Print Inspection: RL008693

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear instruction to staff for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. Resident 2’s clinical records were reviewed, interviews with staff and the resident were conducted, and observations were made. The 11/20/25 service plan was not reflective of the resident care needs and lacked clear direction to staff in the following areas: * Transfers; * Mobility; * Dressing; * Bathing; and * Toileting. During lunch on 01/07/26, Resident 2 was observed needing hands on assistance from staff to push his/her wheelchair to and from the dining room. On 01/08/26 at approximately 3:30pm, the need to ensure resident service plans were reflective of resident care needs and provided clear direction to staff was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2022 and was subsequently diagnosed with conditions including generalized anxiety disorder and auditory hallucinations. The resident's record, including the most recent service plan, dated 12/04/25, progress notes, dated 10/07/25 through 01/05/26, and temporary service plans were reviewed, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident's status and/or did not provide clear direction regarding the delivery of services in the following areas: * Specific and clear directions to staff regarding the resident’s paranoid delusions and hallucinations (e.g. what they relate to and what staff need to do when the resident exhibits them); * Use of PRN psychotropics and effective non-pharmacological interventions; and * Pain status and non-pharmacological interventions for pain. On 01/09/26 at 12:30 pm, the need to ensure the service plan was reflective of the resident’s current status and provided clear directions for staff was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings.

All resident records were reviewed for accuracy or completeness on or before January 27, 2026. Resident records identified as having outdated or missing information were updated on or before January 27, 2026. The Administrator or designee re-educated staff to ensure all required elements are included in resident records. Resident records will be audited weekly for completion. The Administrator or designee will conduct weekly audits of resident records for completion for 12 weeks or until substantial compliance is achieved.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0055 (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 have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 1 and 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed. Findings include but are not limited to: 1. Resident 1 moved into the facility in 06/2022 and had diagnoses which included unspecified abdominal pain and unspecified osteoarthritis, and s/he had recently been admitted to hospice services. The resident’s 12/01/25 through 01/05/26 MARs, Controlled Substance Disposition Log, and current physician orders were reviewed, and the following was identified: Resident 1 had an order for oxycodone HCL (narcotic analgesic) 5 mg, one tablet every four hours PRN for breakthrough pain or shortness of breath. Resident 1's Controlled Substance Disposition Log identified five occasions when staff signed on the drug disposition log that the oxycodone was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition log were reviewed with Staff 2 (RN) and Staff 3 (LPN) on 01/06/26 at 11:00 am and 01/09/26 9:00 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. The resident's 12/01/25 through 01/05/26 MARs, Controlled Substance Disposition Log, and current physician orders were reviewed and identified the following: Resident 2 had signed physician orders for oxycodone, 2.5 mg by mouth every 6 hours as needed for pain. There were four occasions where the medication has been documented as administered on the Controlled Substance Disposition Log but were not signed out on the MAR. In an interview on 01/06/26 at approximately 2:18pm, Staff 3 (LPN) reported she did not audit the Controlled Substance Disposition Log and MAR to ensure they were reflective of one another and instead audited the Controlled Substance Disposition Log and medication bubble packs to ensure they were reflective of one another. On 01/08/26 at approximately 3:30pm, the inconsistencies between the MARs and Controlled Substance Disposition Log were reviewed Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3, Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings.

Director of Health Services or designee completed an audit of narcotic book to MAR on or before January 16, 2026. Director of Health Services or designee re-educated staff to facility policy for narcotic administration. Narcotic administration will be audited at least weekly for proper documentation. Director of Health Services or designee will conduct at least weekly audits of resident records for completion for 12 weeks or until substantial compliance is achieved.

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 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 2 of 2 sampled residents (#s 2 and 3) who had documented medication refusals. Findings include, but are not limited to: Resident 3 moved into the facility 08/2022 with diagnoses including stroke, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Resident 3's record including the 12/01/25 – 01/05/26 MARs was reviewed during the survey and identified the resident had multiple medication refusals between 12/01/25 and 01/05/26. The medications refused included: *Aspirin (for stroke); *Clopidogrel (for stroke); *Escitalopram oxalate (for major depressive disorder); *Metoprolol (for hypertension); *Pantoprazole (for gastroesophageal reflux disease); *Buspirone (for anxiety disorder); *Macrobid (for UTI); *Tylenol (for pain); *Latanoprost (for glaucoma); *Trelegy Ellipta (for chronic obstructive pulmonary disease); *Brimonidine (for glaucoma); and *Nystatin Powder (for yeast rash). There was no documented evidence the facility notified the physician when the resident refused consent to the physician’s orders. During an interview conducted on 01/08/26 at approximately 2:00 pm, Staff 1 (MCC Administrator) confirmed the facility did not have a system in place to notify the physician when a resident refused medications. On 01/09/26 at 12:30 pm, the need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), and Staff 5 (RCC). They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. The resident’s 12/01/25 through 01/05/26 MARs, physician orders, and 10/07/25 through 01/05/26 progress notes were reviewed. The resident refused consent to orders for the following medication: *Systane Ophthalmic Solution 0.4-0.3% (for dry, irritated, burning eyes) on four occasions. There was no documented evidence the prescriber was notified after each refusal for the medication. On 01/08/26 at approximately 3:30pm, the need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings.

Director of Health Services or designee completed an audit of medication refusal on the MAR on or before January 16, 2026 Director of Health Services or designee added medication refusal instructions to the MAR for all residents. Director of Health Services or designee will audit resident MARs quarterly, at change of condition and as needed to ensure medication refusals are documented timely. Director of Health Services or designee will conduct at least weekly audits or resident records for completion for 12 weeks or until substantial compliance is achieved.

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

OAR 411-054-0037 (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 staff were providing to each resident as outlined in each individual service plan for 2 of 4 sampled residents (#s 1 and 2) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. Interviews with staff, observations of the resident, and review of the resident’s service plan indicated Resident 4's ABST minutes did not accurately capture the care time staff provided in the following areas: *Personal hygiene such as shaving and mouth care; *Time responding to call lights; *Time spent providing non-drug intervention for pain; *Time ambulation, escorting to/from meals/activities; *Transfers in/out of bed/chair; *Bathing; *Bowel/bladder management; and *Dressing/undressing. On 01/08/26 at approximately 3:30pm, the need to accurately capture care time on the resident's ABST was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2022 and had diagnoses which included unspecified abdominal pain and unspecified osteoarthritis, and s/he had recently been admitted to hospice services. Interviews with staff during the survey and review of the resident’s current service plan dated 12/04/25 and the 12/01/25 through 01/05/26 MARs indicated Resident 1’s ABST minutes did not accurately capture the care time staff provided in the following areas: * Time is spent providing non-drug interventions for pain management; * Time is spent providing treatments? (e.g. skin care, wound care, antibiotic treatment); and * Time is spent ensuring non-drug interventions for behaviors. Multiple staff interviews during the survey indicated the resident routinely received topical treatments to his/her hands for arthritis and was frequently provided with ice packs to the knee for pain management. In addition, due to the resident’s mental health needs, staff reported they were required to regularly intervene and de-escalate situations to support the resident’s safety and well-being. The need to accurately capture care time on the resident's ABST was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC) on 01/09/26 at 12:30 pm. They acknowledged the findings.

All resident's ABST were reviewed for accuracy on or before January 20, 2026. The Administrator or designee re-educated staff on ensuring ABST accuracy. ABST will be audited by RCCs for accuracy. Administrator or designee will conduct weekly audits of up to 5 residents ABST for accuracy for 12 weeks or until substantial compliance is achieved

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 facility’s acuity-based staffing tool (ABST) was updated following a significant change of condition for 1 of 4 sampled residents (#2), and multiple unsampled residents whose ABST evaluations were reviewed. Findings include but are not limited to: 1. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. The resident service plan was last reviewed and updated on 11/20/25. Clinical records were reviewed, and interviews with staff and Resident 2 were conducted, and it was determined Resident 2 experienced a significant change of condition on 12/19/25. Resident 2’s ABST was last updated on 08/23/25, and the facility failed to update the resident ABST quarterly and following a significant change of condition as required. 2. 12 unsampled resident ABST evaluations had not been updated within the last 90 days. On 01/08/26 at approximately 3:30pm, the need to ensure the facility ABST was updated when a resident experienced a significant change of condition and no less than quarterly was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings.

All resident's ABST were reviewed for accuracy on or before January 20, 2026. The Administrator or designee re-educated staff on ensuring ABST accuracy. Residents with a CoC ABST will be audited weekly for accuracy. Administrator or designee will conduct weekly audits of COC ABST for accuracy for 12 weeks or until substantial compliance is achieved

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 pre-service orientation in all required topics and pre-service dementia training was completed prior to beginning job duties for 2 of 4 newly hired staff (#s 11 and 13) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 01/07/26 through 01/09/26. The following was identified: There was no documented evidence Staff 11 (CG), hired 10/22/25, had completed the following required pre-service orientation training prior to beginning job responsibilities: * Infectious disease prevention; and * Pre-service dementia training. b. There was no documented evidence Staff 13 (CG), hired 09/02/25, had completed the required pre-service dementia training prior to beginning job responsibilities. The need to ensure staff completed all required pre-service orientation and training prior to beginning their job responsibilities, and for direct care staff to complete required pre-service dementia training prior to providing care to residents was reviewed on 01/09/26 at 10:15 am with Staff 1 (MCC Administrator) and Staff 7 (Staff Coordinator). They acknowledged the findings

All employees identified in survey have completed required trainings on or before January 20, 2026. The Administrator re-educated the Staffing Coordinator to required pre-service training and documentation on or before January 20, 2026. New hire training documentation will be audited for completion of required elements weekly. The Administrator or designee will conduct weekly audits of new hire training records for completion fo r12 weeks or until substantial compliance is achieved.

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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and had documentation of all required components. Findings include, but are not limited to: Fire and life safety records dated 07/2025 through 11/2025 were reviewed with Staff 8 (Maintenance Director) at 2:00 pm on 01/07/26. The facility fire drills lacked documentation of the following required components: * Escape route used; and * Evidence alternate routes were used during the fire drills. The need to ensure fire drills were conducted in accordance with the OFC and that documentation included all required components was reviewed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), and Staff 5 (RCC) on 01/09/25 at 12:30 pm. All staff acknowledged the findings.

Facility fire drill documentation form has been updated to include all required elements. The Administrator or designee re-educated all staff on fire drill requirements on or before January 27, 2026. The facility will practice fire drills and/or provide an in-service monthly. The Administrator or designee will conduct monthly audits of fire drill training records for all required elements for 12 weeks or until substantial compliance is achieved.

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