Print Inspection: RL006492

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office, unless an immediate facility investigation reasonably concluded and documented abuse had been ruled out for 2 of 3 sampled residents (#s 1 and 2) with injuries of unknown cause. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2020 with diagnoses including dementia and type 2 diabetes. Narrative Charting from 06/04/25 to 09/01/25 and incident reports, dated 06/23/25 to 08/27/25 were reviewed and noted the following: • 07/11/25: “… area near left elbow measuring 1 cm x 1 cm…”; and • 08/08/25: “Additional bruising is observed on the right hand.” There was no documented evidence the incidents had been reported to SPD and/or immediately investigated to rule out abuse. On 09/05/25 at 11:00 am, additional documentation was requested, but no additional documentation was provided. The need to ensure incidents were immediately investigated and if abuse or suspected abuse could not be ruled out, the incidents were reported to the local SPD office was discussed with Staff 1 (ED), Staff 4 (Interim Administrator) and Staff 20 (AL Administrator) on 09/05/25 during the exit interview. They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2021 and had diagnoses including early onset Alzheimer's dementia. A review of Resident 1's Narrative charting notes, incident reports and investigations, interim service plans (ISPs), and outside provider notes, identified the following: • On 07/17/25, a hospice note from the shower aide indicated two bruises to the left elbow. There was no evidence the bruises were investigated until 07/24/25 and found “consistent with a recent fall.”; • On 07/24/25, a hospice note from the shower aide noted “…red sheer area to right knee”. No documented evidence the knee injury was investigated until 08/26/25; and • On 08/07/25, a hospice note indicated Resident 1 had a bruise to the right forearm. There was no documented evidence the bruise was investigated until 08/12/25. The injuries identified from the hospice notes constituted injuries of unknown cause. On 09/04/25, Staff 4 (Interim Administrator) confirmed the facility had not promptly completed an investigation or incident report to rule out abuse or reported the injury to the local SPD office if abuse or suspected abuse could not be ruled out. The need to ensure incidents were immediately investigated and if abuse or suspected abuse could not be ruled out, the incidents were reported to the local SPD office was discussed with Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC) and Staff 20 (AL Administrator) and Witness 1 (Consultant Nurse/RN) on 09/05/25 at 9:40 am. They acknowledged the findings.

1. Actions • Community investigated injuries for residents #1 and #2 based on State survey, and filed IR reports with SPD. 2. System Changes • DHS/ CFLD or designee are responsible for investigation and documentation of any injuries of unknown cause, and SPD reporting within 24 hours unless abuse or neglect is ruled out • Re-trained care and supervisory staff on: o Identifying and reporting injuries o Abuse reporting rules per OAR 411-054-0028 • Staff signed forms confirming understanding. • Administrator or designee will review incident reports on EHR system daily and follow up as needed. If necessary, IR reports will be submitted to SPD. 3. Monitoring • Weekly audits of incident reports to ensure investigations and proper reporting are completed. This will be done by the Executive Director or designee • Results will be reviewed in weekly QA meetings and corrective measures initiated if needed. • Audits will continue for 6 months or until deemed in substantial compliance by QA committee 4. Responsible Party Executive Director/CFLD/Administrator or designee

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

OAR 411-054-0036 (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 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 06/2021 and had diagnoses including early onset Alzheimer's dementia. Observations of the resident, interviews with staff, review of interim service plans, Narrative Charting notes from 06/02/25 through 09/01/25, and review of the service plan, dated 08/13/25, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff: • Dressing, including number of female versus male staff to provide assist; • Bathing, including the outside provider who provides the assistance, frequency, and when facility staff would also provide; • Toileting, including number of female versus male staff required, assistance needed and who provides briefs; • How to minimize anxiety or aggressive behaviors when staff provide ADL assistance; • Sexual behaviors during ADL assistance and how staff should respond to the behavior; • Skin integrity including chronic intermittent redness on buttocks and how to manage; • Eating, including ability and assistance needed from staff; • Fall risk history including falls at night and interventions identified; • Medications being provided; and • Communication, including the ability to be understood and understand others. During an interview on 09/04/25, Staff 13 (CG) reported Resident 1 needed staff to move slow and talk through what they were helping him/her with and allow time to process that information. “Otherwise, s/he will grab onto your arm and become agitated.” Staff 13 also indicated Resident 1 benefitted from visual and verbal cues of the ADL task to help with his/her understanding of the assistance being provided. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC), Staff 20 (AL Administrator) and Witness 1 (Consultant Nurse/RN) on 09/05/25. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2020 with diagnoses including dementia and type 2 diabetes mellitus. Observations were made of the resident's care from 09/04/25 through 09/05/25. Interviews with facility staff were conducted. The current service plan dated 09/03/25 and Temporary Service Plans, dated 06/04/25 through 08/27/25, were reviewed. Resident 2's service plan was not reflective of the resident's current needs, lacked clear instructions to staff and was not implemented as outlined in the following areas: • Use of a cushion while in a wheelchair; • Apply barrier cream; • Check incontinence status 12 times per shift; • Place a rolled towel under one side or other when in the wheelchair; and • Reposition every two hours. The need to ensure the service plan reflected resident’s current needs, provided clear instruction to staff and was implemented as outlined was reviewed with Staff 1 (ED), Staff 4 (Interim Administrator) and Staff 20 (AL Administrator) on 09/05/25 at 8:45 am. They acknowledged the findings. 3. Resident 3 moved into the community in 03/2021 with diagnoses including Alzheimer’s dementia. The resident’s service plan dated 08/04/25 was reviewed, observations were made, and staff interviews were conducted. During the entrance interview, the resident was identified as needing full assistance for all ADLs. The resident's service plan was not implemented in the area of grooming. The resident’s service plan instructed staff to “provide oral care with toothpaste and sponge applicator morning and night…Use small amount of toothpaste on sponge, then use sponge with water to rinse.” Staff 21 (MT/CG) reported in an interview on 09/04/25 that they never use a sponge when providing oral care for Resident 3, and “always uses a toothbrush because [s/he] has teeth.” On 09/04/25 at 3:30 pm, the need to ensure service plans were implemented was discussed with Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC), Staff 20 (AL Administrator), and Witness 1 (Consultant Nurse/RN). They acknowledged the findings.

1. Actions Resident #1: • Updated service plan on 09/15/2025 to include dressing preferences, bathing, toileting, skin care, meal help, fall prevention, medications, and communication. • Staff reviewed these updates. Resident #2: • Updated plan on 09/15/2025 for wheelchair positioning, barrier cream, incontinence checks, and repositioning schedule. • Staff reviewed these updates. Resident #3: • Grooming plan updated on 9/4/2025 through TSP to reflect natural teeth and use of toothbrush instead of sponge. Service plan updated to reflect changes. • Proper oral care reviewed with caregivers. 2. System Changes • Service plans for all residents will be audited by November 3, 2025 and corrected if needed. • Community will audit and update current assessments to reflect all required elements as outlined in the state regulation and incorporate person-centered care with clear instructions based on residents' preferences. 3. Monitoring • Administrator/designees will do a random monthly audit of scheduled and pre-move-in assessments and work with DHS/CFLD to correct and personalize if needed. Community and will use the resident evaluation form to ensure that all elements of the resident's needs are identified and personalized in the service plan. Audit results will be discussed at QA meetings and corrective action taken if needed. 4. Executive Director/CFLD/Administrator or designee.

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 resident-specific interventions for residents following a change of condition, monitor the resident according to their needs, including effectiveness of interventions, and/or monitor and document weekly progress until the condition resolved for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 06/2021 and had diagnoses including early onset Alzheimer's dementia. The resident's clinical record including Narrative Charting notes from 06/02/25 through 09/01/25, service plan, updated on 08/13/25, and Temporary Service Plans (TSP’s) were reviewed during this survey. Resident 1 was admitted to hospice on 06/17/25. a. Resident 1's weight records from June 2025 to August 2025 were reviewed and indicated the following: * 06/05/25 - 179.0 pounds; * 07/22/25 - 158.0 pounds; and * 08/19/25 - 153.0 pounds. Resident 1 was identified with a significant weight loss on 07/22/25. An RN assessment was completed on 07/25/25 and interventions were identified as a result of the weight loss on 07/30/25. Interventions communicated to staff on a TSP included “encourage meals [sic] attendance cueing and remind resident to increase intake, offer room trays, report refusals to hospice, nurse and leadership.” On 08/18/25 a “Significant change of condition note” was completed by the RN and identified s/he “lost another 5.5 lbs. [pounds] in the last month [s/he] now weighs 153 lbs...Today staff reported [s/he] has been doing better and seen eating [his/her] breakfast independently...Staff are to…encourage meals and snacks and assist when needed. No other changes to plan of care this week.” On 08/25/25 a “Significant change of condition note” by the RN noted “...[Resident 1] has been feeding [himself/herself] without staff assistance and doing well...weight has not been obtained since last week but continued weight loss to be expected as part of the natural hospice decline.” No changes made at this time. On 09/04/25, Resident 1 weighed 149.5 pounds, indicating an additional 3.5-pound weight loss. During survey on 09/03/25, observations of Resident 1 included s/he ate 95% at breakfast and 100% at lunch with intermittent assistance from staff to cut up the French toast at breakfast and initiate using the utensils at breakfast and lunch. In an interview on 09/04/25 at 5:10 pm, Witness 1 (Consultant Nurse/RN) acknowledged the RN notes, on 08/18/25 and 08/25/25, lacked evidence the current weight interventions were consistently monitored for effectiveness. She acknowledged the facility had several different nurses involved in monitoring the resident and they no longer work in the facility. During the interview, Witness 1 indicated she had initiated implementation of new interventions on 09/04/25 which included meal monitoring, ordering weighted utensils, updated the MAR to obtain weight weekly, and contacted hospice to see if they want to consider a nutritional supplement. The facility failed to implemented weight loss interventions, evaluate the effectiveness of interventions, and monitor the continue weight loss decline. b. The facility failed to monitor the change of condition, at least weekly, until resolved for the following short-term changes of condition: • 05/29/25: Bruising left elbow; • 06/26/25: Discoloration left upper arm near armpit; • 07/02/25: Non-injury fall; • 07/16/25: Non-injury fall; • 07/23/25: Injury fall; • 07/24/25: Bruise to right elbow; • 07/24/25: Hospice shower aide noted “red sheer area to right knee”; • 08/02/25: “Light bleeding almost looked like acne but very small bleed into chux”; and • 08/06/25: Skin tear right elbow. During an interview with Witness 1, (Consultant Nurse/RN) on 09/04/25 at 5:10 pm, she indicated the facility had several nurses who were no longer working in the facility and acknowledged monitoring changes of condition until resolution was not happening consistently. The need to ensure interventions for weight loss were monitored for effectiveness, and changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC), Staff 20 (AL Administrator) and Witness 1 on 09/05/25 at 9:40 am. They acknowledged the findings. 2. Resident 3 moved into the community in 03/2021 with diagnoses including Alzheimer’s dementia. The resident’s 06/03/25 through 09/01/25 Narrative Charting notes and 06/05 through 08/14/25 hospice notes were reviewed. There was no documented evidence that the following changes of condition were monitored at least weekly through resolution: • 08/04/25 – lifting toenail on right foot; • 08/07/25 – bleeding gums; and • 08/14/25 – “red area next to [genital] area.” On 09/04/25 at 3:30 pm, those findings were discussed with Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC), Staff 20 (AL Administrator), and Witness 1 (Administrator Consultant/RN). They acknowledged the findings, and no additional information was provided. 3. Resident 2 was admitted to the facility in 08/2020 with diagnoses including dementia and type 2 diabetes mellitus. Review of the resident's clinical record including Narrative Charting notes from 06/04/25 through 09/01/25, service plan updated on 09/03/25 and Temporary Service Plans (TSPs) were completed during the survey. The facility failed to monitor the change of condition, at least weekly, until resolved for the following changes of condition: • 06/04/25: Refusal of multiple morning medications; • 06/30/25: Changed diet to cut up food; • 07/16/25: Discontinued on Lasix, potassium and lisinopril; and • 08/21/25: Crushed all crushable medications. Additionally, multiple skin issues were identified from June 2025 to September 2025 and each issue was not consistently monitored to resolution. On 09/05/25 at 8:50 am, Witness 1 (Consultant Nurse, RN) reported Staff 20 (ALF Administrator, LPN) reviewed the resident’s skin. When a new facility RN started at the facility, s/he observed the resident’s skin and did not consistently follow up on each skin issue. That RN was no longer working at the facility. The need to ensure the facility monitored the change of condition, at least weekly, until resolved was discussed with Staff 1 (ED), Staff 4 (Interim Administrator) and Staff 20 (AL Administrator) on 09/05/25 at 8:45 am. They acknowledged the findings.

1. Actions Resident #1: • Reviewed weight loss and condition changes. • Started new interventions on 09/15/2025, including meal monitoring, use of weighted utensils, weekly weight checks, and hospice consult. Residents #2 and #3: • Reviewed care plans for changes such as medication refusals, skin issues, and falls. • Updated care plans on 09/15/2025 with interventions and monitoring. • Staff completed training on two-person assist, hoyer and gait belt use for repositioning and transfers. 2. System Changes • Conducted staff training that covered: o Identifying and reporting changes of condition o Creating and monitoring care plans o Documenting progress and communicating concerns • New staff to be trained during onboarding. • QA Committee will review significant changes during the weekly meeting and take action if needed. 3. Monitoring • CFLD or designee will do weekly chart audits of residents with condition changes to ensure care is updated, individualized and documented. • Any issues will be addressed with retraining and/or care plan updates. • QA Committee will reviewaudit results and provide ongoing oversight monthly until deemed in substantial compliance 4. Executive Director/CFLD/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(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site outside providers were communicated to staff and service plans adjusted if necessary for 1 of 2 sampled residents (#s 1) who received outside services. Findings include, but are not limited to: Resident 1 moved into the facility in 06/2021 and had diagnoses including early onset Alzheimer's dementia. Resident 1 was identified during the acuity interview on 09/02/25 as receiving hospice services. Review of Narrative Charting notes and "Outside Provider Communication Forms" from 04/07/25 through 08/14/25 included the following information made by the provider: • 06/27/25: "Red/chapped area to buttocks “add cream please”; • 07/21/25: “…[Resident 1] was soiled in urine (down to mattress) please check for incontinence; and • 07/24/25: Hospice shower aide noted “red sheer area to right knee”. The facility lacked documented evidence the information was communicated to direct care staff or the service plan was adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC) and Staff 20 (AL Administrator) and Witness 1 (Consultant Nurse/RN) on 09/05/25 at 9:40 am. They acknowledged the findings.

1. Actions • Reviewed Resident #1’s records and hospice recommendations. • Shared outside provider instructions with staff. • Updated Resident #1’s service plan on 09/15/2025 to include hospice care recommendations. • Trained staff on timely communication and documentation of outside provider reccommendations. 2. System Changes Outside provider communication form is initiated to be filled out after each visit. When entering the community, outside agencies are informed of expectations to check in with the nurse or director as they enter and exit the community, and fill out the form after each visit. Updated daily team meetings to review outside provider communication. Resident assessments and care plans are updated during the meeting as needed. • Trained relevant staff on the updated process. This will be included in the new hire and yearly training. 3. Monitoring • QA Committee will review outside provider communications and resident documents during the weekly meeting, and take action if needed. 4. Executive Director/CFLD/Administrator or designee

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (# 2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 08/2020 with diagnoses including dementia and type 2 diabetes mellitus. Resident 2's current physician's orders and MAR/TAR dated 08/01/25 through 09/03/25 were reviewed and the following was identified: a. Resident 2 had a physician's order, dated 08/06/25, noted administer insulin degludec 15 units twice daily and to hold if blood sugar level less than 120. Resident 2's 08/01/25 through 09/03/25 MAR revealed there were two occasions CBGs were less than 120, however the insulin was administered when it should have been held. b. Resident 2 had a physician's order, dated 08/06/25, noted administer insulin lispro 5 units three times daily and to hold if blood sugar level less than 120. Resident 2's 08/01/25 through 09/03/25 MAR revealed there were five occasions CBGs were less than 120, however the insulin was administered when it should have been held. c. Resident 2's 08/01/25 through 09/03/25 MAR showed noted administer Tresiba Flextouch 20 units twice daily and to hold if the blood sugar level less than 120. However, on one occasion, the medication was administered when it should have been held. The need to ensure all medications were carried out as prescribed was discussed with Staff 1 (ED), Staff 4 (Interim Administrator) and Staff 20 (AL Administrator) on 09/05/25 at 8:45 am. They acknowledged the findings.

1. Actions • On 09/15/2025, reviewed Resident #2’s insulin orders and medication records with nursing staff. Staff confirmed understanding. • Completed a medication audit and clarified the prescription and doctor’s orders. • Re-trained staff on following physician’s orders regarding holding insulin. 2. System Changes • Re-trained designated med-techs on insulin orders and blood sugar monitoring. 3. Monitoring • CFLD or designee will audit MARS weekly for compliance with physician’s orders. • Results will be reviewed monthly by the QA Committee With follow-up as needed. • Monitoring will continue for six months, or until in compliance. 4. Executive Director/CFLD/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 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included reason for use, resident-specific parameters, and clear staff instruction for 3 of 3 sampled residents (#s 1, 2 and 3) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2020 with diagnoses including dementia and type 2 diabetes mellitus. Resident 2’s 08/01/25 through 09/03/25 MARs were reviewed during the survey and the following was identified: • Multiple PRN cough medications lacked clear parameters for when they should be administered, and which one should be given first; and • Apply Mupirocin 2 % ointment to affected area. However, there was no indication of the specific location for the treatment. On 09/05/25 at 8:45 am, the need for resident-specific parameters and clear instructions for unlicensed staff to follow was discussed with Staff 1 (ED), Staff 4 (Interim Administrator) and Staff 20 (AL Administrator) on 09/05/25 at 8:45 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2021 and had diagnoses including early onset Alzheimer's dementia. Resident 1's MARs, dated 08/01/25 through 09/02/25 were reviewed. a. Haloperidol lacked a documented reason for use on the MARs. b. A new order for Remedy Special Protectant, to be administered 6 times/day, was added on the MAR beginning 08/22/25. It was noted as administered at 2:00 am on 08/22/25, 08/23/25 and 08/26/25, with additional blanks on 08/26/25 at 6:00 pm and 08/28/25 at 6:00 am. All other entries between 08/22/25 and 08/27/25 noted the medication was not in the facility. A Narrative Charting note labeled “RN follow up on missed barrier cream” from 08/26/25 noted “This RN approved barrier cream in the MAR on 8/21 as cream was reported to be on-site. The medication has not been delivered from hospice.” In an interview on 09/05/25 at 9:40 am, Witness 1 (Consultant Nurse, RN) acknowledged the MAR indicated the medication was given despite the medication not being in the facility. c. Resident 1 had 3 PRN medications for pain medications with conflicting parameters regarding administration: * Acetaminophen 325 mg give 2 tablets every four hours PRN pain. Additional instructions included “Give this medication for pain scale 1-10. If no relief within 1 hr (hour), see naproxen”; * Naproxen 250 mg give 1 tablet every 12 hours PRN pain. “For mild pain < 5/10 scale, use naproxen.” * Oxycodone 5 mg give 1 tablet every 2 hours PRN pain/trouble breathing. “For mild pain <5/10 scale, use naproxen first. For moderate to severe pain demonstrated by grimacing, groaning, guarding, rubbing or verbalizing pain, give oxycodone as ordered.” The resident was administered Acetaminophen six times, including five times when pain level was recorded between 5-10. The resident was administered Oxycodone once and had not been administered naproxen. The need to ensure medications on the MARs included reason for use, resident-specific parameters for PRN medications, and the MARs were accurate was discussed with Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC), Staff 20 (AL Administrator) and Witness 1 (RN) on 09/05/25 at 9:40 am. The staff acknowledged the findings. They acknowledged the findings. 3. Resident 3 moved into the community in 03/2021 with diagnoses including Alzheimer’s dementia. The resident’s 08/01/25 through 09/02/25 MAR and corresponding signed physician orders were reviewed. Resident 3 had two PRN medications for pain with conflicting parameters regarding administration: • Acetaminophen 325 mg tablet – give 2 tabs by mouth every 4 hours as needed for pain/fever. Use universal pain scale. Give this medication for pain scale 1-10; and • Oxycodone immediate 5mg – give 1 tablet by mouth every 2 hours as needed for pain/trouble breathing. May give for pain 5-10 on universal pain scale, or if acetaminophen is not effective. The resident was administered Acetaminophen two times, including once when pain level was recorded as 5. The resident was administered Oxycodone once. The need to ensure resident MARs were accurate, including clear and specific instructions to staff administering medication, was discussed with Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC), Staff 20 (AL Administrator), and Witness 1 (Administrator Consultant/RN). They acknowledged the findings.

1. Actions • Reviewed and clarified MARs to ensure: o Clear reasons for each medication o Specific instructions for PRN (as-needed) meds o Clear directions on where and how medications should be applied (e.g., ointment sites) • Removed confusing PRN instructions and replaced with standard, doctor-approved directions. • MARs reviewed for any inconsistencies in documentation or medication availability. • Trained staff on proper documentation and timely re-ordering to ensure medication availability. 2. System Changes • New orders are left for nurse review in the communication binder. • Nurse reviews MARs against physician orders for new orders or changes and clarifies with physician if orders are unclear. • Retrained nursing staff on checking orders and MAR clarity around when and how to administer medications. 3. Monitoring • CFLD/DHS or designee will audit MARs weekly for 3 months, then monthly. • Results and any needs for improvement will be reported to the QA committee. • The QA team will review for trends and make changes as needed to keep compliance. 4. Executive Director/CFLD/Administrator or designee

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements that staff were providing for 2 of 3 sampled residents (#s 1 and 2) as outlined in the individual service plan. Findings include but are not limited to: 1. Resident 2 was admitted to the facility in 08/2020 with diagnoses including dementia and type 2 diabetes mellitus. During the survey, Resident 2 was observed to require staff assistance with transfers and incontinence management with two staff members providing support. The service plan, dated 09/03/25, Temporary Service Plans, 08/01/25 through 09/03/25 MAR and the resident's corresponding ABST individual minutes were reviewed. Resident 2 was observed, and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas: * Non-drug interventions for behaviors; * Transferring; * Bowel and Bladder management; and * Repositioning. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (ED), Staff 4 (Interim Administrator) and Staff 20 (AL Administrator) on 09/05/25 at 8:45 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2021 and had diagnoses including early onset Alzheimer's dementia. During the survey, Resident 1 was observed to require two female staff members provide assistance with incontinent care. The service plan, dated 08/13/25, Temporary Service Plans and the resident's corresponding ABST individual minutes were reviewed. Resident 1 was observed, and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas: • Assisting with communication; • Providing treatments; • Cueing, or supporting while eating; • Ambulation, escorting to and from meals or activities; • Transferring in or out of bed or chair; and • Bowel and bladder management. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 4 (Interim ED) on 09/04/25, Staff 1 (ED), and Staff 5 (Director of Assisted Living/RCC) on 09/05/25 at 9:40 am. They acknowledged the findings.

1. Actions • Audited and corrected ABST records for Residents #1 and #2 to make sure all care time and needed care tasks were recorded correctly. 2. System Changes • Team meets daily to review resident changes, including time needed to complete tasks. CFLD or designee will update the ABST tool based on resident’s changes 3. Monitoring • Executive Director or designee will audit ABST documentation weekly for three months to ensure accuracy. • QA committee will review audit results monthly and address any issues 4. Executive Director/CFLD/Administrator or designee

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 provide fire and life safety instruction to staff on alternating months and to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: On 09/04/25, fire and life safety records, dated 03/2025 through 08/2025, were reviewed and revealed the following: • Fire and life safety instruction was not consistently provided to staff on alternating months; and • Fire drill records lacked documented evidence of the problems encountered and comments relating to residents who resisted or failed to participate in the drills. During an interview on 09/04/25 at 2:40 pm, Staff 22 (Director of Environmental Services) acknowledged fire and life safety instruction to staff on alternate months did not consistently include topics relevant to fire and life safety instruction. In regard to fire drills, he indicated the facility was in the process of working on a new system and the problems encountered had focused on staff, not residents. The need to ensure fire and life safety training was conducted on alternating months and all required components were documented was discussed with Staff 4 (Interim Administrator) on 09/04/25, and Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC), Staff 20 (AL Administrator), and Witness 1 (Consultant Nurse/RN) on 09/05/25. The staff acknowledged the findings.

1. Actions • Reviewed and updated all fire and life safety training records from March 2025 to now. • Gave staff a fire and life safety refresher training. • Trained the DES and assistants to identify and document any resident issues during fire and life safety drills. 2. System Changes • Updated fire drill training schedule to include life safety training. • Rotated training topics to cover all Oregon Fire Code requirements. • Improved fire drill forms to capture any issues and resident involvement. • The Environmental Services Director or designee will review drill documentation following each drill. 3. Monitoring • Monthly audits of training attendance and fire drill records. • Quarterly review of audits and actions by the Quality Assurance Committee. • Retraining and corrective steps if problems are found. 4. Executive Director/CFLD/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:

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 limited to: Refer to C231, C362 and C420.

1. Actions: • Reviewed cited deficiencies (C231, C362, C420) to identify root causes. • Corrected all deficiencies for affected residents, updating care plans, medication administration records, and documentation. 2. Systemic Changes o Implemented mandatory ongoing training on Oregon licensing rules for all direct care and administrative staff. o Conduct quarterly competency assessments to ensure compliance. o Established monthly audits of care plans, medication records, and documentation by Nursing Supervisor; findings reviewed with Administration and QA committee. o Improved communication between direct care staff, nursing, and administration for prompt correction of issues by adding additional questions/ prompts to morning meetings. 3. Monitoring • Monthly audits reported to QA Committee. • Quarterly QA reviews of compliance trends and corrective actions. • Immediate corrective action plans for any non-compliance. 4 Executive Director/CFLD/Administrator or designee

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 4 of 4 newly-hired staff (#s 7, 8, 11, and 14) completed all required pre-service orientation training topics; 3 of 3 newly-hired direct care staff (#s 8, 11, and 14) completed all required pre-service dementia training topics; 1 of 3 newly-hired direct care staff (# 8) demonstrated competency in all assigned job duties within 30 days of hire; and 4 of 4 long-term direct care staff (#12, 15, 18 and 19) completed the required number of annual in-service training hours, including at least six hours of training on dementia care. Findings include, but are not limited to: Staff training records were reviewed on 09/04/25 at 1:55 pm with Staff 2 (Assistant ED). a. There was no documented evidence Staff 7 (Dishwasher/Cook), Staff 8 (CG), Staff 11 (Lead MT), and Staff 14 (CG), hired 03/11/25, 06/18/25, 05/30/25, and 06/04/25, respectively, had completed one or more of the following pre-service orientation topics before completing any job duties: • Resident rights and values of CBC care; • Abuse reporting requirements; • Fire safety and emergency procedures; * HCBS course; • LGBTQIA2S+ course; and * Infectious disease prevention. b. There was no documented evidence Staff 7 completed the following pre-service dementia training topics: • Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; • Techniques for understanding, communicating and responding to distressful behavioral symptoms; • Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and • Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach. c. There was no documented evidence Staff 8, Staff 11 and Staff 14 completed one and/or more of the following pre-service dementia training topics: • 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. d. There was no documented evidence Staff 8 demonstrated competency in one or more of the following areas within 30 days of hire: • Changes associated with normal aging; • Identification, documenting and reporting of changes of condition; and • Conditions that require assessment, treatment, observation and reporting. e. There was no documented evidence that Staff 12 (CG/MT), Staff 15 (CG/MT), Staff 18 (CG), and Staff 19 (CG), hired 04/26/21, 12/09/22, 03/08/23, and 12/13/21, respectively, had completed a minimum of 6 hours of annual in-service training related to dementia care, from their anniversary date in 2023 to their anniversary date in 2024, with the exception of Staff 12, whose anniversary date was 03/2024 through 03/2025. Additionally, there was no documented evidence Staff 8 and Staff 11 had completed a minimum of 10 hours of annual in-service training related to the provision of care in CBC. The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules and staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 2 on 09/04/25, and Staff 1 (ED), Staff 5 (Director of Assisted Living/RCC), Staff 20 (AL Administrator), and Witness 1 (Consultant Nurse/RN) on 09/05/25. They acknowledged the findings.

1. Actions: • Reviewed and updated training records for all new and long-term direct care staff. • Provided overdue pre-service orientation to Staff 7, 8, 11, and 14 covering required topics (resident rights, abuse reporting, fire safety, HCBS, LGBTQIA2S+, infectious disease prevention). • Completed missing dementia-specific training for Staff 7, 8, 11, and 14. • Conducted competency assessments for new hires, ensuring demonstration within 30 days of hire. • Ensured Staff 12, 15, 18, and 19 completed annual dementia-related in-service hours. • Started annual CBC-related training for Staff 8 and 11. 2. Systemic Changes o Implemented a training calendar with tracking. o BOM or designee to oversee competency documentation. o Monthly audits of training records for completeness and compliance. o BOM and CFLD or designee oversee training compliance and report monthly to Administrator. o Incorporated training compliance into staff performance reviews. 3. Monitoring and QA: • Monthly audits of training records and competencies. • Quarterly QAPI review of training effectiveness and compliance. • Immediate corrective actions for any lapses. 4. Responsible Party • ED/BOM or designee

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 ensure health service were consistently provided. Findings include, but are not limited to: Refer to C260, C270, C290, C303 and C310.

1. Actions: • Reviewed all current residents’ health care services, care plans, assessments, and medication records to identify and correct inconsistencies. • Reinforced processes for timely assessments, service plan updates, and accurate documentation. • Ensured medication administration complies with physician orders and policies. 2. Systemic Measures: o Mandatory in-service training on regulatory requirements, assessments, service plan adherence, medication administration, and documentation. o Scheduled ongoing competency evaluations. o Daily shift huddles to review resident needs and service updates. o Health care services reviewed monthly in QAPI meetings. 3. Monitoring and QA: • Weekly audits of care plans and service delivery for six months. • Monthly reports of audit results to facility leadership and QA committee. • Immediate corrective actions for deficiencies. • Quarterly staff refresher training and competency checks. 4. Responsible Party • ED/CFLD or designee

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: