Print Inspection: RL006395

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 determine and document what actions or interventions were needed for short-term changes of condition, communicate resident-specific instructions and interventions to staff on each shift, and monitor changes of condition at least weekly until resolution for 3 of 4 sampled residents (#s 2, 4, and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 11/2023 with diagnoses including chronic kidney disease. The resident’s clinical record was reviewed, observations were made, and staff were interviewed during the survey. The resident’s skin monitoring documentation, 06/05/25 to 08/21/25 progress notes, and “Notification of a Change in Condition” and “Service Plan” forms were reviewed. The following was identified: The resident was noted to have experienced the following short-term changes of condition: a. 06/05/25: Skin tear near left elbow. The resident was placed on alert monitoring; however, there was no documented evidence the skin tear was monitored for progress at least weekly to resolution. b. 06/21/25: Resident reported sores in his/her mouth. The resident’s returned from a doctor’s visit with new medication orders for chlorhexidine mouthwash and triamcinolone dental paste daily. The resident was placed on alert monitoring; however, there was no documented evidence the mouth sores had been monitored for progress at least weekly to resolution. In an interview with Staff 1 (Administrator) on 08/26/25 at 10:46 am, she confirmed the facility lacked documented evidence Resident 5 was monitored with progress noted at least weekly through resolution for the skin tear to left arm and sores in his/her mouth. The need to monitor short-term changes in condition with progress noted at least weekly until the condition is resolved was reviewed with Staff 1 and Staff 2 (RN) on 08/27/25. They acknowledged the findings. 2. Resident 2 moved into the facility in 05/2021 with diagnoses including type 2 diabetes. The resident’s service plan dated 07/23/25, progress notes dated 05/25/25 through 08/20/25 and corresponding incident reports were reviewed. The resident was noted to have experienced the following change of condition: On 07/28/25, Resident 2 was sent to the emergency room due to reports of pain, discoloration, and weakness in his/her legs. S/he was diagnosed with bilateral deep vein thromboses (blood clots) and admitted to the hospital. Resident 2 returned to the facility on 08/01/25 with orders for a new medication, apixaban, a blood thinner. There was no documented evidence resident-specific actions or interventions were determined and communicated on each shift regarding monitoring signs and symptoms of the DVT, such as heat/redness/pain and effectiveness or adverse effects of the apixaban, such as bruising/dizziness/gastrointestinal upset. In an interview on 08/26/25 at 10:35 am, Staff 1 (Administrator) acknowledged no resident-specific actions/interventions had been communicated to staff. The need to ensure the facility determined and documented resident-specific actions or interventions for residents who experienced a short-term change of condition and communicated the interventions to staff was reviewed with Staff 1 on 08/27/25 at 2:00 pm. She acknowledged the findings. 3. Resident 4 moved into the facility in 04/2017 with diagnoses including stroke and type 2 diabetes. The resident's clinical record, including progress notes dated 05/29/25 through 08/23/25, the MAR dated 07/01/25 through 07/08/25, and a corresponding incident report was reviewed, and interviews with staff were conducted. On 07/08/25, staff documented, “Resident did not get [his/her] morning medication due to given to another resident.” The missed medications included apixaban, a blood thinner to prevent blood clots, enalapril, for high blood pressure, metoprolol, for heart failure, glipizide, for diabetes, and metformin, for diabetes. There was no documented evidence actions or interventions were determined and communicated to staff on each shift, and there was no documented evidence the resident was monitored for adverse effects of missing the medications, such as signs and symptoms of a stroke or high blood sugar. During an interview on 08/27/25 at 10:20 am, Staff 1 (Administrator) acknowledged no actions or interventions were determined, and the resident was not monitored through resolution regarding the missed medications. The need to ensure actions or interventions were determined and documented for short-term changes of condition, determined actions or interventions were communicated to staff on all shifts, and changes were monitored with weekly progress noted until the condition resolves was discussed with Staff 1 on 08/27/25 at 10:20 am. She acknowledged the findings.

1. Resident 5, 2, 4 will be assessed by facility RN for issues identified in survey results and documented in progress notes 2. All short term changes of condition will be reviewed by management team during daily stand up meeting Monday-Friday. Facility nurse will review documentation throughout alert charting process and remove from charting when deemed appropriate to do so based on resident needs. 3. Documentation will be audited daily until compliance met and then quarterly through QAPI process 4. Administrator or designee

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure an RN assessment had been completed for 1 of 1 sampled resident (# 3) who had a significant change of condition. Findings include, but are not limited to: Resident 3 was admitted to the facility in 02/2025 with diagnoses including low bone mass. Resident 3's progress notes and physician communications, dated 06/16/25 through 08/07/25, revealed the resident had been identified with an overall decline, including cognition, and experienced falls and depression. The resident continued to decline, and on 08/06/25 was placed on hospice services. This constituted a significant change of condition, requiring an RN assessment that included findings, resident status, and interventions made as a result of the assessment. There was no documented RN assessment reflecting the resident had a decline and was placed on hospice. In an interview on 08/27/25, Staff 2 (RN) confirmed the lack of an assessment for the resident’s significant change of condition. The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Director of Health Services) on 08/27/25. They acknowledged the findings.

1. Resident 3 will be assessed by facility RN for significant change in condition related to being put on Hospice services and documented in progress notes 2. All significant changes of condition will be identified by 24 hour report documentation, outside provider documentation, quarterly nursing evaluations and reviewed during daily stand up meeting Monday-Friday. Facility RN will review and document residents significant change in condition using nursing evaluation forms when appropriate or in progress notes indicating what the change in condition is and how it will be managed by staff to include and not limited to the use of outside providers to manage condition. 3. Documentation will be audited daily until compliance met and then quarterly through QAPI process 4. Administrator or designee

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 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#2 and 4) whose MARs and orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in May 2021 with diagnoses including type 2 diabetes. The resident’s MAR dated 07/01/25 to 08/25/25, progress notes dated 05/25/25 through 08/25/25, and prescriber orders were reviewed, and the following was identified: a. The resident had an order for donepezil HCl 5 mg tablets, one tablet nightly for symptoms related to Alzheimer’s disease. On 08/05/25, the facility discontinued administration of donepezil. In a faxed communication with the facility on 08/01/25, the prescriber documented, “will continue donepezil for now as [s/he] had been stable on this medication and reassess on discharge follow up visit.” The facility did not have a subsequent discontinuation order from the prescriber for the medication. b. On 07/20/25, the resident was prescribed cefuroxime 500 mg, tablet two times daily for five days for cellulitis in his/her left elbow. The MAR documented the medication as administered for six days from 07/22/25 through 07/27/25. The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (Administrator) on 08/27/25 at 2:00 pm. She acknowledged the findings. 2. Resident 4 moved into the facility in 04/2017 with diagnoses including hypertension and left shoulder pain. The resident's MAR, dated 08/01/25 through 08/25/25, corresponding progress notes, and physician orders were reviewed, and the following was identified: a. The MAR was blank on 08/04/25 and 08/2025 for the 5:00 pm blood glucose monitoring check. b. The MAR was blank on 08/12/25 and 08/20/25 for the 2:00 pm doses for the nutritional supplement. c. The MAR was blank on 08/12/25 and 08/13/25 for the 8:00 pm doses of miconazole 2% powder (for ringworm of groin area). d. The MAR was blank on 08/12/25 for the 8:00 pm doses for the following medications: * Acetaminophen 500 mg (for pain) one tablet three times daily; * Apixaban 2.5 mg (for pulmonary embolism prevention) one tablet twice daily; * Atorvastatin 40 mg (for cerebrovascular accident or stroke) one tablet by mouth nightly; * Diclofenac sodium 1% gel (for left shoulder and low back pain), 4 grams topically four times daily, apply 2 grams to shoulder area and 2 grams to low back area four times daily; * Enalapril 20 mg (for high blood pressure) one tablet daily; * Metoprolol succinate 50 mg (for cardiac failure) one tablet by mouth daily; * Miconazole 2% powder (for ringworm of groin area) apply topically twice daily; * Simethicone 80 mg (for gas) one tablet four times daily; * Tamsulosin HCL 0.4 mg (for benign enlargement of prostate) one capsule at bedtime; and * Carboxymethylcellulose 1% ophthalmic solution (for dry eye syndrome) one drop every four hours between morning and bedtime. e. The MAR was blank on 08/20/25 for the two pm doses for the following medications: * Acetaminophen 500 mg (for pain) one tablet three times daily; and * Vitamin A-C-E-zinc-copper (for eye health) take two tablets daily with dinner. On 08/26/25 at 1:36 pm, the surveyor and Staff 9 (MT) observed the computer MAR and medication supply. Staff 9 was unable to verify if the above orders had been followed. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) on 08/27/25 at 10:15 am. She acknowledged the findings.

1. Order for discontinuing Donepezil on resident 2 was faxed to facility with discontinue date of August 5, 2025, reviewed and placed into chart Late entry note documenting resident 4 did receive his medications on August 12 at 8pm after verifying that RN did not properly document in MAR 2. Missed medications and medication exceptions report to be printed daily and reviewed during daily stand up meeting by management team Monday-Friday. Facility nurse will review and document late entry corrections for any missing documentation Facility nurse will follow up with any missed medications to include but not limited to contacting pharmacy, PCP, and resident as indicated for location of medication and any adverse reaction to resident 3. Documentation will be audited daily until compliance met and then quarterly through QAPI process 4. Administrator or designee

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

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 2 sampled residents (# 3) who had documented medication refusals. Findings include, but are not limited to: Resident 3 was admitted to the facility 02/2025 with diagnosis including low bone density. Resident 3's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication refusals between 08/14/25 and 08/24/25. The medications refused included: Acetaminophen (for pain); Sertraline (for depression); Calcium Carbonate (for osteopenia); and Cholecalciferol (for osteopenia). There was no documented evidence the facility notified the physician when the resident refused consent to the orders. On 08/26/25 at 2:08 pm, Staff 9 (MT) stated staff called refusals in directly to the provider for Resident 3 but was unaware if there was a specific system as to how often or by what method each shift should report refusals to the provider. On 08/27/25 the failure to notify physicians of the documented medication refusals was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Resident Service Director). They acknowledged the findings. No further documentation was provided.

1. Resident 3 PCP was notified of residents refusal of medications and documented in progress notes. 2. Medication refusal report to be printed daily and reviewed during daily stand up meeting by management team Monday-Friday. Facility nurse will request from all Providers refusal protocol for all residents and document in MAR for medication aide to follow and notify provider per order Facility nurse will review and discuss with resident reason for refusing medication and document in progress notes. Facility nurse will discuss finding with provider 3. Documentation will be audited daily until compliance met and then quarterly through QAPI process 4. Administrator or designee

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

OAR 411-054-0070 (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 direct care staff (#s 10, 11, and 12) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 08/27/25. The following was identified: There was no documented evidence Staff 10 (MT) hired 03/22/25, Staff 11 (CG) hired 06/16/25, and Staff 12 (CG) hired 03/24/25, had demonstrated competency in the following required areas and within 30 days of hire: Providing assistance with ADLs; Changes associated with normal aging; Conditions that require assessment, treatment, observation and reporting; and General food safety, serving and sanitation. The need to ensure staff had demonstrated competency in all job duties within 30 days of hire was reviewed with Staff 1 (Administrator) on 08/27/25 at 2:00 pm. She acknowledged the findings.

1. All medication aide staff will demonstrate competency in providing assistance with ADL's All staff will be educated via Oregon Care partners for changes associated with normal aging, conditions that require assessment, treatment, observation & reporting, and general food safety, serving, and sanitation 2. All newly hired staff will be trained according to OAR requirements within 30 days of hire All direct care staff will have ADL competencies completed within 30 days of hire 3. Documentation will be audited weekly until compliance met and then quarterly through QAPI process 4. Administrator or designee

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

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long-term direct care staff (#s 13, 14, 15, and 16) completed 12 hours of annual in-service training, including at least six hours of dementia care and one hour of infectious disease training, based on their anniversary date of hire. Findings include, but are not limited to: Training records were reviewed on 08/27/25. The following was identified: There was no documented evidence Staff 13 (CG) hired 01/06/20, Staff 14 (CG) hired 01/09/22, Staff 15 (CG), hired 01/26/16, and Staff 16 (CG), hired 02/27/23, completed at least 12 hours of training related to the provision of care in CBC setting, including a minimum of six hours of training on dementia care topics and at least one hour of infectious disease training annually based on the anniversary date of hire. The need to ensure long-term direct care staff completed the required number of hours of annual in-service training and annual infectious disease training was discussed with Staff 1 (Administrator) on 08/27/25 at 2:00 pm. She acknowledged the findings.

1. All staff requiring annual training will complete 6 hours of dementia training and one hour of infection control training via Oregon Care Partners 2. All staff will be trained according to OAR requirements annually 3. Documentation will be audited weekly until compliance met and then quarterly through QAPI process 4. Administrator or designee

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 08/26/25, review of facility fire drill and fire and life safety instruction records, from 02/2025 through 07/2025, and interviews with staff indicated the facility was not documenting: * Location if simulated fire origin; * The escape route used; and * Problems encountered and comments related to residents who resisted or failed to participate in the drills. On 08/27/25, the need to ensure all areas of fire drills were documented was discussed with Staff 1 (Administer). She acknowledged the findings.

1. Fire drill documentation amended to include location of simulated fire origin, escape route to be used in the event of a fire, problems encountered and comments related to residents who resisted or failed to participate in the drills. 2. Fire drills will be conducted per OAR regulations with all appropriate documentation noted to include but not limited to interventions needed to assist residents who resist participation 3. Documentation will be audited weekly until compliance met and then quarterly through QAPI process 4. Administrator or designee

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: