missing flooring at the doorway; * Shower room had scrapes, spills and dings to walls, missing grout or black caulking around the shower and flooring that was pulling apart at seems which created a gap for debris; * The common area bathroom had cracks in the edges of the floor and a large section of flooring along the baseboard pulling away from the wall; and * Multiple wall corners throughout the facility had chunks of missing plaster. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 06/23/25. She acknowledged the findings.

Items referenced to be out of compliance with OAR 411-054-0200 (4)(d-i) will be addressed and corrected by 8/23/25 with implementation of the following: 1. Carpet Stains in Common Area have been cleaned as of 6/25/25 and housekeeping instructed on checking area weekly for ongoing carpet cleaning needs. 2. Common area flooring to be replaced due to deep gouges, and large scratches. Maintenance Director will obtain Bids for work and outside Vendor will complete work. 3. All areas of kitchen and dining area observed to have debris, dead insects, spills, scrapes, splatters have been cleaned thoroughly as of 6/25/25. Cleaning list for staff have been updated to include target areas of concern and housekeeping staff have received re-education on observation of problem areas. 4. Dining room chairs have all been cleaned as of 6/25/25 and are now included in Noc shift cleaning task list. 5. Flooring with missing area outside resident room has had new thrreshold installed by 7/15/25 by Maintenance Director 6. Shower Room scrapes, spills, dings to wall and missing grout and caulking and flooring concern have been repaired as of 7/9/25 7. All areas of community walls, corners, door frames with digs, scuffs with missing plaster have been repaired and painted as of 7/9/25. 8. Maintenance Director and ED have conducted environmental walkthrough to ensure cleanable and homelike environment and Maintenance Director has received training on conducting weekly walkthroughs to identify and address concerns as observed. 9. Maintenance director will audit memory care environment weekly to ensure ongoing compliance.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure a manually operated emergency call system was located in each toilet facility used by residents and visitors. Findings include, but are not limited to: Observations on 06/23/25 and 06/24/25 showed the common bathroom was unlocked and accessible by residents. Observations of the interior of the restroom on 06/23/25 showed there was no manually operated call system for residents or visitors to obtain help. Staff 1 (ED) confirmed there was no call system in the restroom. The facility had multiple ambulatory residents who moved around the halls and common areas. No residents were observed to use the common bathroom. In interview on 06/23/25 Staff 5 and Staff 10 (CGs) indicated the bathroom was usually unlocked. The staff did not take residents into the bathroom but there were some residents who would take themselves into the bathroom to use it. The need to ensure all toilet facilities used by residents and visitors was equipped with a manually operated call system was discussed with Staff 1 on 06/24/25. She acknowledged the findings.

Item referenced to be out of compliance with OAR 411-054-0200 (11-13) has been corrected as of 7/9/25. New lock has been installed for bathroom and bathroom specified as employee use only with all employees having a key. Residents no longer have access to this bathroom. Residents and visitors have alternate bathrooms available in shower room and lobby.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on bathroom doors for residents who had shared bathrooms. Findings include, but are not limited to: Observations on 06/23/25 of shared bathrooms revealed there was no locking mechanisms on shared bathroom doors to ensure privacy. On 06/23/25, the observations and the need to ensure shared bathroom doors had locks were reviewed with Staff 1 (ED) and Staff 6 (Memory Care Director). The staff acknowledged the findings.

Items referenced to be out of compliance with OAR 411-004-0020(2)(d) will be addressed and corrected by 8/23/25 with implementation of the following: 1. Bathrooms reviewed by ED and Maintenance Director and both were re-educated on requirement for resident privacy in this environment. 2. Locking mechanisms will be placed on bathrooms in residents rooms which are shared by more than one occupant.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their individual units. Findings include, but are not limited to: Review of records for Residents 1, 2, 3, and 4 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms. During an interview on 06/24/25 Staff 1 (ED) reported there was one resident on the unit who had requested and been provided a key to his/her room. The need to ensure all residents were provided keys to their individual units was discussed with Staff 1 on 06/24/25. She acknowledged the findings.

Items referenced to be out of compliance with OAR 411-004-0020 (2)(e) will be addressed and corrected by 8/23/25 with implementation of the following: 1. ED, EED and Maintenance Director re-educated on requirement that each resident receive a key to their apartment. 2. Each resident will be given the opportunity to accept/decline key to their apartment with this documented and for those whom decline direct key access, keys will be placed in resident bathroom taped under cabinet area with this information included in their service plan. 3. EED will audit new move ins for key compliance weekly

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C231, C242, C295, C372, C420, C422, C513 and C555.

See C tags C232, C242, C295, C372, C420, C422, C513 and C555 for Plan of Correction.

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 11, and 13) completed all orientation, pre-service and dementia training topics prior to performing any job duties, 3 of 3 staff (#s 9, 13, and 16) demonstrated competency in all required areas within 30 days of hire, and 2 of 2 long term staff (#s 7 and 15) completed the required number of annual in-service training hours, and Home and Community Based Care (HCBS) training. Findings include, but are not limited to: A review of staff training records with Staff 1 (ED) on 06/24/25 identified the following: * There was no documented evidence that Staff 9 (CG), Staff 11 (CG), and Staff 13 (CG), hired 02/20/25, 05/26/25, and 03/05/25, respectfully, had completed all orientation, pre-service training topics, and dementia training prior to performing any job duties to include one or more of the following: - Abuse reporting requirements; - Fire safety and emergency procedures; - Infectious disease prevention; - Approved LGBTQIA2S+ course; - Environmental factors that are important to a resident’s well-being; - Family support and the role the family may have in the care of the resident; and - Use of supportive devices with restraining qualities in Memory Care communities. * There was no documented evidence that Staff 9 (CG), Staff 13 (CG), and Staff 16 (CG), hired 02/20/25, 03/05/25, and 03/20/25, respectfully, had demonstrated competency in all required areas within 30 days of hire to include one or more of the following: - Role of the service plan in providing individualized care; - Providing assist with ADL cares; - 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. * There was no documented evidence that Staff 15 (CG), hired 06/13/23, respectively, had completed at least 10 hours of annual in-service training related to the provision of care in CBC within their anniversary date of hire (06/13/24 through 06/13/25). * There was no documented evidence that Staff 15 (CG), hired 06/13/23, had completed a minimum of 6 hours of annual in-service training related to dementia care within their anniversary date of hire (06/13/24 through 06/13/25). * There was no documented evidence that Staff 7 (MT) and Staff 15 (CG), hired 06/06/19, and 06/13/23, respectfully, had completed the required HCBS training. The need to ensure staff training requirements were completed in the specified time frames was discussed with Staff 1 on 06/24/25. She acknowledged the findings.

Items referenced to be out of compliance with OAR 411-057-0155 (1-6) will be addressed and corrected by 8/23/25 by implementation of the following: 1. All Employees that do not have documented completion per regulation for LGBTQ1A2s+ and Home and Community Based Services btraining will complete this training via Oregon Care Partners by 7/31/25. 2. All Employees will receive Abdominal Thrust Training by 8/15/25. 3. Employee training records will be audited for any first aid training needed and employees will complete training via Oregon Care Partners by 8/15/25. 4. New Competency checklists have been created for direct care staff including the items found to be lacking: Normal Againg and changes associated with aging, Dietary Food Sanitation Standards, The use of Supportive Devices with restraintive qualities. New competency checklist will be completed with all staff by 8/15/25. New competency checklist will be used for any new direct care staff moving forward. 5. Employee training records will be audited for staff training within 30 days and will address any concerns or missing items. 6. ED will audit new employee records for first 30 days training compliance weekly and utilize staff training tracker tool to ensure ongoing compliance. 7. All Training Records and All Staff Inservice Sign-Ins and Documentation will be stored in ED office.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270.

Please see tag C270 for Plan of Correction

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