Print Inspection: RL013138

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records for 1of 1 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to: Clinical records for Resident 1, were requested and reviewed during the survey. When additional documentation regarding resident changes of condition were requested, Staff 2 (Health Services Director) provided “Resident Care Notes” for the sampled resident. Review of the notes indicated additional changes of condition and a resident-to-resident altercation that were not part of the resident’s clinical record. Staff 2 stated on 07/22/26 at approximately 12:30 pm that the notes were not part of the resident’s clinical record, and they were shredded. She further indicated the facility used the “Resident Care Notes” as a 24-hour communication log. The need to ensure the preparation, completeness, accuracy, and preservation of resident records was discussed with Staff 1 (ED) on 07/23/26 at 5:30 pm. She acknowledged the findings.

In regards to OAR 411-054-0025, Facility Administration: Records and the need to ensure the preparation, completeness, accuracy, and preservation of resident records, the Health Services Director submitted a missing report of a resident on resident verbal altercation from May of 2026 to SPD and AAA on 7/22/26. Both the Executive Director and the Health Services Director had previously spoken with the Resident (#3 in the sampled records), and another resident, (not listed), and did not believe that it was a reportable incident at the time as abuse was ruled out internally. After the altercation, seating was re-arranged in the dining room, and both residents were monitored by carestaff to ensure there was not a repeat incident. In the future, if an internal investigation is done, and abuse ruled out, the investigation will be added to the Resident(s) record, with care notes to monitor resident behavior over the next week. If there are any signs that the residents are still having an issue or have been negatively effected by the incident, it will be reported as possible abuse and escalated to SPD and AAA for further investigation. This same resident, (#3 in the sampled records), had a sudden Change of Condition over a weekend, when they returned to the community on Oxygen without a signed Doctor's Order for the Oxygen. In the future, if a resident is kept overnight in the hospital, they will not be allowed to return without an assessment from the Nurse On Call. Medication Aides will be responsible for contacting the Nurse On Call, and coordinating any new medications with signed doctor's orders. No new medications will be administered without a signed doctor's order. Any new changes to care or medication will be communicated to staff via a written Interim Service Plan (ISP), created by the Nurse on Call or the MedAide on shift, that all direct care staff must sign off on. This will include resident specific actions or interventions for any changes in condition.

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately notify the local Department office of any incidents of abuse and/or promptly investigate the incident for 1 of 1 sampled residents (#3) who experienced a verbal resident-to-resident altercation. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2023 with diagnoses including chronic obstructive pulmonary disease and diabetes type II. Review of the resident's clinical record from 04/20/26 through 07/20/26, and staff “Resident Care Notes” (a 24-hour communication log that was not part of the clinical record) identified the following: On 05/18/26 staff documented in the “Resident Care Notes” that Resident 3 was involved in a verbal altercation with an unsampled resident. The notes indicated staff intervened and redirected the residents away from each other. The incident constituted potential verbal abuse requiring reporting to the local Department office and a facility investigation. There was no documented evidence the incident was immediately reported to the local Department office as suspected abuse and promptly investigated. On 07/22/26 at approximately 12:30 pm, Staff 2 confirmed she had learned about the incident from the “Resident Care Notes,” but she did not investigate the incident other than talking with Resident 3 about the altercation. On 07/23/26 at 2:22 pm, Staff 9 (MT) stated the unsampled resident, who typically ate in the dining room, did not want to come out of his/her room for meals after the incident. On 07/22/26 at 1:23 pm, the facility was asked to report the resident-to-resident altercation to the local Department office. Confirmation of the report was received on 07/22/26 at 4:35 pm. The need to immediately report all suspected abuse to the local Department office and to promptly investigate all resident incidents was discussed with Staff 1 (ED) on 07/23/26 at 5:30 pm. She acknowledged the findings.

In regards to OAR 411-054-0028 (1-3), Reporting & Investigating Abuse-Other Action, the Health Services Director submitted a missing report of a resident on resident verbal altercation from May 18, 2026 to SPD and AAA on 7/22/26. Both the Executive Director and the Health Services Director had previously spoken with the Resident (#3 in the sampled records), and another resident, (not listed), and did not believe that it was a reportable incident at the time as abuse was ruled out. After the altercation, seating was re-arranged in the dining room, and both residents were monitored by carestaff to ensure there was not a repeat incident. In the future, if an internal investigation is done, and abuse ruled out, the investigation will be added to the Resident(s) record, with care notes to monitor resident behavior over the next week. If there are any signs that the residents are still having an issue or have been negatively effected by the incident, it will be reported as possible abuse and escalated to SPD and AAA for further investigation. There will also be an Interim Service Plan (ISP) put in place with instructions to monitor involved residents that the direct care staff will need to sign off on.

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

OAR 411-054-0036 (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 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 5/2025 with diagnoses including type II diabetes, osteoarthritis, dementia and depression. Review of the resident’s clinical record dated 04/21/26 through 07/20/26, survey observations and interviews with multiple staff indicated the resident had a history of leaving the facility, navigating unsafely in the community, approaching strangers to request rides or use of a phone, leaving without appropriate clothing for weather conditions, making suicidal statements, verbally aggressive behaviors toward other residents, repeated refusals of incontinence care, changing clothing and briefs, and shower refusals Staff interviews identified the resident had ongoing skin breakdown related to repeated refusals of care. The service plan did not reflect the resident’s current needs or provide clear directions for staff regarding the delivery of services, including who would provide services and what, when, how, and how often services and interventions were to be provided in the following areas: * The type and level of supervision required when the resident attempted to leave or left the facility; * Who was responsible for supervising the resident and when supervision was to begin; * Interventions for leaving the facility without appropriate clothing or during unsafe weather conditions; * Supervision and interventions after the resident left the facility and while in the community, including unsafe navigation, unsafe street crossing, and approaching strangers to request rides or use of a phone; * Interventions when the resident refused redirection or supervision; * Interventions for the resident’s suicidal statements beyond notifying the Health Services Director; * Interventions to address verbally aggressive behaviors toward other residents; * Interventions to address repeated refusals of incontinence care, changing clothing and briefs, and showering; and * The resident’s ongoing skin breakdown, including monitoring and interventions. On 07/23/26 at 7:30 pm, the need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 2 (Health Service Director). They acknowledged the findings. Example #2: Lindsay 2. Resident 2 moved into the facility in 02/2024 with diagnoses including chronic obstructive pulmonary disease and dementia. Review of the resident’s clinical record dated 04/21/26 through 07/20/26, survey observations, and interviews with multiple staff indicated the resident had recently been involved in a resident-to-resident altercation in which another resident pushed him/her in the chest. Staff reported the other resident had repeatedly attempted to intimidate Resident 2 during mealtimes in the dining room. The resident’s service plan was not reflective and did not provide clear direction to staff in the following areas: * Interventions to protect the resident from intimidating, provoking or physically aggressive behaviors by the other resident. On 07/23/26 at 7:30 pm, the need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 2 (Health Service Director). They acknowledged the findings. Example #3: Liz 3. Resident Resident 3 was admitted to the facility in 05/2023 with diagnoses including chronic obstructive pulmonary disease and diabetes mellitus. Review of the resident’s clinical record from 04/20/26 to 07/20/26 and staff interviews revealed the following: Resident 3 had a history of alcohol use that impacted his/her health conditions as documented in a progress note dated 05/17/26. The 05/17/26 service plan was not reflective of the alcohol use, its impact on the resident’s health conditions, and did not include instructions to staff for what to do if/when the resident drank alcohol. On 07/23/26 at 5:30 pm, the need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED). She acknowledged the findings.

In regards to OAR 411-054-0036 (1-4), Service Plan: General, the Service Plans for residents #1, #2 and #3 were updated to reflect current needs, and written Interim Service Plans, (ISPs) were created to provide clear directions to the direct care staff regarding the delivery of services needed for each resident. For resident #1, an outside one-on-one caregiver was hired by the family from Caring for the Coast to provide assistance to the resident should they choose to leave the community without signing out. Resident Service Plan had been updated on 07/12/2026 to reflect the increased care needs due to refusal of care, suicidal statements, verbally aggressive behavior towards other residents, repeated refusal of incontinence care, changing of clothing and briefs, showering and ongoing skin breakdown, including monitoring. This resident was moved out of the community, into a Memory Care Community on 08/10/2026. In regards to the resident altercation, where another resident pushed him/her in the chest, a written ISP for resident #2 was created on 8/11/2026, to give clear direction to staff on how to protect the resident from intimidating, provoking, or physically aggressive behaviors from other residents in the future. Staff will separate residents and re-direct to introduce other subjects, entertainment options or tasks. The original aggressor was resident #1, who moved out of the community on 08/10/2026. For future care refusals, staff will be given training at the All-Staff meeting on 08/26/26 on reapproaching residents who refuse care, educating them on skin breakdown and the importance of skin checks and proper cleaning as allowed. Any refusals of care, or skin breakdown will be entered into the eMAR system by MedAides and checked daily until resolved. In regards to resident #3, and a progress note regarding alcohol use in May of 2026, a written ISP was created requesting direct-care staff to notate in the 24-Hour book if they notice the resident drinking or appearing intoxicated. A care conference was held with the resident in which they stated that they have quit drinking effective 7/8/2026. The resident's service plan was updated to reflect the impact that alcohol use has on their health conditions and to indicate what staff should do if/when the resident drinks alcohol. ISPs will be created by the Health Services director whenever there is a short term change of condition or a significant change of condition in a resident. These written ISPs will be placed in a binder for Direct Care Staff to sign off on and will include what action or intervention is needed for the resident, what type of monitoring is required and who needs to be notified of changes to resident's physical, emotional and mental functioning. ISPs will be reviewed by the Health Services Director and the Executive Director weekly to ensure accuracy and progress notes will be entered in the resident's electronic record to document weekly progress until resolved or deemed a significant change of Condition. The ISP will become a part of the resident record. Service Plans will be updated by the Health Services Director at move-in, within 30 days of move-in, every 3 months or upon change of condition. For resident #1, an outside one-on-one caregiver was hired by the family from Caring for the Coast to provide assistance to the resident should they choose to leave the community without signing out. Resident Service Plan had been updated on 07/12/2026 and this resident moved out of the community on 08/10/26 to a Memory Care Community. In the future any resident that is displaying ongoing changes of condition, will be placed on an ISP that clearly communicates individualized interventions for staff to attempt. A Care Conference will be held with the resident and family regarding the change of condition and update to Service Plan. The ISP will be monitored weekly by the Health Services Director and Executive Director. Multiple Interventions will be trialed before determining that a higher level of care, (HLOC) is needed. If HLOC is needed, the community will begin the move-out process with the family.

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 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to determine and document resident-specific actions or interventions following changes of condition, communicate the actions or interventions to staff on each shift, and document weekly progress until the condition resolved, and/or failed to monitor residents consistent with evaluated needs and service plan for 3 of 3 sampled residents (#1, 2, and 3) who experienced changes of condition. 1. Resident 1 moved into the facility in 05/2025 with diagnoses including type II diabetes, osteoarthritis, dementia, and depression. Review of the resident’s clinical record, dated 04/21/26 through 07/20/26, including 06/01/26 through 07/20/26 “Resident Care Notes” (a 24-hour communication log that was not part of the clinical record) and investigation reports, identified the following: The resident’s service plan dated 07/12/26 documented the resident left the building without signing out, did not safely navigate the community, and approached strangers to request rides or use of a phone. When more than two staff members were in the building, one staff member was to follow the resident to help ensure her safety. When only two staff members were in the building, staff were instructed to contact a designated family friend, inform him of the direction the resident had gone, or contact non-emergency police if the family friend was unavailable. * On 06/13/26, staff documented the resident left the facility on foot. Staff attempted to redirect the resident without success. At approximately 8:30 pm, neighbors brought the resident back to the facility. The nurse and ED were notified; * On 06/18/26, Staff 2 (Health Services Director) documented the resident refused medications and ADLs, including showers and incontinence care, placing the resident at risk for skin breakdown. The resident left the facility twice, asked strangers for rides and to use their phones, required the resident’s spouse to retrieve the resident from the community, resisted returning with the spouse, and attempted to exit a moving vehicle. Staff 2 documented the resident was no longer following the nurse’s suggestions, had contacted the resident’s spouse and healthcare provider, and planned to seek additional support; * On 07/04/26, Staff 2 (Health Services Director) documented the resident continued to refuse staff assistance with care when upset, left the facility to walk to the store when angry, and that previously implemented interventions were not consistently effective. The Health Services Director documented a recommendation to retry risperidone was pending the healthcare provider’s response; and * On 07/13/26, Staff 2 (Health Services Director) documented that on 07/12/26, the resident was involved in a resident-to-resident altercation during which the resident pushed another resident and the other resident’s walker. There was no documented evidence the facility determined and documented additional resident-specific actions or interventions following the resident’s ongoing changes of condition, including repeated episodes of leaving the facility without notice, inability to return independently, unsafe community behaviors, refusals of medications and ADLs, including incontinence care, and a resident-to-resident altercation; communicated those actions or interventions to staff on each shift; monitored the resident consistent with the resident’s evaluated needs; and/or documented weekly progress until the conditions resolved. On 07/23/26 at 7:30 pm, the need to ensure the facility determined and documented resident-specific actions or interventions following changes of condition, communicated those actions or interventions to staff on each shift, documented weekly progress until the condition resolved, and that residents were monitored consistent with evaluated needs and service plan was reviewed with Staff 1 (ED) and Staff 2. They acknowledged the findings. Example #2: Lindsay 2. Resident 2 moved into the facility in 02/2024 with diagnoses including chronic obstructive pulmonary disease and dementia. Review of the resident’s clinical record, dated 04/21/26 through 07/20/26, including 07/12/26 through 07/20/26 “Resident Care Notes” (a 24-hour communication log that was not part of the clinical record) and investigation reports, identified the following: * On 07/12/26, staff documented the resident was involved in a resident-to-resident altercation. Further documentation noted the resident had been yelled at and pushed in the chest by another resident. There was no further documentation demonstrating the facility determined and documented resident-specific actions or interventions following the incident, communicated those actions or interventions to staff on each shift, or documented weekly progress until the condition resolved. On 07/23/26 at 7:30 pm, the need to ensure resident-specific actions or interventions following changes of condition were determined and documented, communicated to staff on each shift, and documented in the resident record with weekly progress until the condition resolved was discussed with Staff 1 (ED) and Staff 2 (Health Services Director). They acknowledged the findings. Example #3: Liz 3. Resident 3 was admitted to the facility in 05/2024 with diagnoses including chronic obstructive pulmonary disease, diabetes type II, and bullous pemphigoid (a chronic skin condition causing blisters). A review of the resident's clinical record from 04/20/26 through 07/20/26, and staff “Resident Care Notes” (a 24-hour communication log that was not part of the clinical record) was completed, and staff interviews were conducted. The following was identified: The resident’s service plan dated 05/17/26 indicated s/he was prone to skin tears and other wounds, and staff should provide “simple dressing treatment” for his/her wounds. a. There was no documented evidence the facility monitored the resident consistent with evaluated needs and service plan for the following: *05/10/26: Staff documented the resident’s legs were weeping; *05/17/26: Staff documented the resident had weeping sores on legs; *05/12/26: Staff documented a skin tear to the resident’s left forearm; and *06/27/26: Staff documented an approximately 4-5 cm skin tear to the resident’s left elbow. b. There was no documented evidence actions or interventions were determined, documented, and communicated to staff with weekly progress noted to resolution for the following short-term changes of condition: *05/18/26: Resident 3 became agitated and was involved in a resident-to-resident verbal altercation with an unsampled resident in the dining room; *07/08/26: The resident experienced a fall with a skin tear to the right upper extremity. The resident was sent to the ER for evaluation and returned to the facility the same day with a heart monitor to monitor heart rhythm; and *07/09/26: Resident 3 was sent to the emergency room related to shortness of breath and low oxygen saturation levels. The resident returned to the facility on 07/10/26 with newly prescribed continuous oxygen therapy and the need for assistance with ADLs, whereas the resident had previously been independent. On 07/23/26 at 5:30 pm, the need to ensure the facility determined and documented resident-specific actions or interventions following short-term changes of condition, communicated those actions or interventions to the staff on each shift, and documented weekly progress until the condition resolved was reviewed with Staff 1 (ED). She acknowledged the findings.

In regards to OAR 411-054-0040 (1-2), Change of Condition and Monitoring, for resident #1, an outside one-on-one caregiver was hired by the family from Caring for the Coast to provide assistance to the resident should they choose to leave the community without signing out. Resident Service Plan was updated on 07/12/2026 and this resident moved out of the community on 08/10/26 to a Memory Care Community. In the future any resident with ongoiung safety concerns or refusal of care will be put on a written Short Term Monitoring, (STM) program to be updated regularly to document any resident-specific interventions attempted by staff and the result of such interventions until behavior is resolved or deemed a change of condition. A Care Conference will be held with the resident and family regarding the change of condition and update to Service Plan. The STM will be monitored weekly by the Health Services Director and Executive Director. Multiple Interventions will be trialed before determining that a higher level of care, (HLOC) is needed. If HLOC is needed, the community will begin the move-out process with the family. In regards to resident #2 being involved in a resident to resident altercation,a written ISP for resident #2 was created on 8/11/2026, to give clear direction to staff on how to protect the resident from intimidating, provoking, or physically aggressive behaviors from other residents in the future. Staff will separate residents and re-direct to introduce other subjects, entertainment options or tasks. The original aggressor was resident #1, who moved out of the community on 08/10/2026. For resident #3 who is prone to "skin tears and wounds", a daily skin check was added to the eMAR for the MedAides to document any new tears/wounds and any actions or interventions performed. A Wound Care ISP was created on 8/11/2026, with resident-specific actions and interventions for how to address skin tears and leg wounds for this resident. Instructions were given to "document in an Incident Report how the wound happened, size, if redness or heat is present. Use gloves and good hand hygiene. Contact nurse if instruction is needed." MedAides will perform daily skin checks until resolved. Health Service Director and Executive Director will follow up on skin tears/wounds in weekly meeting until resolved. ISPs and Incident Reports will be added to the resident record. The Health Services Director submitted a missing report of a resident on resident verbal altercation from May 18, 2026 to SPD and AAA on 7/22/26. Both the Executive Director and the Health Services Director had previously spoken with the Resident (#3 in the sampled records), and another resident, (not listed), and did not believe that it was a reportable incident at the time as abuse was ruled out. After the altercation, seating was re-arranged in the dining room, and both residents were monitored by carestaff to ensure there was not a repeat incident. In the future, if an internal investigation is done, and abuse ruled out, the investigation will be added to the Resident(s) record, with care notes to monitor resident behavior over the next week. If there are any signs that the residents are still having an issue or have been negatively effected by the incident, it will be reported as possible abuse and escalated to SPD and AAA for further investigation. There will also be an Interim Service Plan (ISP) put in place with instructions to monitor involved residents that the direct care staff will need to sign off on. This resident also experienced a fall with a skin tear on 07/08/26 and was sent out to the ER on 07/09/26 for shortness of breath, returning to the community on 07/10/26 with newly prescribed Oxygen. An ISP was created on 7/17/26 to address any resident-specific actions or interventions needed due to his change of condition and was placed in the binder for direct care staff to sign off on. As the company was in the middle of a staffing change, the Regional Nurse was not available to sign off on the resident's change of condition until 7/18/26. In the future, if a resident is kept overnight in the hospital, they will not be allowed to return without an assessment from the Nurse On Call. Medication Aides will be responsible for contacting the Nurse On Call, and coordinating any new medications with signed doctor's orders. No new medications will be administered without a signed doctor's order. Any new changes to care or medication will be communicated to staff via a written Interim Service Plan (ISP), created by the Nurse on Call or the MedAide on shift, that all direct care staff must sign off on. This will include resident specific actions or interventions for any changes in condition. The ISP will then be reviewed weekly by the Health Services Director and the Executive Director until resolved.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed for 1 of 1 sampled resident (# 3) who experienced a significant change of condition. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2024 with diagnoses including chronic obstructive pulmonary disease and diabetes type II. Review of Resident 3’s clinical record from 07/01/26 to 07/20/26, “Resident Care Notes” (a 24-hour communication log that was not part of the clinical record), and staff interviews revealed the following: On 07/09/26, Resident 3 was sent to the emergency department due to shortness of breath and low oxygen saturation levels. On 07/10/26, the resident returned to the facility with newly prescribed continuous oxygen therapy. Review of “Resident Care Notes” and multiple staff interviews indicated the resident needed increased assistance with ADLs, whereas the resident had previously been independent. The resident’s need for continuous oxygen therapy and increased assistance with ADLs constituted a significant change of condition requiring a timely RN assessment that documented findings, resident’s status, and interventions made as a result of the assessment. The RN completed the significant change of condition assessment on 07/18/26, eight days after the resident returned from the hospital. The need to ensure a timely RN assessment was completed for all residents who experienced a significant change of condition was reviewed with Staff 1 (ED) on 07/23/26 at 5:30 pm. She acknowledged the findings.

In regards to OAR 411-054-0045 (1)(a-f)(A)(C-F), Resident Health Services, What actions will be taken to correct ther rule violation to each example/resident? Resident #3 received a new assessment on 07/21/26, with RN review on 7/22/26. How will the system be corrected so this violation will not happen again? In future, when there is a Change of Condition, resulting in a new Service Plan or ISP, the Health Services Director or Nurse on Call will contact the RN to perform a problem focused assessment, chart review or phone consultation regarding the change of condition in a timely manner. If the Health Services Director is not available, the Nurse on Call will be contacted by Med Aides, and can reach out to the RN for assessment or Service Plan updates. How often will the area for correction be evaluated and who will be responsible to see that the corrections are completed/monitored? Changes of Condition are monitored weekly by the Health Services Director, Executive Director and the RN until resolved or deemed a significant change, after which a new Service Plan is created.

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 411-054-0055 (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 that medication and treatment orders were carried out as prescribed and signed physician orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 1 of 2 sampled residents (#3) whose records were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2024 with diagnoses including chronic obstructive pulmonary disease and diabetes type II. Review of the resident’s clinical record from 07/01/26 to 07/20/26 and staff interviews revealed the following: On 07/09/26, Resident 3 was sent to the emergency room due to shortness of breath and hospitalized overnight. On 07/10/26, Resident 3 returned to the facility with discharge instructions indicating oxygen would be prescribed to use at 1 liter per minute (LPM) at rest and 4 LPM with exertion. In an interview on 07/23/26 at 2:22 pm, Staff 9 (MT) stated MTs were administering 1 LPM at rest and 4 LPM with exertion from 07/10/26 to the date of the interview. In an interview on 07/22/26, Staff 2 (Health Services Director) stated she was unable to find a signed order for the oxygen and would request a copy. On 07/22/26 at 2:24 pm, Staff 2 provided the order that had been faxed to the facility that same day. The signed physician order, dated 07/10/26, indicated oxygen was to be administered at 2 LPM continuously. Staff 2 confirmed that the facility was not administering oxygen to Resident 3 as prescribed. The need to ensure that physician orders were carried out as prescribed and signed physician orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer was discussed with Staff 1 (ED) on 07/23/26 at 5:30 pm. She acknowledged the findings.

In regards to OAR 411-054-0055 (1)(f-h), Systems: Treatment Orders, when resident #3 returned to the community from the hospital on 07/10/26, Oxygen was being administered according to the discharge paperwork and orders from the Oxygen delivery company. The MedAide did not have a signed doctor's order for the Oxygen administration. The signed doctor's order was obtained by the Health Services Director on 07/22/26. Moving forward, if a resident is kept overnight in the hospital, they will not be allowed to return without an assessment from the Nurse On Call. Medication Aides will be responsible for contacting the Nurse On Call, and coordinating any new medications with signed doctor's orders. No new medications will be administered without a signed doctor's order. If the order is not signed, or there is a discrepancy from the discharge paperwork, staff will contact the hospital to clarify the orders and obtain a signed order. Any new changes to care or medication will be communicated to staff via a written Interim Service Plan (ISP), created by the Nurse on Call or the MedAide on shift, that all direct care staff must sign off on. This will include resident specific actions or interventions for any changes in condition. The ISP will then be reviewed weekly by the Health Services Director and the Executive Director until resolved. All Care Staff will be given training on these procedures at the All-Staff Meeting on 08/26/26

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 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents’ MARs included reasons for use for 2 of 2 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2024 with diagnoses including chronic obstructive pulmonary disease and diabetes type II. Review of Resident 3’s clinical record from 07/01/26 to 07/20/26 revealed the following: The following medications lacked an indication for use on the MAR: * Ferrous Sulfate 325mg; * Novolog Insulin; * Pramipexole 0.75mg; and * Torsemide 20mg. The need to ensure MARs were accurate and included reasons for use was discussed with Staff 1 (ED) on 07/23/26 at 5:30 pm. She acknowledged the findings. Example #2: Lindsay 2. Resident 1 moved into the facility in 05/2025 with diagnoses including type II diabetes, osteoarthritis, dementia, and depression. Review of Resident 1’s 07/01/26 through 07/20/26 MAR identified the following medications lacked documented reasons for use on the MAR: * Alprazolam 0.25mg; and * Magnesium oxide 400mg. On 07/23/26 at 5:30 pm, the need to ensure MARs were accurate and provided reasons for use was discussed with Staff 1 (ED). She acknowledged the findings.

In regards to OAR 411-054-0055 (2), Systems: Medication, indications for use were added to the eMAR for all medications. A printed list of common indications of use has been provided to MedAides along with a training of how to enter the indications for use to our eMAR system during a MedAide meeting on 08/24/2026. The eMAR will be checked daily by MedAides to ensure there are proper use indications listed on all resident medication records.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to maintain an accurate ABST that accounted for the resident’s scheduled and unscheduled needs, care elements, and care time for 1 of 3 sampled residents (#1) whose ABST data was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 5/2025 with diagnoses including type II diabetes, osteoarthritis, dementia and depression. Record review identified the resident had ongoing behaviors, left the facility without notice, refused incontinence care, and refused other ADLs requiring staff monitoring, supervision, and response. The resident’s ABST did not accurately reflect the resident’s scheduled and unscheduled care needs, care elements or care time for documented behaviors, assistance and supervision needs. On 07/23/26 at 7:30 pm, the need to ensure residents’ ABSTs accurately reflected residents’ scheduled and unscheduled care needs was discussed with Staff 1 (ED) and Staff 2 (Health Services Director).

In regards to OAR 411-054-0037 (1)(b-g), Acuity Based Stagging Tool-ABST Time, resident #1 was in need of additional staff monitoring, supervision and response due to ongoing behaviors, leaving the facility without notice, refusal of incontenence care and refusal of other ADLs. For resident #1, an outside one-on-one caregiver was hired by the family from Caring for the Coast to provide assistance to the resident should they choose to leave the community or need additional assistance. The Resident Service Plan was updated on 07/12/2026 and the ABST was updated at this time as well. This resident moved out of the community on 08/10/26 to a Memory Care Community and has been archived on the ABST. The ABST is updated by the Health Services Director whenever there is a change of condition or a Service Plan update to reflect any scheduled or unscheduled needs and monitored by the Executive Director regularly to ensure adequate staffing for the community. Scheduled and unscheduled needs are built into the times captured on each resident's plan of care.

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated and reviewed at least quarterly with the resident’s service plan for 1 of 3 sampled residents (#2) whose ABST was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 02/2024 with diagnoses including chronic obstructive pulmonary disease and dementia. Record review identified the resident’s service plan was updated on 06/04/26 to reflect an increase in staff assistance with ADLs. However, the resident’s ABST was not updated concurrently with the quarterly service plan review to reflect the resident’s increased care needs. On 07/23/26 at 7:30 pm, the need to ensure residents’ ABSTs were updated and reviewed at least quarterly with the residents’ service plans. was reviewed with Staff 1 (ED) and Staff 2 (Health Services Director.

In regards to OAR 411-054-0037 (4-6), Acuity Based Staffing Tool-Updates & Staffing Plan, Resident #2 had a service plan update on 06/04/26, but the update to the ABST did not save. The ABST is updated by the Health Services Director whenever there is a change of condition or a Service Plan update to reflect any scheduled or unscheduled needs and monitored by the Executive Director regularly to ensure adequate staffing for the community. Scheduled and unscheduled needs are built into the times captured on each resident's plan of care. The posted Staffing Plan will be updated by the Executive Director with a printed "Updated" Date as needed, or quarterly if no changes are needed.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct care staff (#s 11, and 12) had completed orientation prior to beginning their job responsibilities. Findings include but are not limited to: Staff training records were reviewed with Staff 3 (Business Office Director) on 07/23/26 at 11:50 am. There was no documented evidence that Staff 11 (CG), hired 05/13/26, and Staff 12 (CG), hired 04/08/26, had completed orientation prior to beginning their job responsibilities in one or more of the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious disease prevention; * Home and Community-Based Services (HCBS); * LGBTQIA2S+ protections and non-discrimination; * Dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating, and responding to behaviors, and reducing the use of antipsychotic medications; *Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Specific aspects of dementia care and ensuring the safety of residents with dementia, addressing pain, providing food and fluids, preventing wandering and elopement, and use of a person-centered approach. The need to ensure staff had completed orientation prior to beginning their job responsibilities was discussed with Staff 1 (ED) on 07/23/26 at approximately 5:30 pm. She acknowledged the findings.

In regards to OAR 411-054-0070 (3-4), Staffing Requirements and Training-Pre-service, all new hires will be given a pre-service orientation to include: (a) a review of their written job description with job responsibilities, (b) residents' rights and the values of community based care, LGBTQIA2S+ trainings, (c) abuse and reporting requirements, (d) Fire safety and emergency procedures, € Infectious Disease Prevention, (f) Home and Community Gased Services Training, (g) Food Handling, and Dementia Training. The staff will then be given Orientation to Resident with hands-on, shadowing and supervised training. The company-approved training software, Care Academy is missing some of the required coursework for new hire orientation. These missing courses, will be supplemented through Oregon Care Partners to ensure proper training is completed within the first 30 days of hire for all new hires. Training records for current hires will be reviewed and training completed by 09/21/2026 in the following areas: * Resident rights and values of CBC care * Abuse reporting requirements * Fire safety and emergency procedures * Infectious disease prevention * Home and Community-Based Services (HCBS) * LGBTQIA2S+ protections and non-discrimination * Dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms * Techniques for understanding, communicating, and responding to behaviors, and reducing the use of antipsychotic medications * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities * Specific aspects of dementia care and ensuring the safety of residents with dementia, addressing pain, providing food and fluids, preventing wandering and elopement, and use of a person-centered approach.

OAR 411-054-0070 (3-4) Staffing Requirements and Training ? Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct care staff (#s 11 and 12) had demonstrated competency in all assigned duties within 30 days of hire. Findings include but are not limited to: Staff training records were reviewed with Staff 3 (Business Office Director) on 07/23/26 at 11:50 am. There was no documented evidence that Staff 11 (CG), hired 05/13/26, and Staff 12 (CG), hired 04/08/26, demonstrated competency within 30 days of hire 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; * General food safety, serving and sanitation; and * First Aid/Abdominal thrust. The need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 on 07/23/26 at approximately 5:30 pm. She acknowledged the findings.

In regards to OAR 411-054-0070 (5 & 9-10), Training Within 30 Days of Hire-Direct Care Staff, training records for current hires will be reviewed and demonstrated competency documented by 09/21/2026 in 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 * General food safety, serving and sanitation * First Aid/Abdominal thrust. Review of proper training, and competency sign-off will be completed with MedAides at MedAide meeting on 08/24/26

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 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 1 of 4 sampled newly hired staff (# 12) whose training records were reviewed. Findings include, but are not limited to: Refer to C 370.

In regards to OAR 411-054-0070 (3)(b)(A)(B)(C), Staffing Requirements and Training- Pre-Service, all new hires will be given a pre-service orientation to include approved LGBTQIA2S+ training that will address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. Current staff will be subject to bi-ennial training in these areas. Current staff (who have not completed the training in the last six months), will be scheduled to complete the Oregon Care Partners approved training course in the next 30 days.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training ? Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: