Print Inspection: RL007306

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to accurately track controlled substances that were administered by the facility for 1 of 2 sampled residents (#2) who were administered a PRN narcotic pain medication. Findings include, but are not limited to: Resident 2 moved into the facility in 04/2024 with diagnoses including history of neck fracture and recent elbow fracture. The resident was prescribed tramadol HCL 50 mg tablet (a narcotic pain medication), one tablet every six hours as needed for pain. Review of Resident 2's 10/01/25 through 10/14/25 MARs and Controlled Substance Disposition Logs identified the following: Facility MTs documented on the Controlled Substance Disposition Logs that one tablet of tramadol was removed from locked storage on 18 occasions during the above time period. However, the MAR lacked documentation the medication was administered to Resident 2 on six of those occasions. The discrepancies between the Controlled Substance Disposition Logs and the MAR were reviewed with Staff 2 (Director of Health Services), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services) and Staff 9 (Regional Director of Operations) on 10/16/25. They acknowledged the findings.

1) MAR sheet for R2 was corrected for all narcotic doses noted as given on the narc log. Audit conducted of remaining residents using narcotics to assure MAR accuracy for doses given starting 10-1-25 to current. 2) Re-education provided to all MT staff by 10/31/25 on proper procedure for logging narcotics on both the narc log and the MAR to assure understanding. 3) Routine weekly auditing of MARs to Narc log will be conducted by the ALD/ED or Nurse to assure ongoing compliance. 4) ALD/ED/ or RN

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter, and/or they had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 2 of 2 residents (#s 2 and 4) who self-administered their medications. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 9/2025 with diagnoses including multiple myeloma (a blood cancer) and was identified in the acuity interview as self-administering his/her medications. A review of the resident’s record showed there was no documented evidence the resident had been evaluated for his/her ability to self-administer medications. There was no documented evidence of a physician’s or other legally recognized practitioner's written order of approval for self-administration of medications. The need to ensure residents who chose to self-administer their medications were evaluated upon move-in, and they had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was discussed with Staff 2 (Director of Health Services), Staff 3 (RN), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services), and Staff 9 (Regional Director of Operations) at 10:20 am on 10/16/25. They acknowledged the findings, and no further information was provided. 2. Resident 2 moved into the facility in 04/2024 with diagnoses including history of neck fracture and recent elbow fracture. Review of the resident’s 10/2025 MAR indicated the resident self-administered five prescribed or over-the-counter medications. A progress note dated 07/11/25 indicated a MT met with Resident 2 and identified which medications s/he was self-administering, and the MAR was updated to reflect the medications the resident was self-administering. An evaluation of Resident 2’s ability to safely self-administer medications was requested from the facility on 10/15/25. The facility provided an evaluation that had been completed and dated 10/14/25. In an interview on 10/15/25, Staff 3 (RN) acknowledged she had completed the evaluation on 10/14/25. She stated she did not know if the resident’s ability to safely administer his/her own medications had been evaluated previously. The need to ensure residents who chose to self-administer their medications were evaluated upon move-in, or when they were identified to be administering their own medications, and at least quarterly thereafter was reviewed with Staff 2 (Director of Health Services), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services) and Staff 9 (Regional Director of Operations) on 10/16/25. They acknowledged the findings. No other documentation was provided.

1) R4: Self med is now complete. R2: evaluation was completed just not timely. A review of remaining residents who self-administer all or some meds was conducted to verify completion of self-med eval. 2) Re-education provided to the ED, ALD and RN for timely completion of the self med evaluations to assure understanding. 3) Routine audits will be conducted upon completion of the move in process and monthly thereafter to assure ongoing compliance. 4) Date of compliance: ALD, ED and RN

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. 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 they had a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs and were not able to demonstrate how their staffing system worked. Findings include, but are not limited to: Refer to C363.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 2, and 5) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 09/2024 with diagnoses including dementia. Observations of the resident were made, interviews with the resident and staff were conducted, and the 07/31/25 service plan and Resident 5’s ABST data were reviewed. The following areas were not reflective of the resident’s current ADL assistance: * Time spent responding to call lights; * Time spent monitoring physical conditions or symptoms; * Time spent with bathing; and * Time spent on dressing or undressing. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 2 (Director of Health Services), Staff 3 (RN), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services), and Staff 9 (Regional Director of Operations) on 10/16/25 at 10:55 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 02/2025 with diagnoses including Parkinson’s disease, severe vascular dementia, and psychotic disturbance. The resident's 09/09/25 service plan, progress notes dated 07/14/25 through 10/14/25, and Resident 1's ABST data were reviewed. Staff were interviewed and observations were made of the resident. The following areas were not reflective of the resident's current ADL assistance: * Time required assisting with personal hygiene; * Time spent completing safety checks; * Time spent on PRN Medication administration; * Time spent assisting with transferring out of bed or chair; * Time spent assisting with repositioning in bed; * Time required assisting with bathing; * Time required assisting with dressing undressing; and * Time required assisting with grooming. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 2 (Director of Health Services), Staff 3 (RN), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services), and Staff 9 (Regional Director of Operations) on 10/16/25 at 11:55 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 04/2024 with diagnoses including history of neck fracture and recent elbow fracture. The resident’s clinical record was reviewed, including the most recent service plan, dated 09/27/25. The resident and care staff were interviewed. The resident was identified on 10/08/25 to have sustained a fractured elbow from a recent fall. The following areas were not reflective of the resident's current ADL assistance: *Time spent assisting with bathing; *Time spent assisting with dressing; and *Time spent providing additional care services such as walking Resident 2’s dog. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 2 (Director of Health Services), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services) and Staff 9 (Regional Director of Operations) on 10/16/25. They acknowledged the findings.

1) ABST tool will be updated for all current residents and a review of their care needs conducted to assure accuracy 2) Re-education provided to ALD and ED on ABST tool utilization and timely reviews to assure understanding. 3) ED/ALD will assure ABST tool is reviewed weekly to assure current residents are reflected and information is accurate for care needs/changes of condition. 4) ALD, ED

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

OAR 411-054-0037 (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 ensure the ABST was updated when a resident moved in for 1 of 1 sampled resident (#4) and multiple unsampled residents; with a significant change of condition for 2 of 2 sampled residents with significant changes of condition (#s 1 and 2); no less than quarterly at the same time the resident's service plan was updated for 4 of 4 sampled residents (#s 1, 2, 3, and 5) and multiple unsampled residents; and failed to maintain and update the posted staffing plan. Findings include, but are not limited to: During the acuity interview on 10/14/25, Staff 3 (RN) and Staff 6 (MT) confirmed there were currently 50 residents living at the facility. The facility ABST was reviewed on 10/14/25 at 11:00 am which identified 46 residents entered into the tool. The facility’s ABST data and posted staffing plan were reviewed at 11:00 am on 10/14/25 and revealed the following: a. One sampled resident (#4) and 14 unsampled residents had no ABST data. b. Seven residents who no longer resided at the facility were included in the ABST data. c. Resident 1 experienced a significant change of condition on 09/02/25, and there was no documented evidence the ABST data had been updated. d. Resident 2 experienced a significant change of condition on 10/07/25, and there was no documented evidence the ABST data had been updated. e. Four sampled residents (#s 1, 2, 3, and 5) and multiple unsampled residents lacked documented evidence the ABST data was updated quarterly at the same time as the resident's service plan. During an interview on 10/15/25 at 11:20 am, Staff 10 (Chief Operating Officer) acknowledged the ABST had inaccurate information and had not been maintained and updated. The need to ensure residents’ ABST was updated no less than quarterly and/or with a significant change of condition to determine an accurate staffing plan was discussed with Staff 2 (Director of Health Services), Staff 3 (RN), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services), and Staff 9 (Regional Director of Operations) on 10/16/25 at 10:55 am. They acknowledged the findings.

Staffing: 1) ABST tool will be updated for all current residents and needed care and services 2) Staffing schedule will be compared to ABST tool for potential changes as applicable to staffing levels. 3) Daily review of staffing, hiring needs and shift coverage will be completed daily during stand up meetings. 4) ED will collect monthly working schedule for required archive at the end of each month. 5) ALD, ED

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:

OAR 411-054-0070 (3-4) 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: (a) A review of their written position description with their job responsibilities. (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) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled direct care and non-direct care staff (#s 6, 7, 12 and 14) completed all required training prior to beginning their job responsibilities. Findings include, but are not limited to: Employee training records were reviewed with Staff 1 (Assistant ED) on 10/15/25. The following was identified: a. There was no documented evidence Staff 12 (CG), hired 09/09/25, completed required pre-service orientation training in the following areas: *Resident Rights and values of CBC care; and *Fire Safety and emergency procedures b. There was no documented evidence Staff 7 (CG), hired 09/03/25, completed required pre-service orientation training in the following areas: * Food handler’s certificate; * Approved LGBTQIAS+ course; and * Approved pre-service dementia training, completed within 24 months of hire. c. There was no documented evidence Staff 6 (MT), hired 07/29/25, completed required pre-service orientation training in the following areas: *Approved HCBS course completed within 12 months of hire. d. There was no documented evidence Staff 14 (housekeeper), hired 09/01/25, completed required pre-service orientation training in the following areas: *Approved Infectious Disease Prevention; *Approved HCBS course; and *Approved LGBTQIAS+ course. The need to ensure newly-hired staff completed all required training prior to beginning employee job responsibilities was reviewed with Staff 2 (Director of Health Services), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services) and Staff 9 (Regional Director of Operations) on 10/16/25. They acknowledged the findings. No other documentation was provided.

1) Audit conducted of remaining staff to verify completion of pre-service training requirements was completed. 2) ED and AED have reviewed staff training requirements and time frames to assure understanding. 3) Ongoing compliance will be maintained through routine audits (upon completion of the new hire/orientation process and twice monthly thereafter) of employee training records. 4) AED, ALD, MCD with ED oversight

OAR 411-054-0070 (3-4) 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: (a) A review of their written position description with their job responsibilities. (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) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 7 and 12) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire. Findings include, but are not limited to: Employee training records were reviewed with Staff 1 (Assistant ED) on 10/15/25. Staff 12 (CG), hired 09/09/25, and Staff 7 (CG), hired 09/03/25, lacked documented evidence of demonstrated competency in the following areas: *Role of service plans in providing individualized care; *Providing assistance with ADLs; *Changes associated with normal aging; *Identification, documentation and reporting changes of condition; *Conditions that require assessment, treatment, observation and reporting; *General food safety and sanitation; and *First Aid/Abdominal Thrust. The need to ensure newly hired direct care staff had documentation of satisfactory performance in all required areas within 30 days of hire was reviewed with Staff 2 (Director of Health Services), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services) and Staff 9 (Regional Director of Operations) on 10/16/25. They acknowledged the findings. No other documentation was provided.

1) Skills checklists completed for sampled staff 2) Audit of remaining staffs skills checklists conducted to verify completion 3) Review of skills checklist completion with ALD and AED to assure understanding 4) Audits will be conducted upon completion of the initial training process and at least twice monthly for ongoing compliance. 5) AED, ALD and ED

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed at least annually in general safety procedures and a written record of fire safety training was maintained, including the content of the training sessions. Findings include, but are not limited to: Documentation of annual fire and life safety instruction to residents was requested on 10/16/25. In an interview on 10/16/25 at 12:30 pm, Staff 15 (Maintenance Director) stated he had not provided fire and life safety training to residents in over a year and had not been documenting the training provided. The need to ensure residents were instructed about the facility’s fire and life safety procedures at least annually and the content of the training was documented was reviewed with Staff 2 (Director of Health Services), Staff 4 (Regional Nurse Consultant), Staff 5 (Director of Health Services) and Staff 9 (Regional Director of Operations) on 10/16/25. They acknowledged the findings. No other documentation was provided.

1) Review of First Life Safety training with all residents will be completed by 10/31/25 and documentation will reside in the FLS binder. 2) ED and MD have reviewed requirements and community plan to assure understanding. 3) ED and MD will audit monthly to assure ongoing compliance. 4) MD and ED

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: