Print Inspection: RL011978

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 5 sampled residents (#s 2 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2021 with diagnoses including Arnold-Chiari syndrome (a congenital brain condition causing hydrocephalus), Type 2 diabetes mellitus, and abnormality of gait and mobility. Interviews with the resident and facility staff were conducted during the survey. Resident 5's service plan, dated 03/18/26, was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with transfers; * Updated fall prevention interventions; * Home health services from an outside provider; and * Staff escort to medical appointments. The need to ensure the service plan reflected residents' current care needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (RN, Health Services Director) on 05/20/26 at 12:45. They acknowledged the findings 2. Resident 2 was admitted to the facility in 05/2025 with diagnoses including macular degeneration and dementia and had recently been admitted to hospice services. Observations of Resident 2, interviews with the resident and staff, and review of the resident’s clinical record from 03/02/26 through 05/17/26 were completed during the survey. The 03/30/26 service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Ambulation with an assistive device; * Toileting assist; and * Level of assistance required for personal hygiene and grooming tasks. The need to ensure the service plan reflected Resident 2’s current needs and provided clear instruction to staff regarding the delivery of services was reviewed with Staff 1 (Administrator) and Staff 2 (RN, Health Services Director) on 05/20/26 at 12:55 pm. They acknowledged the findings.

Resident # 2 and #5 SP have been udated to reflect the identified needs. 100% audit will be completed of all current resident's Service Plans to ensure accuracy. Any areas of non-compliance will be immediately corrected. An in-service will be provided to ALF IDT to ensure the team is adequately updating their department's Service plan to reflect residents care. Facility Administrator will complete a weekly audit of all residents due for Serivce Plan reviews for 4 weeks and then quarterly thereafter. Administrator will address any areas of non-complaiince with the appropriate IDT to immediately correct any areas of inaccurate Service Plans. Administrator will be audit results to QA review to address areas of non-compliance.

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 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by an RN, including findings, resident status, and interventions made as a result of the assessment, for 3 of 3 sampled residents (#s 3, 4, and 5) who had significant weight changes. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including congestive heart failure and chronic kidney disease. During the acuity interview on 05/18/26, the resident was identified as having edema and being on weekly weights. Review of the resident’s clinical record, including weight records from 06/2025 through 05/18/26, observations of the resident, and interviews with staff and the resident identified the following: * 02/06/26 – 172.4 pounds; and * 03/06/26 – 158.8 pounds. Between 02/06/26 and 03/06/26, the resident lost 13.6 pounds, or 7.9% of his/her total body weight, in 30 days, which was a severe weight loss. There was no documented evidence an RN had completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment. Observations of the resident on 05/19/26 at 10:55 am revealed s/he had edema in both lower legs and was wearing Tubi Grips (compression stockings). The resident reported staff weighed him/her every morning and assisted in putting compression stockings on every morning and removing them every evening. Weight records indicated that Resident 4 was weighed daily beginning 03/14/26. Between 03/14/26 and 05/18/26 the resident’s weight fluctuated between 145 pounds and 169.4 pounds. The resident was observed on 05/19/26 eating 100% of his/her lunch independently. In an interview on 05/19/20 at 2:37 pm, Staff 2 (RN, Health Services Director) provided additional documentation, but there was no RN assessment which addressed the resident’s significant weight loss. The need to ensure all significant weight changes were assessed by an RN, with findings, resident status, and interventions made as a result of the assessment documented, was discussed with Staff 1 (Administrator) and Staff 2 on 05/20/26 at 11:15 am. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 10/2021 with diagnoses including Arnold-Chiari syndrome with hydrocephalus (congenital brain condition) Type 2 diabetes mellitus, and abnormality of gait and mobility. Review of the resident’s clinical record, including weight records from 02/2026 through 05/18/26, observations of the resident, and interviews with staff and the resident identified the following: * 02/14/26 – 252 pounds; and * 03/14/26 – 239 pounds. Between 02/14/26 and 03/14/26, the resident lost 13 pounds, over 5% his/her total body weight, in 30 days, which was a significant weight loss. There was no documented evidence an RN had completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment. An interview conducted on 05/19/26, at 3:00 pm, with Staff 2 (RN/Health Services Director) confirmed that no RN assessment was completed for Resident 5’s weight loss. During the survey Resident 5 was observed eating in the dining room with over 75% of meal eaten, and review of the record showed Resident 5 had regained six pounds since the significant weight loss was identified. The need to ensure an RN conducted and documented an assessment of a resident's significant change of condition was discussed with Staff 1 (Administrator) and Staff 2 on 05/20/26 at 12:45 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 10/2024 with diagnoses including hypertension and dementia. The resident's (add dates) clinical record was reviewed. Weight records identified the following: * 10/03/25 – 98.4 pounds; and * 04/03/26 – 112 pounds. Between 10/2025 and 04/2026, Resident 3 gained 13.6 pounds, or 13.8% of his/her total body weight in six months which constituted a severe weight gain. On 05/20/26, survey requested Resident 3 be weighed. The facility reported his/her weight was 105.2 pounds. Observations and interviews with staff indicated the resident was independent with dining and ate meals in his/her room. There was no documented evidence the RN completed a timely assessment of the resident following the identified weight gain between 10/03/25 and 04/03/26, which included findings, resident status, and interventions made as a result of the assessment. An interview conducted on 05/19/26, at 3:50 pm, with Staff 2 (RN/Health Services Director) confirmed that no RN assessment was completed for Resident 3’s weight gain. The need to ensure the RN assessed residents with significant changes of condition in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 2 on 05/20/26 at 12:30 pm. They acknowledged the findings.

Resident 3, 4 and 5 Weight assessment has been completed by RN, interventions and follow up implemented as indicated. 100% audit will be completed of all residents currently flagging for a weight exception. RN will complete an ALF Weight Change Evaluation for these residents falling outside of their physician-set parameters. An in-service will be provided to IDT, including RN regarding weight exception process including monthly weight audit, ALF Weight Change Evaluation and requirement per facility policy and procedures. RN or designee will complete monthly audit and review all residents who flag for a weight exception. RN or designee will complete an ALF Weight Change Evaluation for any residents who have not previously flagged for a weight exception to determine if there is a significant change and implementation of weight change documentaton per policy. RN will bring a summary of each month's weight audit to QA review to address any areas of non-compliance.

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

OAR 411-054-0037 (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 acuity-based staffing tool (ABST) was completed for each resident before admission for 1 of 1 sampled resident (# 6) and 3 of 3 unsampled residents whose ABST evaluations were reviewed. Findings include, but are not limited to: The facility’s ABST was reviewed during the survey and the following was identified: Review of the ABST for four newly admitted residents showed the following: * Resident 6 was admitted to the facility in 03/2026. The ABST was not completed for Resident 6 until 10 days after admission; and * ABST data was not entered for an additional three unsampled residents before admission to the facility. The need to ensure residents’ ABST data was completed prior to move-in was discussed with Staff 1 (Administrator), and Staff 2 (RN, Health Services Director) on 05/20/26 at 11:45 am. They acknowledged the findings.

Resident 6 ABST has been updated. 100% audit has been completed of all residents ABST to ensure updated and accurate to resident(s) needs. RSC re-inserviced and education provided on ABST regulatory rule of completing the ABST evaluation for all new move-ins prior to their move-in date. Administrator or RSC will complete new resident's ABST evaluation for all new residents based on the Move-in Evaluation prior to the resident moving in, updated with Service Plan quarterly reviews and PRN. Administrator or designee will audit weekly for 4 weeks then quarterly thereafter, to ensure that all new move-ins and post quarterly SP, to ensure compliance. Administrator is responsible for monitoring and ensuring compliance and will bring audit results to QA reivew to address any areas of non-compliance.

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 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled staff (#s 7, 11, 13, and 17) demonstrated competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/19/26 and 05/20/26, and the following was identified: Staff 7 (MT) was hired 10/14/24, Staff 11 (CG) was hired 10/31/25, Staff 13 (CG) was hired 10/13/25, and Staff 17 (MT) was hired 08/13/25. There was no documented evidence Staff 7, 11, 13, and 17 demonstrated competency in their assigned job duties within 30 days of hire. On 05/20/26 at 11:15 am, the need to ensure all direct care staff demonstrated competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (RN, Health Services Director). They acknowledged the findings, and no additional documentation was provided.

100% audit will be completed for all ALF employees to ensure all caregivers and medication techs have a fully completed orientation checklist in their personnel file. Any areas of non-compliance will be immediately corrected. Staffing Director will be re-inserviced and education provided on training records required to adequately demonstrate compentecy within 30 days of hire. Staffing Director will ensure that all new hires will complete job specific orientation within 30 days of hire. Administrator, or designee, will audit all new hire's weekly for 4 weeks and then quarterly thereafter. Administrator, or designee, will bring audit results to QA review and any areas of non-comliance will be addressed.

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 staff were provided fire and life safety training on alternate months of the fire drills and that the fire drills included documentation of the required elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 05/2026 was reviewed on 05/18/26 through 05/20/26. The following was identified: a. There was no documented evidence all staff were provided fire and life safety training every other month. b. Fire drill documentation did not include one or more of the following required elements: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Escape route used; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. The facility was combining fire drills between post-acute rehabilitation and assisted living. The fire drills documented did not indicate if the required elements were completed in assisted living. On 05/19/26 at 1:15 pm, Staff 5 (Maintenance Director) acknowledged the documentation did not clearly state what elements of the fire drill were applicable to the assisted living. The need to provide fire and life safety training for all staff on alternate months of fire drills, as well as the need to address all required elements in fire drill documentation, was discussed with Staff 1 (Administrator) and Staff 2 (RN/Health Services Director) on 05/20/26 at 12:30 pm. They acknowledged the findings.

Annual Fire & Life Safety in-service calendar will be completed with fire and life safety education topics to be covered on opposite months from fire drills. Current fire drill documentation form will be audited and edited to ensure all required elements are included on the form. Maintenance Director and IDT will be in-serviced on ALF Fire and Life Safety regulations including required education, staff and resident participation, and proper documentation on fire drill forms. Administrator will audit monthly for 3 months for fire drill compliance and education on oppositie months. Results will be brought to QA review and any areas of non-compliance will be addressed.

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: