Print Inspection: RL006868

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, record review, and interview, it was determined the facility failed to ensure flooring, baseboards, and cabinetry were in good repair in order for the surfaces to be cleanable in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen, dry food storage area, and lunch meal service on 09/24/25, from 10:07 am through 12:13 pm, revealed the following: * The flooring in the kitchen was observed to have deep scratches and gouges between the entrance and the food preparation table; * Water damage was observed in the flooring and the baseboards between the sink and the dishwasher; * Baseboards throughout the kitchen were observed to be cracked in the corners; * There was a hole in the drawer under the toaster and ice counter which had exposed wood; and * Two areas in the lower cupboards located to the right of the stove had gouges in the wood. The above areas were toured with Staff 2 (House/Kitchen Manager) on 09/24/25 and with Staff 1 (RCC/Administrator Assistant) on 09/25/25. Both acknowledged that the flooring, baseboards, and exposed wood were in need of repair or were uncleanable surfaces.

1. The damaged flooring will be replaced by a licensed contractor (see attached bid from Dovetail Design & Construction). 2. After the flooring is replaced, routine maintenance will be followed to assure that baseboards and flooring are replaced or repaired as needed. 3. Monthly inspection by contracted maintenace employee. 4. The Administrator assure completion of the flooring is completed in consultation with licensed contractor and owner.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, record review, and interview, it was determined the facility failed to ensure flooring, baseboards, and cabinetry were in good repair in order for the surfaces to be cleanable in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the main facility kitchen, dry food storage area on 12/04/24, revealed the following: * The flooring in the kitchen was observed to have deep scratches and gouges between the entrance and the food preparation table; * Water damage was observed in the flooring and the baseboards between the sink and the dishwasher; * Baseboards throughout the kitchen were observed to be cracked in the corners; * There was a hole in the drawer under the toaster and ice counter which had exposed wood; and * Two areas in the lower cupboards located to the right of the stove had gouges in the wood. The above areas were toured with Staff 11 (Owner) on 12/04/25. The findings were acknowledged.

1. A bid has been obtained to replace the flooring and baseboards in the kitchen by compliance date. 2. After replacement routine maintenance will be followed to assure that baseboards and flooring are replaced or repaired as needed. 3. Monthly inspection by contracted maintenace employee. 4. The Administrator to assure completion of the remodel in consultation with licensed contractor and owner.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to ensure service plans were reflective of residents’ current needs and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2025 with diagnoses including dementia and experienced falls. The resident’s clinical record, including the service plan, dated 09/18/25, and Temporary Care Plans were reviewed. Resident 1 was observed, and staff were interviewed. The service plan was not reflective of the resident’s current needs and lacked a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas: * Exit seeking; * Fall mat placement; and * Information on outside service providers. Resident 1 was observed throughout the day on 09/25/25 in his/her unit, laying in a hospital bed with bi-lateral siderails in the raised position. A fall mat was on the right side of his/her bed on the floor. The fall mat was not reflected on the resident’s service plan. The need to ensure service plans were reflective of the resident’s current needs, provided clear direction to staff, and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (RCC/Administrator Assistant) on 09/25/25. She acknowledged the findings 2. Resident 2 moved into the facility in 05/2023 with diagnoses including unspecified dementia. The resident’s clinical record, including the service plan, dated 08/15/25, and Temporary Care Plans were reviewed. Resident 2 was observed, and staff were interviewed. The service plan was not reflective of the resident’s current needs and lacked a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas: * Conflicting information relating to thickened liquids and staff being able to provide "popsicles, sherbert, fruit slushes and gelatin desserts"; * How the resident exhibited agitation; * How staff were to offer one-on-one support; * Current behaviors; * Ability to walk; * Conflicting information relating to setting up Resident 2's meals; * Instruction to staff relating to siderails, what to monitor them for, and who to report to if the siderails were loose or in disrepair; and * Assistance needed to sit up. Resident 2 was observed during the survey, from 09/23/25 through 09/25/25, to receive thickened liquids at each meal. The resident was observed sitting in either a regular wheelchair or in a recliner and was not observed walking. Resident 2 slept in a hospital bed with siderails. The siderails had different colored pool noodles on the bars. This was not reflected in his/her service plan. The need to ensure service plans were reflective of the resident’s current needs, provided clear direction to staff, and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (RCC/Administrator Assistant) on 09/25/25. She acknowledged the findings and updated Resident 2’s service plan prior to exit.

1. Resident 1 and 2 Service plans were reviewed and updated. The Service Plan binder has been updated with current service plan, activity plan and nutrition plan.The binder also includes any pertinent instructions from Home Health, hospice, behavioral support, and community nurse. 2. Service plans are printed quarterly at the same time the service conference occurs to assure timely updates. Service plans are printed any time a TSP, Signficant change of condition, or any other change is made to the service plan. An acknowledgement form for staff to sign will be kept with service plans. 3. Monthly review to assure that the latest service plan is included. 4. Administrator in consultation with contracted community nurse as indicated.

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 interview and record review, it was determined the facility failed to ensure significant changes of condition were referred to the facility nurse, actions or interventions were determined, documented, and communicated to staff on each shift for residents who experienced changes of condition, and changes were monitored, with weekly progress noted through resolution, for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2025 with diagnoses including dementia, a history of abnormal weight loss beginning in 2018, and experienced multiple falls. The resident’s clinical record was reviewed. Resident 1 experienced the following changes of condition between 07/03/25 and 09/21/25: a. On 07/03/25, staff documented Resident 1’s weight as 105.8 pounds. The previous weights were recorded on 03/25/25 at 128.4 pounds and on 02/05/25 at 135 pounds. Between 02/05/25 and 07/03/25, the resident lost 29.2 pounds or a total of 21.6% in five months. The weight loss was considered a significant change of condition. There was no documented evidence the RN had assessed Resident 1 for the weight loss. The facility had interventions in place prior top 07/03/25, directing staff to offer Resident 1 an instant breakfast drink for his/her morning snack and to offer a nutritional drink for an after lunch snack snack and as a snack before bed. On 07/11/25, a multivitamin (supplement) and Remeron (used to treat depression and is also an appetite stimulant) were implemented. On 09/25/25 at approximately 8:30 am, Staff 1 (RCC/Administrator Assistant) verified she had not communicated the weight loss documented on 07/03/25 to the facility RN. She explained that the system for the RN to review any resident was that Staff 1 would document what a resident was experiencing and would leave that communication in the RN's binder. The facility failed to refer the significant change in Resident 1's weight to the RN. b. On 07/05/25, the resident had a fall that resulted in a hip fracture. On 07/11/25 Resident 1 returned to the facility. Temporary Care Plans were implemented relating to the surgical site, fall, and medication changes on 07/11/25. Alert charting began and documentation continued through 07/28/25. The facility failed to monitor Resident 1 with weekly progress noted through resolution. c. On 07/12/25, the resident had a non-injury fall. The facility failed to evaluate the resident in order to determine actions or interventions and monitor Resident 1 relating to the fall with weekly progress noted through resolution. d. On 09/05/25 the resident had a fall that resulted in a “nickel sized skin tear on left knee.” The facility failed to determine actions or interventions needed for the skin tear and monitor Resident 1's skin, with weekly progress noted through resolution. e. The resident fell on 09/10/25 in the dining room and hit his/her head on a chair. Staff documented that Resident 1 lost consciousness momentarily, and the facility sent him/her to the Emergency Department (ED). The facility failed to determine actions or interventions needed relating to the resident hitting his/her head and monitor Resident 1's head injury with weekly progress noted through resolution. f. On 09/11/25, Resident 1 was complaining of pain in his/her “right hand knuckle (index finger) and thumb area” was swollen. The resident’s spouse took him/her to urgent care. The facility failed to determine actions or interventions needed relating to the resident's hand pain and swelling, and monitor Resident 1 with weekly progress noted through resolution. g. Resident 1 fell on 09/21/25 and reported s/he was trying to go to the bathroom. Staff noted the resident was complaining of head pain and observed both swelling and bleeding. The facility sent Resident 1 to the ED. The facility failed to determine actions or interventions needed relating to the resident hitting his/her head and monitor Resident 1's head injury with weekly progress noted through resolution. The need to ensure significant changes of condition were referred to the facility RN, and actions or interventions were determined, documented, and communicated to staff on all shifts relating to the resident experiencing changes of condition, and those actions or interventions were monitored for effectiveness, with weekly progress noted in the resident record until the condition resolved, was discussed with Staff 1 on 09/25/25. She acknowledged the findings. 2. Resident 2 moved into the facility in 05/2023 with diagnoses including unspecified dementia. The resident’s clinical record was reviewed. Resident 2 experienced the following changes of condition between 06/29/25 and 08/10/25: a. Staff documented on 06/29/25 in the progress notes, "Elder has a scratch on [his/her] left eye on [his/her] bottom eye lid." Hospice RN assessed the eye and reported it appeared to be a "sty on [his/her] right eye." The Hospice RN put a treatment in place for the facility staff to follow and directed staff on when Resident 2 would need to be seen by a "physician for evaluation," which was transcribed on to a Temporary Care Plan document. On 07/14/25, the facility RN noted there was "no sign of sty in eye." There was no documented evidence the eye condition was monitored at least weekly with progress noted. b. On 08/10/25, a Hospice Bath Aide noted “that there was a sty under the [resident's] right eye." There was no documented evidence the resident's eye was evaluated to determine if any interventions were needed, nor was there weekly progress noted until the condition resolved. The need to ensure actions or interventions were determined, documented, and communicated to staff on all shifts for changes of condition and those actions or interventions were monitored for effectiveness, with weekly progress noted in the resident record until the condition resolved, was discussed with Staff 1 (RCC/Administrator Assistant) on 09/25/25. She acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure changes of condition had actions or interventions determined, documented, and communicated to staff on each shift, with weekly progress noted through resolution, for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2025 with diagnoses including dementia, with a history of abnormal weight loss beginning in 2018 and having experienced multiple falls. The resident’s clinical record was reviewed. Resident 1 experienced the following changes of condition between 07/03/25 and 09/21/25: a. On 07/05/25, the resident had a fall that resulted in a hip fracture. On 07/11/25 Resident 1 returned to the facility. Temporary Care Plans were implemented relating to the surgical site, fall, and medication changes on 07/11/25. Alert charting began and documentation continued through 07/28/25. There was no additional documentation that noted progress in the three areas. The facility failed to monitor Resident 1 with weekly progress noted through resolution. b. On 07/12/25, the resident had a non-injury fall. The facility failed to determine actions or interventions and monitor Resident 1 relating to the fall with, weekly progress noted through resolution. c. On 09/05/25 the resident had a fall that resulted in a “nickel sized skin tear on left knee.” The facility failed to determine actions or interventions and monitor Resident 1's skin, with weekly progress noted through resolution. d. The resident fell on 09/10/25 in the dining room and hit his/her head on a chair. Staff documented Resident 1 lost consciousness momentarily, and the facility sent him/her to the Emergency Department (ED). The resident returned on the same day with no new diagnoses. The facility failed to monitor Resident 1's head injury with weekly progress noted through resolution. e. On 09/11/25, Resident 1 was complaining of pain in his/her “right hand knuckle (index finger) and thumb area” was swollen. The resident’s spouse took him/her to urgent care. The facility failed to determine actions or interventions needed relating to the resident's hand pain and swelling, and monitor Resident 1 with weekly progress noted through resolution. f. Resident 1 fell on 09/21/25 and reported s/he was trying to go to the bathroom. Staff noted the resident was complaining of head pain and observed both swelling and bleeding. The facility sent Resident 1 to the ED. The resident returned with the diagnosis of a head injury. The facility failed to determine actions or interventions needed relating to the resident’s head injury and monitor Resident 1's skin with weekly progress noted through resolution. The need to ensure changes of condition had actions or interventions determined, documented, and communicated to staff on all shifts, and those actions or interventions were monitored for effectiveness, with weekly progress noted in the resident record until the condition resolved, was discussed with Staff 1 on 09/25/25. She acknowledged the findings. 2. Resident 2 moved into the facility in 05/2023 with diagnoses including unspecified dementia. The resident’s clinical record was reviewed. Resident 2 experienced the following changes of condition between 06/29/25 and 08/10/25: a. Staff documented on 06/29/25 in the progress notes, "[The resident] has a scratch on [his/her] left eye on [his/her] bottom eye lid." Hospice RN assessed the eye and reported it appeared to be a "sty [sic] on [his/her] right eye." The Hospice RN put a treatment in place for the facility staff to follow and directed staff on when Resident 2 would need to be seen by a "physician for evaluation," which was transcribed onto a Temporary Care Plan document. On 07/14/25, the facility RN noted there was "no sign of sty [sic] in eye." There was no documented evidence the eye condition was monitored at least weekly with progress noted between 06/29/25 and 07/14/25. b. On 08/10/25, a Hospice Bath Aide noted “that there was a sty [sic] under the [resident's] right eye." There was no documented evidence the facility monitored the residents right eye with weekly progress noted until the condition resloved. The need to ensure actions or interventions were determined, documented, and communicated to staff on all shifts for changes of condition and those actions or interventions were monitored for effectiveness, with weekly progress noted in the resident record until the condition resolved, was discussed with Staff 1 (RCC/Administrator Assistant) on 09/25/25. She acknowledged the findings.

1.Residents identified (1 and 2)have had service plans updated and sig. change of condition completed by RN and service plans were updated for the elements noted in the statement of deficiency.. A review of all TSP's was completed and resolved or further service planned. 2. The community will follow the following processes to assure TSP's and Sig. change of conditions will be promptly completed. The community utilizes the following processes available in EHR (electronic health record.) a.In-Service with Med Techs on using Temporary Service Plan and Alert Charting. b. EHR Alert Charting following the Alert Charting Guidelines Administrator responsibilities: a.Review Notes Monday- Friday b.Review Incident Reports Monday -Friday- c.Administrator to work with Med Techs to assure alert charting and TSP’s are utilized appropriately and that the information is accurate.. d.Review Alert Charting in EHR Monday-Friday e.Coordinate Care with home health, hospice, wound clinic for wounds assessment monitoring by RN. f.Assure WhiteBoard up to date of residents on TSP or change of condition requring weekly monitoring and resolution of condition. Med Tech responsibilities: a.Prompt notifications following Nurse notification guidelines document. b.Follow charting guidelines to assure prompt and accurate reporting of resident status d.Med Techs to use Med Tech to Med Tech communication log (24 hour report) each shift.

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

OAR 411-054-0055 (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 medication and treatment orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2025 with diagnoses including dementia. The resident’s facility records, including MARs dated 08/01/25 through 09/23/25, and prescriber’s orders were reviewed. The following was identified: a. There was a signed order dated 08/08/25 which directed the facility to weigh Resident 1 weekly for six weeks and check his/her blood pressure "2 - 3" days a week. The prescriber wanted the facility to notify her if Resident 1's blood pressure was below "100/60." There was no documented evidence the order was transcribed onto the MAR or that staff followed the orders. b. The following prescriber-ordered directions to staff lacked documentation of staff initials: * Monitor healing process of left hip incision area. Notify if redness occurs or hot to the touch [or] oozing begins"; * Nail care: 12 times; * Oral care: 73 times; * Shower: 12 times; and * Skin checks: 12 times. On 09/23/25 at 2:05 pm, Staff 5 (MT/Universal Worker) reported that blanks on the MAR meant the medication was not administered or the treatment had not been completed. The need to ensure the facility followed the physician’s orders was discussed with Staff 1 (RCC/Administrator Assistant) on 09/25/25. She acknowledged the findings. 2. Resident 2 moved into the facility in 05/2023 with diagnoses including unspecified dementia, Parkinson’s disease, and a history of constipation. The resident’s facility records, including MARs dated 09/01/25 through 09/23/25, and physician’s orders were reviewed. The following physician-ordered medications and directions to staff lacked documentation of staff initials: * Bowel monitoring on each shift: Five times; * Carbidopa-L-Dopa (for Parkinson's symptoms): Twice; * Monthly vitals and weight: Once; * Nail care: Six times; * Oral care: 33 times; * Quetiapine (for agitation): Once; * Shower: Six times; * Skin checks: Six times; and * Trazodone (for insomnia): Once. On 09/23/25 at 2:05 pm, Staff 5 (MT/Universal Worker) reported that blanks on the MAR meant the medication was not administered or the treatment had not been completed. The need to ensure the facility followed the physician’s orders was discussed with Staff 1 (RCC/Administrator Assistant) on 09/25/25. She acknowledged the findings.

1.Complete MAR audit to be completed by nursing. When completed new 90 day orders will be sent to providers. Resident 1 and 2 had PRN parameters and order of PRN use placed in EMAR. 2. 90 Day orders are done quarterly by the RN and sent to providers. All new orders, changes, or DC orders will be overseen by qualified staff. 3 check med review in place. In-Service with Med Techs on assuring MAR accuracy and documentation 3. Daily monitoring of "out of stock" meds, "holes" and missed medications by Admistrator will occur. 4. Administrator with RN oversight.

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 residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2025 with diagnoses including dementia and documented falls. The resident's 08/01/25 through 09/23/25 MARs and prescriber’s orders were reviewed, and the following was identified: a. The facility documented interventions for falls, skin, and bowel monitoring on the resident's MAR. The following lacked documentation of staff initials: * Bed Alarm – “Make sure alarms are attached and turned on. Batteries charged and active. When the elder awakens, turn off bed alarm and put alarm part on med room desk. In pm, prior to elder going to bed, put the alarm piece back on the pad and test alarm”: Four times; * Safety checks every two hours: 369 times; * Monitor skin tear on the left knee: Once; and * Bowel monitoring: Once. b. Resident 1 had two PRN medications to treat constipation, which were docusate and a bisacodyl suppository. The MAR lacked staff instruction on the sequential order in which to administer the medications. c. The following PRN medications were transcribed on Resident 2's MAR twice: * Acetaminophen (to treat pain); * Bisacodyl suppository; * Docusate; and * Loperamide (to treat loose stools). The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (RCC/Administrator Assistant) on 09/25/25. She acknowledged the findings. 2. Resident 2 moved into the facility in 05/2023 with diagnoses including unspecified dementia, a history of constipation, and documented falls. The resident's 09/01/25 through 09/23/25 MARs and physician's orders were reviewed, and the following was identified: a. Fall interventions were located on the resident's MAR. The following lacked documentation of staff initials: * Staff to check the resident's bed alarm to ensure it was attached, turned on, and the batteries were in working order: Twice; and * Safety checks every two hours: 231 times. b. Resident 2 had two PRN medications to treat pain, which were acetaminophen and Morphine. The resident was administered the Morphine on one occasion. The MAR lacked staff instruction on the sequential order in which to administer the medications. c. The resident had multiple PRN medications to treat constipation. The MAR lacked clear instruction of the sequential order in which to administer the medications: * Bowel monitoring check: "Staff to monitor twice a week bowel movements, if no bowel movement in [three] days staff to give PRN suppository"; * Bisacodyl: "Unwrap and insert one suppository rectally once daily as needed"; * MiraLax: For “no [bowel movement] for [three] days"; and * Senna: For “no [bowel movement in four] days and MiraLax has [been] ineffective" d. The following PRN medications were transcribed on Resident 2's MAR twice: * Peg 3350 Powder (generic form of MiraLax); and * Senna. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (RCC/Administrator Assistant) on 09/25/25. She acknowledged the findings.

1.Complete MAR audit to be completed (RN) by alleged compliance date. When completed new 90 day orders will be sent to providers. Nursing specifically looking for diagnoses, parameters, and instructions for unlicensed staff. Med Tech in-service on completion of all tasks and meds assigned in EHR each shift. In-service with med techs to recognize orders that need further review by RN such as parameters and order of use. 2. Daily review of EMAR for "holes" or missed documentation. 3. Evaluated daily as new changes occur, in addition during 90 day MAR audit as 90 day physician orders are prepared. 4. Med Tech, RN, in addition to oversight of Administrator.

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 accurate MARs were kept for all medications and treatments ordered by a legal prescriber and administered by the facility, for 1 of 2 sampled residents (#3) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 3 moved into the facility in 09/2025 with diagnoses including type 2 diabetes mellitus. The resident's 11/01/25 through 11/30/25 MAR and physician’s orders were reviewed, and the following was identified: The following lacked documentation of staff initials: * Skin monitoring for breakdown in groin area and belly folds: four times; * Atorvastatin (for hyperlipidemia): four times; * Cefadroxil (for bacteremia): five times; * Combivent (bronchodilator inhaler): six times; * Daily CBG check (for blood sugars): 13 times * Duloxetine (for major depressive disorder) two times; * Easy touch MIS 31GX3/16 insulin injection (for glucose levels): six times; * Lubricating eye drops: six times; * Hydralazine (for type 2 diabetes mellitus with hyperglycemia): four times; * Insulin aspart 100 unit/ML pen (for type 2 diabetes mellitus with hyperglycemia): seven times; * Melatonin (for sleep): four times; * Nystatin powder (for candidiasis of skin): four times; * Oral care: two times; * Pregabalin (for type 2 diabetes mellitus with hyperglycemia): two times; * Sliding scale insulin (for blood glucose level): seven times; and * Toujeo solo injection (for type 2 diabetes mellitus with hyperglycemia) two times. On 12/04/25 at 1:35 pm, Staff 3 (MT) reported that blanks on the MAR could have meant the medication was administered or the treatment had been completed but the MTs forgot to sign off. The need to ensure MARs were accurate was discussed with Staff 1 (RCC/Administrator Manager) and Staff 11 (Owner/Operator) on 12/05/24. They acknowledged the findings.

1. A Med Room Manager was hired in place of a Lead Med Tech. Staff have been retrained and are now required to show the oncoming shift that they have completed every Medication or Care that is required to be signed. 2. Daily review of EMAR for "holes" or missed documentation by Administrator. Staff who miss a sign off will be required to make a late entry addressing whether that medication or care was actually given. Tracking will be done and staff monitored for excessive "misses". 3. Daily by Administrator 5 days per week and Lead Med Tech on days the administrator is out of the building 4. Med Tech, Administrator in addition to oversight of RN

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure adequate staffing to meet fire safety and evacuation standards on the overnight shift, and a minimum of two care staff available whenever a resident required the assistance of two staff for scheduled and unscheduled needs for 1 of 1 sampled resident (# 2) and one unsampled resident. Findings include, but are not limited to: During the acuity interview on 09/23/25, the consensus was confirmed at 15 residents, with Resident 2 needing one- to two-person assistance for transfers and/or ADL cares and one unsampled resident needing two-person assistance with a mechanical lift for all transfers. The facility’s posted staffing plan and staffing schedule from 09/15/25 through 09/21/25 were reviewed. The following was identified: The posted staffing plan for the facility was as follows: * Day shift: 1 MT, 1 Universal Worker, and 1 Kitchen Staff/Universal Worker; * Evening shift: 1 MT, 1 Universal Worker, and 1 Kitchen Staff/Universal Worker; and * Night shift: 1 MT/Universal Worker. The need to ensure adequate staffing to meet the residents’ scheduled and unscheduled needs and fire safety and evacuation standards was discussed with Staff 1 (RCC/Administrator Assistant) on 09/24/25. Staff 1 increased the number of caregiving staff during the night shift from one to two.

1. The community has increased Night shift staffing to two-person. There are sufficient staff to meet the scheduled and unscheduled needs of residents including evacuation on night shift (10PM-6AM). 2.The community continues to monitor two person transfer residents and staff for the ABST for scheduled, unscheduled, and evaucation needs. 3. At least monthly evaluation of ABST in addition to changes of condition and new or discharged residents. 4. Administrator

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete or update and review the acuity-based staffing tool (ABST) evaluation for each resident before a resident moved in and no less than quarterly at the same time the resident's service plan was updated for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents whose ABST records were reviewed. Findings include, but are not limited to: a. Resident 1 moved into the facility in 02/2025. His/her ABST was created on 03/19/25. The resident’s service plan was updated on 09/18/25. There was no documented evidence Resident 1’s ABST was updated at the same time as the resident’s service plan. b. Resident 2’s ABST was updated on 01/20/25. The resident’s service plan was updated on 08/15/25. There was no documented evidence Resident 2’s ABST was updated at the same time as the resident’s service plan. c. There were two unsampled residents listed on the facility’s ABST that were no longer at the facility. d. The facility’s newest admission had not been entered into the ABST as of 09/24/25. e. One unsampled resident, admitted on 02/05/25, and another unsampled resident, admitted on 03/14/25, were not added to the facility’s ABST until 03/19/25. f. Nine unsampled residents’ ABST had not been updated since 01/20/25. g. One unsampled resident’s ABST had not been updated since 06/22/22. The need to ensure residents’ ABST evaluations were completed prior to move-in and no less than quarterly at the same time the residents’ service plan was updated was discussed with Staff 1 (RCC/Administrator Assistant) on 09/24/25. She acknowledged the findings.

1. Residents 1 and 3 have been updated to reflect their current needs. The ABST is updated prior to new residents moving in and once residents have moved out. The ABST is a reviewed and adjusted as needed when completing evaluations. Staffing and schedule updated daily as changes accur. 2. The ABST review added to the new resident movein check list ensuring completion prior to moving in. The ABST added as part of complete evaluation process as they are scheduled. Quarterly updates done in conjuction with service planning. The staffing plan will be updated quarterly and as needed based upon the changing ABST. Administrator is maintaining schedule to assure adequate staffing. Current days staffing is reviewed each morning to anticipate any staffing gaps that day. 3.The ABST is reviewed and updated daily as needed when changes occur and less than quartley with complete evaluations. Staffing and scheduling updated daily as needed when changes occur. 4.Administrator

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

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents. Findings include, but are not limited to: An environmental walk-through of the MCC between 09/23/25 and 09/25/25 identified the following: * The resident units consisted of single and double occupancy (shared) units; * Each resident unit entrance door lacked a lockable lever-style handle; * Residents 1 and 2 resided in double occupancy rooms that had a shared bathroom, and three unsampled residents were noted to share a bathroom. The shared bathrooms did not have a locking mechanism on the door; and * Resident 1’s room lacked privacy if s/he received personal care while in the bed with their roommate present. In an interview on 09/25/25, Staff 1 (RCC/Administrator Assistant) confirmed four resident units were shared and there was no locking mechanism on the bathroom doors. The need to ensure privacy in individual resident units was reviewed with Staff 1 on 09/25/25. She acknowledged the findings.

1. Locking hardware will be placed on all shared bathrooms. Foldable Privacy Screens have been purchased to use with any resident who is receiving personal care in a shared room will have a visual barrier. Staff will be trained to use the privacy screen and not rely on opening closet doors to block visualization 2. All future installations assure that share a bathroom door shall allow for privacy with a locking mechansim. Privacy Screen purchases have been completed. 3. With the installation of any new hardware. 4. Maintenance Director and Administrator.

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

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) 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. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 3 of 3 newly hired staff (#s 4, 5, and 8) whose training records were reviewed. Findings include, but are not limited to: Refer to Z155.

Refer to Z 155

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) 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. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 1 of 2 newly hired staff (# 5) whose training records were reviewed. Findings include, but are not limited to: Refer to Z155.

Refer to Z155

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) 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. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. 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 C240 and C360.

Refer to C240 and C360

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 C240.

Refer to C240

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 4, 5, and 8) completed all pre-service orientation and dementia training and demonstrated competency in all duties assigned within 30 days of hire; and 2 of 2 long-term staff (#s 3 and 7) failed to complete the required 16 hours of annual in-service training, which included six hours of dementia care topics and infectious disease training. Findings include, but are not limited to: Staff 1 (RCC/Administrator Assistant) provided the requested training records on 09/25/25. Survey reviewed the training records with Staff 1 on 09/25/25 at approximately 3:00 pm. The following was discussed: Training records for Staff 3 (MT), hired 08/22/23, Staff 4 (MT), hired 02/24/25, Staff 5 (MT/Universal Worker), hired 08/04/25, Staff 7 (Universal Worker), hired 06/02/23, and Staff 8 (Universal Worker), hired 08/18/25, were reviewed. a. Staff 4, 5, and 8 lacked documented evidence of the following pre-service orientation topics: * Resident rights and values in CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Approved LGBTQIA2S+ course; and * The use of supportive devices with restraining qualities in memory care communities. b. Additionally, Staff 4 and 5 lacked documented evidence of the following pre-service orientation topics: * Infectious disease prevention; * Approved Home and Community Based Services (HCBS) course; * All pre-service dementia topics prior to providing care and services for all staff, all additional pre-service training required for direct care staff prior to providing personal care, and all pre-service training required for direct care staff prior to independently providing care and services. c. There was no documented evidence Staff 4, 5, and 8 had demonstrated competency in all required areas within 30 days of hire, including the following: * Role of the service plan in providing individualized care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. d. There was no documented evidence Staff 3 completed at least 16 hours of annual in-service training hours, which included a minimum of ten hours related to the provision of care in the Community Based Care (CBC) setting. e. There was no documented evidence Staff 7 completed at least 16 hours of annual in-service training hours, which included a minimum of six hours on dementia care topics, or the annual infectious disease training. The need to ensure direct care staff completed all pre-service orientation, pre-service dementia training, including the additional pre-service training, prior to performing any job duties or independently providing care, and demonstrated competency in all duties assigned within 30 days of hire, and to ensure long-term direct care staff completed 16 hours of annual in-service training, which included six hours of dementia care topics, and infectious disease with Staff 1 on 09/25/25. She acknowledged the findings.

1.Complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. 2. Process: Hire, Onboarding with Orientation form and required pre-service trainings (Oregon Care Partners: Pre-Service Dementia, Infection control, Providing Inclusive Care, HCHB IBL) including CPR, First Aid,and Food Handlers, shadowing on the floor, demonstrated competencies, finish 30 day trainings. Administrator monitors staffing to assure compliance and trainings are completed. Annual Training is completed with a variety of methods including training at All-Staff (documented appropriate with trainer, time, and topic), assigned Relias Courses, and company provided training with certificates documenting topic, hours, and trainer. 3.The Administrator maintains the tracking spreadsheet to assure accuracy of training and within all required timeframes per policy and OAR. 4.Administrator

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 5 and 9) completed all pre-service orientation and dementia training. This is a repeat citation. Findings include, but are not limited to: Training records for Staff 5 (MT/Universal Worker), hired 08/04/25, and Staff 9 (Universal Worker), hired 10/15/25, were reviewed. a. Staff 5 lacked documented evidence of the following pre-service orientation topics: * Abuse reporting requirements; * Fire safety and emergency procedures; * Approved Home and Community Based Services (HCBS) course; * Approved LGBTQIA2S+ course; and * All pre-service dementia topics prior to providing care and services for all staff. b. Staff 9 lacked documented evidence of the following pre-service orientation topics: * Resident rights and values in CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; and * Pre-service dementia training required for direct care staff prior to independently providing care and services. The need to ensure all staff completed all pre-service orientation and pre-service dementia training, and direct care staff completed dementia training prior to providing care and services independently, was discussed with Staff 1 (RCC/Administrator Manager) on 12/05/25. She acknowledged the findings.

1.Complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. 2. Process: Hire, Onboarding with Orientation form and required pre-service trainings (Oregon Care Partners: Pre-Service Dementia, Infection control, Providing Inclusive Care, HCHB IBL) including CPR, First Aid,and Food Handlers, shadowing on the floor, demonstrated competencies, finish 30 day trainings. Administrator monitors staffing to assure compliance and trainings are completed. Annual Training is completed with a variety of methods including training at All-Staff (documented appropriate with trainer, time, and topic), assigned Relias Courses, and company provided training with certificates documenting topic, hours, and trainer. 3.The Administrator maintains the tracking spreadsheet to assure accuracy of training and within all required timeframes per policy and OAR. 4.Administrator with oversight of owner.

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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C303, C310, and C363.

See C260, C270, C303, C310, C363

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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C303, C310, and C363.

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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C310.

See C310

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: