Print Inspection: RL009598

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, provided clear instruction to staff, including a written description of who should provide the services and what, when, how, and how often the services should be provided, and/or were implemented, for 2 of 4 sampled residents (#s 1 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including?dementia, subdural hematoma (a brain bleed), and right-sided weakness. Resident 1’s service plan, dated 01/08/25, and interim service plans (ISPs), dated 12/11/25 through 02/16/26, were reviewed, observations were made, and interviews with staff, the resident, and a witness were conducted. The service plan was not reflective of the resident’s care needs and lacked clear instructions to staff in the following areas: * Dressing; * Showering; * Toileting; * Side rail use; and * Exercise program. The service plan was not implemented in the following areas: * Transferring to wheelchair three times a day; and * Positioning when eating in bed. An ISP dated 01/27/26 stated, “As time allows, get [resident] into wheelchair 3x day. Ideally at meals.” On 01/25/26, Resident 1 was not observed in the dining room during lunch service. Staff 14 (CG) reported that she had asked the resident if he would like to stay in his/her room and have lunch in bed. Staff 14 reported she was unaware that the resident’s service plan stated s/he was to be transferred to his/her wheelchair three times a day, ideally at meals. An ISP dated 01/02/26 stated, “Help [resident] with written instructions for HEP [home exercise program] that are placed on bedside table.” The service plan, dated 01/08/26, did not include the resident’s exercise program. In an interview on 02/25/26 at 2:00 pm, Staff 1 (ED), confirmed that the resident still required the exercise program and that it should have been included in the service plan. On 02/26/26 at 11:45 am, the need to ensure the service plan was reflective of the resident’s current status, provided clear instruction to staff, and was implemented, was discussed with Staff 1, Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and?Staff 4 (RCC). They acknowledged the findings. ??2. Resident 1 was admitted to the facility in 08/2025 with diagnoses including late onset Alzheimer’s disease with behavioral disturbance. The resident’s clinical record, dated 11/23/25 through 02/22/26, was reviewed. Observations were made and interviews were conducted with staff. The 01/24/26 service plan and 11/27/25 to 02/20/26 interim service plans were not reflective of the resident’s current status, lacked clear instructions for staff, or were not implemented in the following areas: * Use of a cushion while in the wheelchair; * Oxygen therapy status, including current settings and required care; * Escorting to activities; * Eating status; * Ambulation, repositioning, transfer, and mobility status; and * Fall prevention interventions. During the acuity interview on 02/23/26, staff reported the resident had frequent falls. The 01/24/26 service plan showed the resident required two-person assistance for transfers, incontinence care, ambulation, mobility, and repositioning. During an observation on 02/24/26, one staff member provided transfer and incontinence care. The need to ensure service plans were reflective of the resident’s status, provided clear direction to staff regarding the delivery of services, and were implemented was reviewed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and Staff 4 (RCC) on 02/26/26 at 10:05 am. They acknowledged the findings.

1) Resident #1 and #5 Service Plan’s will be updated to reflect their current needs with clear instructions provided in their service plan for the staff to follow. This includes; who is providing service, what, when, how, and how often the service is needed. 2) The RCC and HSD will receive additional training regarding all required components of a resident service plan. A Service Plan Audit will be implemented for the clinical team. The Service Plan Audit Tool will be utilized during each service plan update to ensure all required components are present and that resident needs and interventions are accurately documented. 3) Service plans will be audited weekly for one month to ensure accuracy and completeness of all required components. After the initial monitoring period, monthly audits will be conducted to ensure continued compliance. 4) RCC, HSD, and ED, Designee.

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

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's current service plans were reviewed during the survey. There was no documented evidence service plans were developed and reviewed by a service planning team. The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and Staff 4 (RCC) on 02/26/25 at 11:20 am. They acknowledged the findings.

1) Care conferences will be scheduled and completed for Resident #1, #2, #3, and #4 with the Service Planning Team. Conferences will be documented in the resident record upon completion. 2) The RCC will contact responsible parties to coordinate and schedule care conferences. Care conferences will be conducted weekly for one month to ensure all current residents have an updated care conference completed. Thereafter, care conferences will occur quarterly and with any significant change in condition. A Care Conference Audit Tool will be implemented to ensure conferences are scheduled, completed, and properly documented 3) Weekly for a month and then quarterly and with any significant change of condition. 4) RCC, HSD, and ED, Designee.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. 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 1 of 2 sampled residents (# 1) whose MARs and controlled substance disposition logs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2025 with diagnoses including late onset Alzheimer’s disease with behavioral disturbance. During the acuity interview on 02/23/26, staff reported the resident received hospice services and was administered pain and anxiety medications as needed. The resident's 01/01/26 through 02/23/26 MARs and controlled substance disposition log were reviewed, and the following was identified: * Resident 1 had signed physician orders for Morphine Sulfate, 10 mg twice a day scheduled and 10 mg every 30 minutes for pain as needed. There were discrepancies noted on nine occasions; either there was no documented evidence the medication was administered to the resident or there were no corresponding entries in the controlled substance disposition log. * The resident had signed physician orders for lorazepam, 0.5 mg to be administered every hour as needed for anxiety. The MAR showed the medication was administered on three occasions, but there were no corresponding entries on the controlled substance disposition log. The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and Staff 4 (RCC) on 02/26/26 at 10:05 am. They acknowledged the findings.

1) A full audit of all controlled substances, the narcotic book, and corresponding MARs will be completed. Any discrepancies will be reconciled and corrected. 2) A medication audit process will be implemented for all PRN narcotics and psychotropic medications to verify that the MAR and narcotic book match and are accurately documented. Med Techs will be in-serviced on proper procedures for administering and documenting controlled substances, including documenting in both the MAR and narcotic book at the time of administration. Ongoing medication audits will be conducted to monitor compliance and address any discrepancies identified. 3) Medication Audits will be completed weekly for a month and bi-weekly thereafter. 4) RCC, HSD, ED, and Designee.

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)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 2, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2025 with diagnoses including Alzheimer’s unspecified dementia with behaviors. The resident’s clinical record from 11/28/25 to 02/23/26 was reviewed, and the following was identified: a. Resident 2 had physicians’ orders for lisinopril, 10 mg to be administered once daily and to hold if systolic blood pressure was less than 105. An interview with Staff 2 (Assistant ED) and Staff 10 (CG/MT) on 02/25/26 at 12:42 pm confirmed the facility had not been taking Resident 2’s blood pressure before administering lisinopril to determine whether the blood pressure was outside of parameters. The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 3 (Health Services, RN), and Staff 4 (RCC) on 02/26/26 at 10:40 am. They acknowledged the findings. 2. Resident 5 moved into the MCC in 12/2025 with diagnoses including?dementia, subdural hematoma (a brain bleed), and right-sided weakness. Resident 5’s MAR, dated 02/01/26 through 02/23/26, and corresponding prescriber orders were reviewed. The following was identified. The resident had orders for the following PRN medications for pain: * Acetaminophen Extra Strength 500 mg tablet; take 2 tablets by mouth three times daily as need (mild-moderate pain); and * Oxycodone 5 mg tablet; take 1 tablet by mouth every four hours as needed for moderate pain (unresponsive to non-opioid medication). a. Between 02/01/26 and 02/23/26, Resident 5 received acetaminophen 31 times. On four occasions the acetaminophen was documented as ineffective, and on 11 occasions there was no documentation of the acetaminophen being effective or ineffective. The resident never received oxycodone between 02/01/26 and 02/23/26, and on multiple occasions the resident received successive doses of acetaminophen (see b). Staff 6 (MT) reported in an interview on 02/26/26 at 10:10 am that s/he didn’t like to give the resident oxycodone because s/he asked for acetaminophen by name. b. Between 02/01/26 and 02/23/26, Resident 5 received acetaminophen at an interval shorter than the prescribed eight hours,14 of 31 times. The need to ensure medications and treatments were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and?Staff 4 (RCC) on 02/26/26 at 11:45 am. They acknowledged the findings.? 3. Resident 1 was admitted to the facility in 08/2025 with diagnoses including late onset Alzheimer’s disease with behavioral disturbance. Resident 1’s MAR, dated 02/01/26 through 02/23/26, and corresponding prescriber orders were reviewed. The following was identified: a. Resident 1 had physician orders to track bowel movements daily and to administer docusate sodium, 100 mg twice daily as needed; senna, 8.6 mg daily as needed for constipation; and suppository, 10 mg if no bowel movement after 3 days. Staff documented the resident had no bowel movement on the following dates: * 02/03/26 – 02/08/26, for 5 days; * 02/11/26 – 02/12/26, for 1 day; * 02/13/26 – 02/15/26, for 2 days; and * 02/18/26 – 02/22/26, for 4 days. There was no documented evidence those prescribed medications were administered as ordered when the resident did not have a bowel movement. b. Resident 1 had physician orders to apply oxygen at 3.5 liters per minute for increased dyspnea (shortness of breath) and hypoxia (low oxygen levels). During observations made on 02/24/26, the resident did not have the oxygen in place. Surveyor notified staff, and they placed the oxygen on the resident. The resident did not have any signs of shortness of breath or difficulty breathing during the time the oxygen was not placed. The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and Staff 4 (RCC) on 02/26/26 at 10:05 am. They acknowledged the findings.

1) Resident #1, #2, and #5 will receive a medication and treatment order review by the RN. Physician orders and parameters will be reviewed with Med Techs and updated in the MAR as needed. 2) All new physician orders will be reviewed by the HSD/RN during clinical meetings to verify parameters and instructions are accurately reflected in the MAR. The HSD/RN will review incoming orders, confirm accuracy of instructions and hold parameters, and sign off after review. Med Techs will be in-serviced on following physician orders and documenting required parameters prior to medication administration. 3) New physician orders will be reviewed five days per week for two weeks, then weekly thereafter. 4) HSD/RN, ED, and Designee.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters that included signs and symptoms for the administration of PRN psychotropic medications and failed to ensure that staff administered PRN psychotropic medications only after non-drug interventions had been attempted and were documented as ineffective for 1 of 1 sampled resident (# 1) who had orders for PRN psychotropic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2025 with diagnoses including late onset Alzheimer’s disease with behavioral disturbance. Resident 1’s MAR, dated 02/01/26 through 02/23/26, and corresponding prescriber orders were reviewed. The following was identified: * Ativan, 0.5 mg for dyspnea and restlessness every hour as needed; * Quetiapine, 25 mg for agitation every day as needed; * The PRN Ativan was administered on 21 occasions and quetiapine was administered on one occasion; * The MAR lacked written instruction indicating how the resident exhibited restlessness or agitation; and * There was no documented evidence unlicensed staff documented non-pharmacological interventions were attempted with ineffective results prior to administering these PRN psychotropic medications. On 02/26/26 at 2:50 pm, Resident 1's record was reviewed with Staff 2 (Assistant ED), and at 3:46 pm with Staff 1 (ED), and the need to ensure resident-specific parameters and to attempt non-pharmacological interventions prior to administering PRN psychotropic medications was discussed. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters that included signs and symptoms for the administration of PRN psychotropic medications and failed to ensure that staff administered PRN psychotropic medications only after non-drug interventions had been attempted and were documented as ineffective for 1 of 1 sampled resident (# 1) who had orders for PRN psychotropic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2025 with diagnoses including late onset Alzheimer’s disease with behavioral disturbance. Resident 1’s MAR, dated 02/01/26 through 02/23/26, and corresponding prescriber orders were reviewed. The following was identified: * Ativan, 0.5 mg for dyspnea and restlessness every hour as needed; * Quetiapine, 25 mg for agitation every day as needed; * The PRN Ativan was administered on 21 occasions and quetiapine was administered on one occasion; * The MAR lacked written instruction indicating how the resident exhibited restlessness or agitation; and * There was no documented evidence unlicensed staff documented non-pharmacological interventions were attempted with ineffective results prior to administering these PRN psychotropic medications. On 02/26/26 at 2:50 pm, Resident 1's record was reviewed with Staff 2 (Assistant ED), and at 3:46 pm with Staff 1 (ED), and the need to ensure resident-specific parameters and to attempt non-pharmacological interventions prior to administering PRN psychotropic medications was discussed. They acknowledged the findings.

1) Resident #1 chart will be reviewed by the RN/HSD to obtain resident-specific parameters and signs/symptoms for PRN psychotropic medications. Physician orders will be updated as needed to include appropriate parameters and instructions. 2) The community will conduct an audit of all PRN psychotropic medications to review resident-specific signs/symptoms and non-pharmacological interventions related to agitation, anxiety, or restlessness. The RN will review all new physician orders during clinical meetings and add resident-specific parameters and interventions as needed. Med Techs will be in-serviced on attempting and documenting non-pharmacological interventions prior to the administration of PRN psychotropic medications. 3) Medication documentation for PRN psychotropic medications will be reviewed weekly for one month and monthly thereafter. 4) HSD, RCC, ED, and/or Designee.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. 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 an assessment by a PT, OT, or RN was completed for assistive devices with potentially restraining qualities prior to the use of the device, and that caregivers had been instructed on the correct use of and precautions related to the device for 1 of 1 sampled resident (#5) who had a supportive device. Findings include, but are not limited to: Resident 5 moved into the MCC in 12/2025 with diagnoses including?dementia, subdural hematoma, and right-sided weakness. During the acuity interview on 02/23/26, staff reported Resident 5 had side rails on his/her bed. Observations of the resident’s room showed a half side rail on the side of the bed that was not against the wall. The side rail was observed to always be in the up position. On 02/25/26 the surveyor requested and the facility provided a “Supportive Device with Restraining Qualities Assessment” dated 02/25/26 at 2:30 pm. There was no documented evidence the facility RN, PT, or OT had conducted a thorough assessment prior to 02/25/26, or that the facility had instructed caregivers on the correct use of and precautions related to the device. On 02/26/26 at 11:45 am these findings were discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and?Staff 4 (RCC). They acknowledged the findings.

1) An assessment for the assistive device with restraining qualities (bed rails) was completed by the RN for Resident #5. Service plan instructions will be updated to include proper use and precautions for care staff. 2) A move-in checklist will be implemented to verify that all required assessments are completed upon admission, including assessments for assistive devices with restraining qualities. Residents with assistive devices will be reviewed and assessed as needed. Service plans will be updated to include caregiver instructions and precautions related to the device. Assistive device assessments will also be re-evaluated during service plan updates. 3) Upon Move-In, Quarterly, and/or for Significant Change of Conditions. 4) HSD, ED, and/or Designee.

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On 02/25/26, the posted staffing plan and the 02/15/26 through 02/21/26 staffing schedule were reviewed. The facility’s posted staffing plan, based on the Acuity-Based Staffing Tool, indicated the following: * Six direct care staff were scheduled for the day shift, 6:00 am to 2:00 pm; * Six direct care staff were scheduled for the swing shift, 2:00 pm to 10:00 pm; and * Three direct care staff were scheduled for the overnight shift, 10:00 pm to 6:00 am. Review of the 02/15/26 through 02/21/26 staffing schedule identified that the facility did not meet the posted staffing plan on five of 21 shifts, including day shifts on two occasions that were staffed at four, instead of the required six. Staff 2 (Assistant ED) stated in an interview on 02/26/26 at 11:45 am that she would often come in to cover a shift if staffing was insufficient. No further documentation of staffing for the week of 02/15/26 through 02/21/26 was provided. The facility's staffing schedule was reviewed with Staff 1 (ED), Staff 2, Staff 3 (Health Services, RN), and?Staff 4 (RCC) on 02/26/26 at 11:45 am. They acknowledged the findings.

1) The staffing schedule will be reviewed and adjusted to align with the community’s ABST staffing requirements. 2) The schedule will be reviewed against the community’s ABST to confirm staffing levels meet required staffing for each shift. The community is actively working with recruiters to hire additional staff to support staffing needs. Adjustments to the schedule will be made as needed to align with the ABST. 3) Staffing schedules will be reviewed weekly for one month and monthly thereafter. 4) ED, RCC, HSD, and Designee.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined 2 of 3 sampled newly hired direct care staff (#s 13 and 15) failed to complete first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (Assistant ED) on 02/25/26 at 9:17 am. The following was identified: Staff 13 (CG) was hired 01/20/26, and Staff 15 (CG) was hired 01/22/26. There was no documented evidence Staff 13 and Staff 15 completed the required first aid and abdominal thrust training within 30 days of hire. The need to ensure newly hired staff completed all required training within the specified timeframes was reviewed with Staff 1 (ED), Staff 2, Staff 3 (Health Services, RN), and Staff 4 (RCC) on 02/26/26 at 10:05 am. They acknowledged the findings.

1) Staff #1 and Staff #2 will complete First Aid and Abdominal Thrust training. 2) A training tracker will be implemented to monitor required trainings for newly hired direct care staff as well as ongoing annual training requirements. Required trainings, including First Aid and Abdominal Thrust, will be scheduled and completed within 30 days of hire. The tracker will be used to review training completion and due dates. 3) Training records will be reviewed weekly for one month and monthly thereafter. 4) AED, ED, and/or Designee.

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

OAR 411-054-0090 (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 and recorded according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Upon survey’s entrance to the facility on 02/23/26, fire and life safety records for the past six months were requested. The following was determined: Fire drill documentation lacked information for the following required elements: * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. These findings were reviewed with Staff 17 (Environmental Services Director) on 02/25/26 at 10:20 am, and with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and?Staff 4 (RCC) on 02/26/26 at 11:45 am. They acknowledged the findings.

1) The ESD will review the fire drill documentation form and complete documentation with all required components. 2) The ESD will be re-trained on proper completion of the fire drill documentation form, including documenting the location of simulated fire origin, escape route used, problems encountered, resident participation, evacuation time, and number of occupants evacuated. 3) Fire drill documentation will be reviewed after each fire drill. 4) ESD, ED, and Designee.

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

OAR 411-054-0090 (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 instruct residents within 24 hours of admission 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 and failed to re-instruct residents at least annually. Findings include, but are not limited to: On 02/25/26 at 9:54 am, the surveyor interviewed Staff 1 (ED) regarding the facility's process and documentation for instructing residents on fire and life safety procedures within 24 hours of move-in and reinstructing residents annually. Staff 1 was unable to provide the requested documentation. In an interview on 02/25/26 at 10:20 am, Staff 17 (Environmental Services Director) confirmed the lack of documentation. The need to ensure fire and life safety instruction was provided to residents within 24 hours of admission, and at least annually thereafter, was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (Health Services, RN), and?Staff 4 (RCC). They acknowledged the findings.

1) Resident service plans will be reviewed and updated to include documentation that residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places. 2) The RCC will be in-serviced on documenting resident Fire and Life Safety training in the service plan, including instruction on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting locations. Residents will also receive Emergency/Disaster orientation upon move-in. Resident instruction will be documented upon admission and annually thereafter. 3) Service plans will be reviewed weekly for one month and quarterly thereafter. 4) RCC, ESD, ED, and/or Designee.

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:

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 C 360, C 372, C 420, and C 422.

Refer to C360, C372, C420, and C422.

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 4, 11, 13, and 15) completed all required orientation and pre-service training before performing any job duties and failed to ensure 3 of 3 sampled newly hired direct care staff (#s 11, 13, and 15) completed pre-service training in all required training areas 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 2 (Assistant ED) on 02/25/26 at 9:17 am. The following was identified: Staff 4 (RCC) was hired 02/11/26, Staff 11 (CG/MT) was hired 10/13/25, Staff 13 (CG) was hired 01/20/26, and Staff 15 (CG) was hired 01/22/26. a. There was no documented evidence Staff 4 and Staff 11 completed orientation in: * Approved HCBS course; * Approved LGBTQIA2S+ course; and * Use of supportive devices with restraining qualities in memory care communities. Additionally, there was no documented evidence Staff 13 and Staff 15 completed infectious disease prevention training. b. There was no documented evidence Staff 11, Staff 13, and Staff 15 had demonstrated competency in one or more of the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to ensure newly hired staff completed all required training was reviewed with Staff 1 (ED), Staff 2, Staff 3 (Health Services, RN), and Staff 4 (RCC) on 02/26/26 at 10:05 am. They acknowledged the findings.

1) Staff #4, #11, #13, and #15 will complete all required orientation and pre-service training. Direct care staff will complete all required pre-service training prior to performing job duties. 2) A training tracker will be implemented to monitor completion of orientation and pre-service training for all newly hired staff. Required trainings will be scheduled and completed prior to staff performing job duties. The training tracker will also be used to monitor ongoing annual training requirements. 3) Training records will be reviewed weekly for one month and monthly thereafter. 4) AED, ED, and Designee.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to 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 C 260, C 262, C 302, C 303, C 330, and C 340.

Refer to C260, C262, C302, C303, C330, 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 develop an individualized activity plan based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 5) whose evaluations and services plans were reviewed. Findings include, but are not limited to: The most recent evaluations and current service plans were reviewed for Residents 1, 2, 3, and 5. The following was identified: 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. In an interview with Staff 5 (Activities Director) on 02/26/26 at 9:45 am, she confirmed the facility did not develop an individualized activity plan for each resident based on their activity evaluation. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), and Staff 4 (RCC) on 02/27/26 at 2:30 pm. They acknowledged the findings.

1) Resident activity evaluations will be reviewed and updated to include individualized activity preferences and specific details on what activities should be offered, how they should be offered, and how often staff should assist residents with participation. 2) The RCC and Activity Director will be in-serviced on developing individualized activity plans that include resident preferences and clear guidance for staff on what activities to offer, how they should be provided, and the frequency of participation. Activity evaluations will be updated to reflect individualized engagement needs. 3) Activity plans will be reviewed weekly for one month and quarterly thereafter. 4) RCC, Activity Director, ED, and designee.

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: