Print Inspection: RL008478

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure incidents, accidents, and injuries of unknown cause were promptly investigated to rule out abuse and neglect and reported to the local Seniors and People with Disabilities (SPD) office when required for 2 of 2 sampled residents (#s 1 and 3). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2025 with diagnoses including dementia and anxiety. Review of the resident’s 10/15/25 through 12/16/25 record, including progress notes and incident reports, was completed. The resident had an unwitnessed fall on 10/18/25 where s/he sustained a left hip fracture. There was no documented evidence the incident with injury was immediately investigated and reported to the local SPD. During an interview with Staff 1 (Director of Health Services) on 12/17/25 at 11:20 am, she reviewed the incident report and verified an investigation was not completed, and the fall with fracture was not reported to the local SPD. The facility was requested to report the incident to the local SPD office, and a confirmation of the report was provided to the survey team prior to exit. The need to ensure incidents were investigated promptly to rule out abuse and neglect, and reported to the local SPD office when required, was discussed with Staff 1, Staff 2 (Director of Clinical Operations), Staff 3 (Nurse Manager), and Staff 25 (RCC) on 12/18/25. The staff acknowledged the findings. 2. Resident 3 moved into the community in 05/2024 with diagnoses including Alzheimer’s disease. In an Interdisciplinary Note dated 11/02/25, staff documented the presence of a bruise to the resident’s right lower extremity. There was no documented evidence the injury of unknown cause was immediately investigated to rule out abuse. During an interview at 2:15 pm on 12/17/25, Staff 25 (RCC) confirmed the bruise was not investigated and had not been reported to the local SPD office. The surveyor requested the injury of unknown cause be reported to the local SPD office. Confirmation of reporting was received at 12:17 pm on 12/18/25. The need to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse unless an immediate facility investigation reasonably ruled out abuse was reviewed with Staff 1 (Director of Health Services), Staff 2 (Director of Clinical Operations), Staff 3 (Nurse Manager), and Staff 25 (RCC) on 12/18/25 at 2:57 pm. They acknowledged the findings.

C0231 411-054-0028 (1-3) Reporting & Investigating Abuse – Other Action 1. Actions to Correct Rule Violation: Two incidents for separate residents were identified as lacking a documented investigation. Those incidents have been reported to Adult Protective Services (APS). A comprehensive internal investigation has been conducted and has ruled out abuse or neglect for both incidents. APS is conducting an independent investigation as well, and we will implement appropriate measures to address any APS findings. All incident reports dated back to July 1, 2025 will be reviewed to verify that an investigation was conducted and documented and abuse and neglect ruled out. Any incidents without a documented investigation or where abuse and neglect were not ruled out will be investigated, investigation documented, and APS reports will be made for any incident where abuse and neglect could not be ruled out. All residents will be assessed for signs of injuries of unknown origin, abuse, or neglect. Any identified injuries or signs of abuse or neglect will be promptly investigated and reported in accordance with mandatory reporting requirements. 2. Systemic Changes to Prevent Recurrence: The policy and procedure for response to incidents, including but not limited to incidents of abuse, suspected abuse, or injuries of unknown origin will be reviewed and updated. All Nurses and Med Techs will receive education on the policy, including: Requirement for completion of an incident report for injuries of unknown origin; Requirement for thorough and timely investigation of all incidents; Requirement to rule out abuse or neglect within 24-hours of incident or report the incident to APS within that 24-hours. All Nurse Managers will be educated on the policy, including: Requirement for incident investigations to include time, date, place, and individuals present; Description of the event as reported; Response of staff at the time of the event; Follow-up action, including whether or not abuse and neglect have been ruled out and whether or not the incident has been reported to APS. The Administrator will review all incidents. All new incident reports will be reviewed daily by the Interdisciplinary Team (IDT), Monday through Friday, during stand-up meetings to ensure appropriate investigation and reporting. The 24-hour (or 72-hour on Monday) report will be reviewed by the IDT during stand-up meetings to review for any noted injuries of unknown origin without a corresponding incident report as well as other noted events that may require an incident report. 3. Monitoring to Ensure Sustained Compliance: On a quarterly basis, the Nurse Manager will report to the quality assurance committee any instances of events requiring an incident report being found in progress notes without an incident report already created and address any trends. The Nurse Manager will also report to the quality assurance committee any instances in which abuse or neglect could not be ruled out and confirm timely reporting The quality assurance committee will adjust the plan as needed to identify any trends found. 4. Person Responsible: Nurse Manager

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure each resident who experienced a short-term change of condition was monitored, with weekly progress noted through resolution, for 1 of 4 sampled residents (# 3) who experienced short-term changes of condition. Findings include, but are not limited to: Resident 3 moved into the community in 05/2024 with diagnoses including Alzheimer’s disease. The resident’s clinical record was reviewed. Resident 3 experienced the following changes of condition between 09/16/25 and 12/15/25: a. On 10/09/25 and 10/21/25, the facility received physician orders to change the resident’s diet texture to ground with gravy and nectar thick liquids, respectively. Observations of two lunch meals were completed on 12/16/25 and 12/17/25, and the resident received the physician ordered diet texture and liquid consistency. In an interview with Staff 25 (RCC) on 12/17/25 at 4:17 pm, she acknowledged there was no documented monitoring of the changes to the resident’s diet to ensure there were no complications related to swallowing. b. On 11/14/25 and 12/02/25, the resident’s Interdisciplinary Notes indicated redness to the sacrum and bilateral heels and toes, respectively. Observations throughout the survey confirmed the resident’s heels were floated, and s/he received frequent positional changes to offload pressure to boney prominences. In an interview with Staff 25 on 12/17/25 at 4:17 pm, she acknowledged there was no documented monitoring of the resident’s skin redness to ensure continued skin integrity. The need to ensure short-term changes of condition included weekly progress noted in the resident record until the condition resolved was discussed with Staff 1 (Director of Health Services), Staff 2 (Director of Clinical Operations), Staff 3 (Nurse Manager), and Staff 25 on 12/18/25 at 2:57 pm. They acknowledged the findings.

C0270 411-054-0040 (1-2) Change of Condition and Monitoring 1. Actions to Correct Rule Violation: One resident was identified as having had multiple short-term changes of condition without weekly progress notes indicating nurse monitoring through resolution. The RN has assessed the short-term changes of condition, and weekly progress notes will be made through resolution or until the change of condition is no longer considered to be short-term. All residents will be reviewed to determine if a short-term change of condition exists. Residents identified as having a short-term change in condition will have nurse monitoring and corresponding progress notes no less than weekly through resolution. 2. Systemic Changes to Prevent Recurrence: The Monitoring and Reporting policy will be updated to specify the day charge nurse to complete alert charting to ensure weekly progress note indicating monitoring through resolution. The 24-hour (or 72-hour on Monday) report will be reviewed by the IDT during stand-up meetings to review for any potential short-term changes of condition that may require a nurse assessment and monitoring. At weekly Radar meetings, the team will review any short-term changes of condition, including the documented progress notes. The IDT will review for thoroughness and determine if any additional assessment or service plan updates are needed. 3. Monitoring to Ensure Sustained Compliance: On a quarterly basis, Nurse Managers will report to the quality assurance committee on short-term changes of condition for the quarter, including the date the short-term change of condition occurred, verification of weekly progress notes indicating monitoring, and the date the short-term change of condition was resolved. The quality assurance committee will adjust the plan as needed to identify any trends found. 4. Person Responsible: Nurse Manager

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced significant changes of condition were assessed by an RN and/or the assessments were completed in a timely manner and included findings, resident status, and interventions made as a result of the assessment, for 2 of 3 sampled residents (#s 1 and 3) who experienced significant changes in condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2025 with diagnoses including dementia and anxiety and was receiving hospice services. Multiple observations of the resident between 12/16/25 and 12/18/25 showed the resident in bed. The resident did not leave his/her apartment. Staff provided two-person assist with bed mobility and all cares, as well as meal assistance. Resident 1’s record was reviewed, including 10/15/25 through 12/16/25 progress notes, incident reports, provider communications, service plan, and interim service plans. a. On 10/18/25 the progress notes and an incident report indicated the resident had an unwitnessed fall that resulted in a left hip fracture, hospitalization with surgical repair, and a readmit to the facility on 11/11/25. Staff indicated when Resident 1 admitted to the facility s/he used a wheelchair for mobility and was a one-person assist with toileting and ADL tasks. Since his/her return to the facility, staff stated the resident was primarily bedbound due to the pain from the left hip but was a two-person Hoyer lift the few times s/he was assisted up from bed. Staff reported the resident needed two-person assist for bed mobility and toileting, and s/he needed one to two-person assist for all ADLs now. The fall with hip fracture and decline in mobility constituted a significant change of condition. b. During the acuity interview, staff reported that Resident 1 had a significant weight loss. Observations on 12/16/25 and 12/17/25 at lunch time found the resident refused all meal trays offered but would drink a Boost shake with assistance. On 12/18/25, a visitor was observed assisting the resident to drink a glass of foamed milk with chocolate instant breakfast. Weight records were reviewed and identified the following: 10/15/25 = 119.4 pounds; and 11/21/25 = 96.4 pounds. From 10/15/25 to 11/21/25 the resident lost 23 pounds, or 19.4% of his/her total body weight, which constituted a severe weight loss and required an RN assessment. On 12/17/25 a hospice nurse provided documentation of the resident’s current arm circumference record indicating continued weight loss: 21.5 cm on 11/26/25; and 19.5 cm on 12/17/25. Staff reported Resident 1 refused most of his/her meals or would only accept a chocolate protein shake or chocolate instant breakfast drink in foamed milk since admission. Staff 7 (CNA) reported that at times the resident would accept a few small bites of chocolate pudding and liked ice water between bites. During an interview on 12/17/25 at 10:45 am with Staff 2 (Director of Clinical Operations), she reported there was no documented RN assessment completed for the significant changes of condition. The facility failed to ensure an RN assessment was completed for the resident’s fall with hip fracture, which caused a decline in mobility and ADL functioning, as well as a severe weight loss from admission, through hospitalization, and then return to the facility. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Director of Health Services), Staff 2, Staff 3 (Nurse Manager), and Staff 25 (RCC) on 12/18/25. The staff acknowledged the findings. 2. Resident 3 moved into the community in 05/2024 with diagnoses including Alzheimer’s disease. During the acuity interview on 12/16/25, staff reported Resident 3 recently admitted to hospice due to a general decline, with weight loss and a decrease in overall appetite. The resident’s record was reviewed, and interviews with staff were conducted. The following was identified: a. According to an Interdisciplinary Note dated 10/10/25, the resident received a hospice evaluation the week of 10/13/25 and then admitted to hospice on 10/16/25. Staff 2 (Director of Clinical Operations) documented a “Significant Change Initiation-Hospice Admission” note on 10/21/25, or five days following the resident’s admission to hospice. The facility failed to ensure the significant change of condition assessment was completed timely. b. Staff documented the following weights: * 07/10/25 – 114.20 pounds; * 08/18/25 – 110.40 pounds; * 09/18/25 – No weight recorded; * 10/03/25 – 108.40 pounds; * 11/19/25 – 96.0 pounds; and * 12/07/25 – 89.0 pounds (requested during survey). Between 08/18/25 and 11/19/25, the resident experienced a weight loss of 14.4 pounds, or 13.04% of his/her total body weight in 90 days. The weight loss constituted a significant change of condition and required an RN assessment. There was no documented evidence of an RN assessment for the significant change of condition related to the severe weight loss that included RN findings, resident status, and interventions made as a result of the weight loss. In an interview at 11:09 am on 12/18/25, Staff 2 acknowledged no significant change of condition assessment had been completed for the resident’s severe weight loss. According to the RN assessment for the resident’s admission to hospice, dated 10/21/25, Staff 2 identified the resident’s initial weight loss secondary to a decrease in alertness, oral intake, and interest in food. Moreover, Staff 2 implemented interventions that would mitigate further weight loss. These interventions included diet modifications and offering smaller meals of preferred foods as tolerated. Lunch observations were made on 12/16/25 and 12/17/25. During each meal, caregiving staff were observed to provide two different plates of food and to provide one-on-one assistance with eating. With each food item, the resident accepted small bites of every item and then grimaced and shook her head no. On 12/16/25, caregiving staff also offered two different flavors of nutritional supplement. The resident took small sips of each flavor and then grimaced and shook her head. Resident 3 then indicated she wanted to go to bed. When questioned, the resident denied hunger or oral pain. The resident consumed negligible amounts of food and liquids both days. Interviews were completed with caregivers and the resident’s family during the survey. The interviews confirmed the resident had demonstrated a decline in interest in food with minimal intake overall. In addition, the resident’s family indicated s/he had previously “raved” about the food but was no longer interested. The need to ensure an RN assessment was completed timely for residents who experienced a significant change of condition, including findings, resident status, and interventions made as a result of the assessment was reviewed with Staff 1 (Director of Health Services), Staff 2, Staff 3 (Nurse Manager), and Staff 25 (RCC) on 12/18/25 at 2:57 pm. They acknowledged the findings.

C0280 OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services 1. Actions to Correct Rule Violation: Two residents were identified as missing a documented RN assessment, service plan changes, and updated ABST for a significant change in condition. The RN Assessment has been completed and the service plans and ABST have been updated. All residents will be reviewed by the RN to determine whether or not a significant change of condition has occurred since the last RN assessment. All significant changes of condition will be assessed by an RN and the service plan and ABST will be updated. 2.Systemic Changes to Prevent Recurrence A significant change of condition checklist will be established to provide guidance to direct care staff on when to initiate the significant change of condition protocol by notifying the Nurse Manager or the Manager-on-Duty when the Nurse Manager is not present. The 24-hour (or 72-hour on Monday) report will be reviewed by the IDT during stand-up meetings to review for any potential significant changes of condition that may require a nurse assessment and monitoring. At weekly Radar meetings, the IDT will review any significant changes of condition, including the RN assessment, service plan updates, and ABST updates. 3. Monitoring to Ensure Sustained Compliance: On a quarterly basis, the Nurse Manager will report to the quality assurance committee on significant changes of condition, including the date the significant change of condition occurred, the dates the RN assessment, service plan update, and ABST update was completed. The quality assurance committee will adjust the plan as needed to identify any trends found. 4. Person Responsible: Nurse Manager

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

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the use of a supportive device with restraining qualities was thoroughly assessed by an RN, PT, or OT prior to use, failed to instruct caregivers on the correct use of and precautions related to the supportive device, failed to document use of the device in the resident's service plan, and failed to evaluate the devices quarterly for 2 of 2 sampled residents (#s 2 and 3) who used side rails. Findings include, but are not limited to: 1. Resident 2 moved into the community in 12/2024 with diagnoses including macrocytic anemia (a blood disorder affecting red blood cells). On 12/16/25 at 11:15 am, the surveyor observed two quarter-length side rails in the up position on the resident's bed. There was no information documented in Resident 2’s service plan, dated 09/15/25, relating to the use of side rails, instructions to caregivers on the correct use of the side rails, or precautions related to the supportive device. On 12/16/25 at 3:20 pm, Staff 25 (RCC) confirmed there was no documented evidence of a quarterly evaluation or an assessment of the side rails completed by an RN, PT, or OT. The need to ensure supportive devices with restraining qualities were thoroughly assessed by an RN, PT, or OT prior to use, caregivers were instructed on the correct use and precautions, the devices were documented in the resident’s service plan, and were evaluated quarterly was discussed with Staff 1 (Director of Health Services), Staff 2 (Director of Clinical Operations), Staff 3 (Nurse Manager), and Staff 25 on 12/18/25 at 2:14 pm. They acknowledged the findings. 2. Resident 3 moved into the community in 05/2024 with diagnoses including Alzheimer’s disease. On 12/16/25 at 11:07 am, the surveyor observed two quarter-length side rails in the up position on the resident’s bed while s/he was resting. In an interview with Staff 15 (CNA) on 12/17/25 at 12:25 pm, she reported the resident used the side rails to assist with bed mobility during ADL care. Staff 25 (RCC) was asked to provide an assessment of the side rails completed by an RN, OT, or PT. Staff 25 provided the requested assessment which was completed on 06/24/24; however, no additional documentation was provided to demonstrate the devices were evaluated quarterly after 06/2024. The need to ensure supportive devices with restraining qualities were evaluated quarterly was discussed with Staff 1 (Director of Health Services), Staff 2 (Director of Clinical Operations), Staff 3 (Nurse Manager), and Staff 25 on 12/18/25 at 2:57 pm. They acknowledged the findings.

C0340 OAR 411-054-0060 Restraints and Supportive Devices 1. Actions to Correct Rule Violation: The two residents identified as having bed mobility bars or other supportive devices with restraining qualities in place without required evaluation and documentation have been evaluated for continued appropriateness. Devices were removed for both residents following the evaluation. All resident beds have been evaluated for the presence of bed mobility bars or other supportive devices with restraining qualities. Residents identified as using these devices have been audited to confirm the presence of a qualifying evaluation, provider order, and corresponding service plan item. For any resident who does not meet required criteria, the device has been removed and alternative safety interventions implemented as appropriate. 2. Systemic Changes to Prevent Recurrence: The bed mobility bars and supportive devices with restraining qualities policy will be updated to reflect that the Nurse Manager must approve the installation of any bed mobility bars or supportive devices with restraining qualities prior to their installation. The Nurse Manager will monitor for a qualified evaluation, provider order, and corresponding service plan item. The Interdisciplinary Team (IDT) will maintain an active list of residents with bed mobility bars and other supportive devices with restraining qualities in place. This list will be reviewed weekly during Radar meetings to verify that required evaluations, orders, and service plan documentation are current and complete. 3. Monitoring to Ensure Sustained Compliance: On a quarterly basis, all beds will be visualized by a member of the quality assurance committee to confirm that no unauthorized bed mobility bars or assistive devices have been installed. 4. Person Responsible: Nurse Manager

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 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 resident ABST entries were updated as required. Findings include, but are not limited to: Review of the facility’s ABST entries was completed and showed the following: * ABST entries were not updated at least quarterly in conjunction with the residents’ service plans for 3 of 4 sampled residents (#s 2, 3, and 4); and * The ABST was not updated for Resident 4 after a significant change of condition. The need to ensure all residents’ ABST entries were updated at least quarterly and after a significant change of condition was discussed with Staff 1 (Director of Health Services) and Staff 2 (Director of Clinical Operations) on 12/17/25 and on 12/18/25. They acknowledged the findings.

C0363 OAR 411-054-0037 (4-6) Acuity Based Staffing tool – Updates & Staffing Plan 1. Actions to Correct Rule Violation: Four residents were identified as having an ABST that was not updated in the past quarter in conjunction with the service plan update or with a significant change of condition. Service plans have been reviewed and the ABST has been updated to reflect the current service plan. All resident ABSTs will be audited to identify any that are overdue or not reflective of the resident’s current service plan. Any ABSTs identified as out of compliance will be updated to ensure accuracy, completeness, and timeliness. 2. Systemic Changes to Prevent Recurrence: The ABST policy will be updated to define required timeframes, triggering events for updates, including changes in condition, and staff responsibilities. Nurse Managers will be educated on this policy, with emphasis on timely review and revision of ABSTs. 3. Monitoring to Ensure Sustained Compliance: On a quarterly basis, the Nurse Manager will report to the quality assurance committee on timeliness of ABST updates and adjust the plan as needed to identify any trends found. 4. Person Responsible: Nurse Manager

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 411-054-0090 (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 3 of 4 residents (#s 2, 3, and 4) were instructed on fire and life safety procedures within 24 hours of admission and re-instructed, at least annually. Findings include, but are not limited to Fire and life safety records were requested and reviewed with Staff 6 (Security, Safety, and Transportation Manager) on 12/17/25, and the following was identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission for Residents 2, 3, and 4; and * There was no documented evidence of fire and life safety training provided to residents at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 (Director of Health Services) on 12/18/25 at 1 pm. She acknowledged the findings.

C0422 OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents 1. Actions to Correct Rule Violation:: Three residents were identified as not having received instruction on fire and life safety procedures within 24 hours of admission and on an annual basis. Those residents will immediately receive required instruction, including general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area. This instruction will be documented in the medical record. For residents whose cognitive capability does not allow for retaining such instruction, that determination will be documented in the medical record. All residents will receive required instruction, including general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area. This instruction will be documented in the medical record. For residents whose cognitive capability does not allow for retaining such instruction, that determination will be documented in the medical record. 2. Systemic Changes to Prevent Recurrence: Fire and Life Safety Training will be added to the admission checklist for the Nurse Manager or their designee to complete within 24-hours of admission. Fire and Life Safety instruction will be conducted at quarterly care conferences in Q1 and Q3 of each calendar year. This instruction will be documented in the medical record. 3. Monitoring to Ensure Sustained Compliance: On a quarterly basis, the Nurse Manager will report to the quality assurance committee on completed Fire and Life Safety Training and adjust the plan as needed to identify any trends found. 4. Person Responsible: Nurse Manager

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:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their unit for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to: Current evaluations and service plans were reviewed for Residents 1, 2, 3, and 4. There was no documented evidence the residents were provided a key to their room or the residents were evaluated and determined to be unable to utilize a key. During an interview with Staff 1 (Director of Health Services) on 12/17/25 at 3:30 pm, she reported keys had not been provided to the current residents of the RCF or the MCC. The need for residents and only appropriate staff to have a key to their units was discussed with Staff 1, Staff 2 (Director of Clinical Operations), Staff 3 (Nurse Manager), and Staff 25 (RCC) on 12/18/25 at 2:57 pm. They acknowledged the findings.

H1518 OAR 411-004-0020(2)(e) Individual Door Locks: Key Access 1. Actions to Correct Rule Violation:: Four residents were identified as not have been provided a key to their room nor having been evaluated to determine to be unable to utilize a key. These four residents will be evaluated for their ability to utilize a key, and if able, a key will be provided. This evaluation and key distribution will be documented in the medical record. All residents will be evaluated for their ability to utilize a key, and if able, a key will be provided. This evaluation and key distribution will be documented in the medical record. 2. Systemic Changes to Prevent Recurrence: Evaluation for the ability to use a key will be assessed for every resident at or prior to move-in. A key to the resident’s home will be provided at time of move-in and will be documented in the medical record. At weekly Radar meetings, the IDT will review any new move-ins to review for documentation that their ability to use a key was evaluated and that they received a key if determined to be able to utilize. 3. Monitoring to Ensure Sustained Compliance: The IDT will report any gaps in compliance to the quality assurance committee who will adjust the plan as needed. 4. Person Responsible: Administrator

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C363, and H1518.

Z0142 OAR 411-057-0140(2) Administration Compliance For Plan of Correction, Refer to Plans of Correction for C231, C363, and H1518

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 11 and 24) completed all pre-service orientation training prior to beginning their job responsibilities and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 4 (Human Resource Specialist) and Staff 5 (Human Resource Specialist) on 12/17/25 and with Staff 2 (Director of Clinical Operations) on 12/18/25. The following was identified: 1. (a) There was no documented evidence Staff 11 (Resident Care Assistant), hired 07/07/25, completed required pre-service orientation training prior to beginning job duties in the following area: * Home and Community-Based Services; and * LGBTQIA2s+ Inclusion course. (b) There was no documented evidence Staff 11 demonstrated competency in the following assigned duties within 30 days of hire: * Changes associated with normal aging. 2. (a) There was no documented evidence Staff 24 (Resident Care Assistant), hired 09/10/25, completed required pre-service orientation training prior to beginning job duties in the following area: * Home and Community-Based Services. (b) There was no documented evidence Staff 24 demonstrated competency in the following assigned duties within 30 days of hire: * Role of service plans; * Providing assistance with ADL; * Changes associated with normal aging; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure newly hired staff completed all pre-service orientation prior to performing job duties, and direct care staff demonstrated competency in all assigned duties within 30 days of hire, was discussed with Staff 1 (Director of Health Services) and Staff 2 (Director of Clinical Operations) on 12/17/25 and on 12/18/25. They acknowledged the findings

Z0155 OAR 411-057-0155(1-6) Staff Training Requirements 1. Actions to Correct Rule Violation: Two staff members were identified as not having completed all pre-service training orientation and training and been evaluated for competency within 30 days of hire. The identified staff members will have the missing required trainings assigned to them via Relias, and the Nurse Manager or their designee will assess the staff members for competency. Training and competency records will be reviewed for all memory care staff. Staff who did not complete all required pre-service orientation and training will have those trainings assigned to them in Relias. Staff who were not evaluated for competencies within 30-days of hire will be assessed for competency by the Nurse Manager or their designee. 2. Systemic Changes to Prevent Recurrence: A form will be developed that lists all required pre-service orientation and training modules. Staffing Coordinators will be responsible for tracking completion of pre-service orientation and training on the form and forms must be signed off on by the Nurse Manager, Director of Nursing, or Administrator prior to the staff member starting work. Staffing Coordinators will monitor completion of 30-day competency evaluations. As each competency evaluation is completed, the Staffing Coordinator will bring to the Nurse Manager to sign-off acknowledging completion of competencies. If a staff member has not completed their 30-day competency evaluation 4 weeks post hire, Staffing Coordinators will remove the staff member from the schedule until the staff member can meet with the Nurse Manager or their designee to complete their competency evaluations. 3. Monitoring to Ensure Sustained Compliance: Staffing Coordinators will report to the quality assurance committee on a quarterly basis on any gaps experienced in compliance with pre-service orientation and training or 30-day competency evaluations, and the quality assurance who will adjust the plan as needed. 4. Person Responsible: Staffing Coordinators

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270, C280, and C340.

Z0162 OAR 411-057-0160(2b) Compliance with Rules Health Care For Plan of Correction, Refer to Plans of Correction for C270, C280, and C340

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

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1 and 4’s activity evaluations were requested on 12/16/25, and service plans were reviewed during survey. the facility had not evaluated the residents’: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no individualized activity plan developed for each resident based on his/her activity evaluation which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans which were based on a thorough assessment of the resident's interests, abilities, and needs was discussed with Staff 1 (Director of Health Services), Staff 2 (Director of Clinical Operations), Staff 3 (Nurse Manager), and Staff 25 (RCC) on 12/18/25. They acknowledged the findings.

Z0164 OAR 411-057-0160(2d) Activities 1. Actions to Correct Rule Violation: Two residents were determined to have not received activities evaluations and to be lacking an activities service plan. These residents will be evaluated using the Therapeutic Recreation/Activity Evaluation form. The information gathered on this form will be used to create a person-centered, activities plan, which will be documented and available to direct care staff. The plan will include what, when, how, and how often staff should offer and assist residents with person-centered activities. All residents will have an activities evaluation completed using the therapeutic recreation/activity evaluation form. The information gathered on this form will be used to create a person-centered activities plan, which will be documented and available to direct care staff. The plan will include what, when, how, and how often staff should offer and assist residents with person-centered activities. 2. Systemic Changes to Prevent Recurrence: Activities evaluations will be conducted at time of move-in and will be updated quarterly thereafter. The evaluation will be used to create a person-centered activities plan, which will be documented and available to direct care staff. The plan will include what, when, how, and how often staff should offer and assist residents with person-centered activities. At weekly Radar meetings, the IDT will review any new move-ins to assure completion of an activities evaluation and activities plan. Nurse Managers and Resident Care Coordinators will review resident service plans on a quarterly basis, including monitoring for an updated activities evaluation and plan. 3. Monitoring to Ensure Sustained Compliance: The Life Enrichment (Activities) Director will report to the quality assurance committee on a quarterly basis on completion of new move-in activities evaluations and on quarterly activities evaluations and plans. The quality assurance committee who will adjust the plan as needed. 4. Person Responsible: Life Enrichment Director

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