Print Inspection: RL005581

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 preferences, provided clear direction regarding the delivery of services, and/or were implemented for 1 of 2 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 08/2023 and had diagnoses including Alzheimer's Disease and osteoporosis. Observations of the resident, interviews with staff and resident’s family, review of temporary service plans, progress notes from 04/01/25 through 07/14/25, and review of the service plan, dated 05/21/25, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not implemented in the following areas: * Use of a slotted spoon for soups and jello; * Resident preference for keeping the door open; * Pressure relief precautions; * How to provide upper body dressing assistance to protect the right shoulder from a prior fracture; * Frequency of providing cueing during meals when eating in the room; * Pain, including where it is located and non-drug interventions; and * Wheelchair mobility for escorts when leaving the room. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator) on 7/15/25 and 07/16/25, and with Staff 2 (RN) and Staff 3 (Nursing Home Assistant Administrator) on 07/16/25 at 12:00 pm. They acknowledged the findings.

1. Resident #2 SP will be updated to include; use of slotted spoon, resident's preference to keep the door opened, pressure relief precautions, how to proivde upper body dressing assistance, frequency of providing cues during meals when eating in her room, pain location and non-drug interventions, and wheelchair mobility when leaving room. 2. A copy of the resident's SP will be posted for care staff to review and provide input for each resident's move-in, quarterly and significant change SP review. This information will be used when updating the SP to ensure it's accurate and person-centered. A copy of the SP will be providered to family/POA with each SP review for further feedback and validation. 3. Resident SP's will be reviewed at least quarterly and with significant changes. The SP review processes will be evaluated quarterly. 4. Memory Care Administrator and Nursing Home Assistant Administrator.

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 action or interventions were needed following short-term changes of condition, communicate the interventions to staff and document weekly progress until resolved for 1 of 2 sampled residents (# 2) who experienced short-term changes of condition. Findings include, but are not limited to: Resident 2 moved into the facility in 08/2023 and had diagnoses including Alzheimer's Disease and osteoporosis. The resident's current service plan dated 05/21/25, temporary service plans, progress notes dated 04/01/25 through 07/14/25, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 07/14/25 and 07/16/25. The facility failed to determine actions or interventions needed for the resident, communicate the actions or interventions to staff on each shift, and/or document weekly progress until the condition resolved for the following short-term changes of condition: * 03/31/25 – Skin tear/bruising on left elbow; * 04/05/25 – Redness under breasts with odor; * 04/24/25 – Self reported fall; * 05/12/25 – Bruising on left elbow; and * 05/26/25 – Itching on shin with bleeding. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Nursing Home Assistant Administrator) on 07/16/25 at 12:00 pm. The findings were acknowledged.

1. Facility RN reviewed intial skin condition and notified the provider requesting a treatment plan. The RN to initiate TSP with this treatment plan. Med-techs will communicate the treatment plan with the care staff. Skin checks completed weekly to determine if the treatment plan is appropriate and validate healing. Documentation until, and including, resolution will be entered in the resident's medical record. 2. A skin book will be created. Each resident with skin conditions requiring monitoring will have a skin monitorning log initated. The RN will review and document regular skin audits in this log until resolution. 3. The facility RN will complete weekly skin checks and document in the skin log for each resident until resolution. RN and administrator will evaluate monthly for the next 90 days and quarterly there after. 4. Memory Care Administrator and RN

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#s 1), who experienced significant changes of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 07/2024 with diagnoses including dementia and diabetes mellitus type II. Resident 1 was observed eating independently on 07/14/25 and 07/15/25 and weighed 146 pounds at the time of the survey. Progress notes dated 04/14/25 to 07/14/25, evaluations, service plans, and service plan updates, and weight records were reviewed. The following was identified: Resident 1 weights from 04/14/25 to 07/14/25 revealed the following: * 04/14/25 - 154.2 pounds; and * 05/09/25 - 144.2 pounds. The unexplained 10-pound weight loss (6.5% of body weight) in 25 days constituted a significant change of condition for which an RN assessment was required. In an interview on 07/15/25 at 2 pm, Staff 2 (RN) acknowledged there was no documented assessment that included findings, resident status and interventions made as a result of the assessment. 2. An incident report, dated 06/02/25, documented the discovery of a 1x1 cm open wound on Resident 1’s inner buttock. During an interview at 2:00 pm on 07/15/25, Staff 2 (RN) acknowledged the wound appeared to be a stage II pressure ulcer. The development of a stage II pressure ulcer constituted a significant change of condition which required an RN assessment. Staff 2 acknowledged there was no documented assessment that included findings, resident status and interventions made as a result of the assessment. The need to ensure an RN assessment for residents who experienced significant changes of condition included documentation of resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Nursing Home Assistant Administrator) on 07/16/25 at 12:00 pm. They acknowledged the findings.

1. RN completed an assessment for weight loss, skin conditions and preventative measures were put into place for resident #2. The service plan was reviewed and updated on 7/18/2025 and 7/31/2025 to use a pressure relief cushion while resting in a recliner or eating at the dining room table and to apply silicon cream to buttock after each toileting episode. 2. A weight book will be developed and monitored weekly by administrator and RN. 3. A weekly review for significant change of condition completed with administrator and RN ongoing. 4. Memory care administrator and RN.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2024 with diagnoses including dementia and diabetes mellitus type II. Resident 1’s individual acuity-based staffing was not accurate for the minutes required in the areas of: * Safety checks and fall prevention; * Assisting with leisure activities; * Cueing due to dementia; and * Supporting while eating. The need to accurately determine the time needed for resident care as part of the ABST was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Nursing Home Assistant Administrator) on 07/16/25. They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2023 and had diagnoses including Alzheimer's Disease and osteoporosis. The service plan, dated 05/21/25, temporary service plans, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed, and interviews were conducted with staff and resident’s family. The resident's care time and care elements were found to not be reflective in the following areas: * Safety checks and fall prevention; * Responding to call lights; * Bowel and bladder management; * Transferring in or out of a bed or a chair; * Repositioning in bed or a chair; * Supervising, cueing, or supporting while eating; * Providing non-drug interventions for pain management; * Providing treatments; * Ensuring non-drug interventions for behaviors; * Monitoring physical conditions or symptoms; * Monitoring behavioral conditions or symptoms; and * Safety checks and fall prevention. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator) on 07/15/25 and 07/16/25, and with Staff 2 (RN), and Staff 3 (Nursing Home Assistant Administrator) on 07/16/25. The findings were acknowledged.

1. Administrator will review and update the ABST for resident #1 and #2. Information will be gathered through staff interviews and observing the resident while each listed ABST taks is completed. 2. Two residents will be reviewed each week for the next 4 weeks using the process listed in section 1. All remaining residents will be reviewed and updates to the ABST will be entered by date of compliance for each resident, as appropriate. 3. Each residents ABST will be reviewed at least quarterly and with significant change as part of the service plan review process. 4. Memory Care Administrator

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

OAR 411-054-0090 (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 and that fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records were reviewed between 02/2025 and 06/2025. The following was identified: * Unannounced fire drills were not conducted and recorded at different times to include evening shifts; and * Lacked evidence alternative escape routes were used. Additionally, the records reviewed did not show life safety training was consistently provided on alternate months from fire drills. The need to ensure all required components were addressed and documented for each fire drill, and that drills were conducted on alternate months from fire and life safety training, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 07/15/25. The staff acknowledged the findings.

1. A fire drill will be conducted in August on evening shift using an alternate evacuation location. 2. A schedule will be created that outlines the fire drill schedule and Fire and Life Safety (FLS) topics to be reviewed on the opposite months of fire drills. The schedule will include the planned date, shift and evacuation location for each fire drill. The schedule will also list the FLS topics for each month these in-services will occur. Topics will include specific information related to FLS for staff education. 3. Quarterly. 4. Memory Care Administrator

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:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. 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 locking mechanism on shared bathroom doors for residents who shared a bathroom. Findings include, but are not limited to: On 07/14/25 at 3:00 pm, Staff 1 (Administrator) completed a walk through of the environment with the surveyor, observed the only shared bathroom, and confirmed the memory care community had one shared room (414 A and B), and that shared resident bathroom did not have a locking feature. The need to ensure privacy and dignity related to shared resident units and the capacity to lock shared bathroom doors was discussed with Staff 1 and Staff 2 (RN) on 07/16/25 at 12:00 pm. They acknowledged the findings.

1. The resident in 414A has moved into a private room and one resident remains in the shared room at this time. 2. Administator, NH Assistant Administrator and Maintenance are researching best options for door locking systems in the room. A new locking system will be installed no later than the date of compliance. 3. Annually. 4.Memory Care Administrator and Maintenance Director

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 362 and C 420.

Refer to C362 and C420.

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 2 of 2 newly-hired staff (#s 6 and 7) received a written job description prior to performing job duties and completed all required pre-service dementia training topics; and 1 of 2 long-term direct care staff (#9) completed the required number of annual in-service training hours, including at least six hours of training on dementia care and infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 07/15/25 at 2:10 pm with Staff 1 (Administrator). The following was identified: a. There was no documented evidence Staff 6 (CG) and Staff 7 (MT), hired 06/23/25 and 01/13/25, respectively, had a written description of their job responsibilities. Additionally, there was no documented evidence of completing of the following pre-service dementia training topics: * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. b. Documented annual in-service hours acquired between 10/09/23 and 10/09/24 were reviewed for Staff 9 (CG), hired 10/09/18. There was no documented evidence Staff 9 had completed the required number of annual in-service training hours, including at least six hours of training related to dementia care and infectious disease training. The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 07/15/25 and 07/16/25 and Staff 3 (Nursing Home Assistant Administrator) on 07/16/25. They acknowledged the findings.

1. Care staff #6 and #7 will be provided job descriptions to review with administrator and sign. Administrator will audit employee personnel files for a signed job description and any employees found to not have a signed job description will be provided one by date of compliance. Adminstrator will review pre-service dementia topics and create a training plan through Relias that meets regulations. An audit will be completed on each employee for missing pre-service and annual training components. Employees found to not be in compliance with training compents will be provided a timeline for completion. Employees that don't complete required training within the timeline administrator provides, will be taken off the schedule until completed. 2. A tracking tool will be created for new employees to track compliace with pre-service and 30 day training requirements. A monthly audit will be conducted for annual training compliance. 3. Monthly. 4. Memory Care Administrator

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: C260, C270 and C280.

Refer to C260, C270 and C280.

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

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to evaluate residents for activities and develop an individualized activity plan based on the evaluation for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to: Residents 1, 2, and 3's most recent “resident profile”, evaluations and service plans were reviewed. The records did not address one or more of the required elements: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. There was no individualized activity plan developed based on the evaluation that reflected the resident's activity preferences and needs for Residents 1, 2 and 3. The need to ensure the facility provided meaningful activities, evaluated each resident for activities, and developed an individualized activity plan based on the evaluation was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Nursing Home Assistant Administrator) on 07/16/25. They acknowledged the findings.

1. Resident #1, #2 and #3 SP will be reviewed for individualized actvitiy plan and updated as applicable. 2. Resident Activity Profile will be update to include a resident's current abilities, skills, physical limitations and acommendations needed to participate in activities. SP will include resident specific redirection tools such as listening to music, arts/crafts or a tactile objects. 3. At least quarterly and with significant change of condition. 4. Memory Care Administrator and Activity Coordinator

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: