Print Inspection: RL013817

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 3 and 6) whose move-in evaluations were reviewed and failed to ensure smoking status was evaluated for 1 of 2 sampled residents (#1) who chose to smoke. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 07/2026 with diagnoses including emphysema and was receiving hospice services. The move-in evaluation was reviewed and lacked the following required elements: * Customary routine with bathing; * Cultural preferences and traditions; * Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Complex medication regimen; and * Recent losses. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations) and Staff 13 (Regional Director of Health Services/LPN) on 08/27/26 at 10:47am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2025 with diagnoses including paraplegia. The resident’s clinical record, dated 05/14/26 through 08/24/26, was reviewed. Resident 1 and staff were interviewed. The following was identified: During an interview with the resident on 08/25/26 at 10:00 am, a clear bottle containing a green, plant-like substance was observed in Resident 1’s room on a table next to his/her bed. The resident stated s/he used the substance “frequently.” On 08/27/26 at 10:16 am, Staff 5 (CG/MT) confirmed the resident had been observed to smoke on the seventh-floor Sky Lounge, which was not a designated smoking area On 08/25/26 at approximately 1:30 pm, Staff 1 (General Manager) and Staff 4 (Regional Director of Operations) confirmed there was no documented evidence that the resident had been evaluated to independently smoke safely. The need to ensure a smoking evaluation was completed was discussed with Staff 1, Staff 4 and Staff 13 (Regional Director of Health Services/LPN) on 08/27/26 at 10:47am. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 06/2026 with diagnoses including a left side above-the-knee amputation and cerebrovascular accident (stroke). The move-in evaluation was reviewed and lacked the following required elements: * Customary routine with bathing; * Cultural preferences and traditions; * Pain, including pharmaceutical and non-pharmaceutical interventions; * Complex medication regimen; and * Recent losses. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations) and Staff 13 (Regional Director of Health Services/LPN) on 08/27/26 at 10:30 am. They acknowledged the findings.

1. The Resident Care Director (RCD) or designee will complete and document corrected evaluations for Residents 3 and 6, including bathing routines, cultural preferences and traditions, pain and non-pharmacological interventions, complex medication regimen, and recent losses. The RCD or designee will complete and document a smoking safety evaluation for Resident 1 and update the resident's service plan with smoking location, supervision, safety measures, and staff instructions. The same review will be completed for all current residents to identify and correct any other missing required evaluation elements. 2. Merrill Gardens has a Move In Evaluation form that meets all required elements. Staff responsible for evaluations will be retrained on required evaluation elements to not leave any blanks on the Merrill Gardens Move In Evaluation form when completing an evaluation, including smoking, alcohol or non-prescribed drug use, pain, routines, cultural preferences, medication complexity, recent losses, and environmental factors. The RCD will review and sign each evaluation for completeness before the related service plan is finalized. 3.The RCD or designee will review each new move-in evaluation before the related service plan is finalized and review required post-move-in and quarterly evaluations as they come due. Each month, the RCD will sample completed resident evaluations for required elements and consistency with the service plan. Findings will be documented, corrected, and addressed through staff coaching or retraining. The GM will review the audit results and follow-up monthly. 4. The RCD is responsible for implementation and ongoing audits. The General Manager (GM) will review audit results monthly and verify corrective action is completed.

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’ needs and provided clear direction to staff regarding the delivery of services for 4 of 6 sampled residents (#s 1, 2, 4 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2026 with diagnoses including a left side above-the-knee amputation and cerebrovascular accident (stroke). The resident’s clinical record from 06/29/26 through 08/21/26, including the 07/29/26 service plan, was reviewed, interviews with staff and the resident were conducted, and observations were made. Resident 6's current service plan, dated 07/29/26, was reviewed and was not reflective of the resident's current needs and lacked clear directions to staff in the following areas: * Pharmaceutical and non-pharmaceutical pain interventions; * Assistance required for use of a prosthesis, bathing, evacuation during an emergency and transfers; * The resident’s bowel and bladder continence status and toileting needs; * The resident’s food/fluid preferences; * Services from an outside home health agency; * Wound dressing coverage during bathing; and * The use of a thick sock and elevation of the leg to aid with wound healing and prevention of further skin issues. The need to ensure residents’ service plans were reflective of their care needs and provided clear direction to staff was reviewed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10:30 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2025 with diagnoses including paraplegia. The resident’s clinical record, dated 05/14/26 through 08/24/26, which included the 06/09/26 service plan, was reviewed, interviews with staff and the resident were conducted, and observations were made. Resident 1's service plan was not reflective of the resident's current needs and lacked clear directions to staff in the following areas: * Smoking; * Toileting habits and PRN incontinence care; * Alcohol use and safety interventions; * Interventions for suicidal verbalizations; * Preference of not wearing clothing at times; * Family involvement; * Personalized fall interventions; * The use of an electric wheelchair; * Using a manual wheelchair for a shower chair; * Caregivers providing PRN housekeeping and laundry; * Male caregivers providing ADL assistance when available, relating to behaviors; * PRN assistance with bathing; and * Use of a pendent call system. During an interview with the resident on 08/25/26 at 10:00 am, Resident 1 stated his/her daughter was not speaking to him/her relating to his/her current alcohol use, that s/he preferred to urinate in disposable cups while in bed, had a preference of not wearing clothes “when the sun is beaming through my window,” and confirmed s/he did not have a call pendent and used the call system button located behind the head of the bed. Resident 1 stated that s/he would rather have a pendent to be able to alert staff when s/he needed assistance. On 08/25/26 at approximately 11:00 am, Staff 1 (General Manager) confirmed the resident did not have a pendent and one would be provided to him/her by the end of the day. On 08/27/26 at 10:16 am, Staff 5 (CG/MT) confirmed Resident 1’s smoking and toileting habits, the need for PRN incontinence care, alcohol use, only using a manual wheelchair for showers, CGs providing PRN housekeeping and laundry, staff trying to have only male MTs and CGs assist the resident, relating to the resident’s behaviors, and PRN assistance with showering. The need to ensure residents’ service plans were reflective of their care needs and provided clear direction to staff was reviewed with Staff 1, Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10:47 am. They acknowledged the findings. Confirmation the facility provided a call pendant to Resident 1 was completed on 08/26/26 at 9:00 am. 3. Resident 2 was admitted to the facility 12/16/24 with diagnoses including chronic kidney disease. Observations were made from 08/24/26 through 08/26/26. Interviews with the resident, facility staff, and the residents outside providers were conducted. The current service plan dated 07/14/26 was reviewed. Resident 5's service plan was not reflective of the resident's current needs and lacked a written description of who would provide the services, and what, when, how, and how often the services would be provided in the following areas: * Services from an outside caregiving agency and home health physical therapy; * Use of a wrist brace and post-fracture precautions; * Fall prevention interventions including use of a wheelchair and walker; * Assistance needed with toileting; bathing, and dressing; * Assistance needed with transferring and mobility; * Assistance needed with pet care for a dog; * Ability to safely exit the building unsupervised; and * Number of staff needed to assist with emergency evacuations. The need to ensure the service plan reflected residents 2’s current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (General Manager), Staff 2 (Resident Care Director/LPN), and Staff 4 (Regional Director of Operations) on 08/27/26 at 1:00 pm. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 12/2025 with diagnoses including spinal stenosis. The resident’s 05/03/26 to 08/26/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The resident’s current service plan, dated 08/19/26, was not reflective of the resident’s current care needs and lacked clear instructions to staff in the following areas: * Colostomy care instructions, including who should empty and change the bag; and * Monitoring skin for irritation and changes in stoma (surgical opening on the abdomen) color. Observations on 08/25/26 at 2:17 pm showed a caregiver changed the resident’s colostomy bag. During an interview on 08/25/26 at 10:00 am, Resident 4 reported s/he emptied the colostomy bag but staff changed the bag every three to four days. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1 (General Manager) and Staff 4 (Regional Director of Operations) on 08/26/26 at 2:35 pm. They acknowledged the findings.

1.The RCD or designee will revise the service plans for Residents 1, 2, 4, and 6 so each plan accurately reflects current needs and gives clear directions stating who will provide each service and what, when, how, and how often the service will be provided. Corrections will address all areas identified in the survey, including pain interventions, transfers and mobility, toileting, bathing, dressing, emergency evacuation, outside services, wound and skin care, colostomy care, fall interventions, call system use, personal preferences, and other resident-specific needs. The service planning team, including the resident or representative as applicable, will participate in the updates. 2. System correction to prevent recurrence: The facility will use a service-plan quality checklist requiring each identified need to be translated into resident-specific staff direction. Service plans will be reconciled against the most current evaluation, provider orders, outside-provider recommendations, change-of-condition documentation, and ABST care elements before approval. Changes will be dated and initialed, prior history retained, and a copy offered to the resident or legal representative. 3. Monitoring and evaluation frequency: The RCD or designee will review each new or revised service plan before staff implement it and sample completed plans each month, including plans updated after evaluations or changes of condition. The review will check for resident-specific directions, consistency with orders and evaluations, and communication to staff. Unclear or missing directions will be corrected and communicated to direct-care staff. The GM will review findings and follow-up monthly. 4. Responsible person: The RCD is responsible for service-plan completion and audits. The GM will review monthly audit results and verify follow-up.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to evaluate residents who experienced changes of condition and refer to the facility nurse when required, determine and document what actions or interventions were needed for short-term changes of condition, communicate actions or interventions to staff on all shifts, monitor residents consistent with their evaluated needs, and document weekly progress until the condition was resolved for 4 of 6 sampled residents (#s 1, 2, 5, and 6) who experienced changes of condition. Findings include, but are not limited to: 1.Resident 5 was admitted to the facility in 01/2025 with diagnoses including hypertension, type 2 diabetes, and gout. The resident’s clinical record from 05/16/26 through 08/23/26 was reviewed, observations of the resident were made, and interviews with the resident and facility staff were conducted. The facility failed to determine specific actions or interventions needed for the resident, communicate the determined actions or interventions to staff, or document weekly progress until the conditions were resolved for the following short-term changes of condition: * 05/22/26 – Not feeling well and an episode of vomiting; * 05/25/26 - Emergency room visit; * 06/22/26 – Returned after skilled nursing home stay; * 07/06/26 – Missing scheduled insulin; * 07/08/26 – New medication, Semaglutide 14 mg daily for diabetes; and * 08/23/26 – Changes in medication, from Rybelsus to Ozempic for diabetes. On 08/26/26 at 10:35 am, Staff 2 (Resident Care Director/LPN) reported she was new to the facility and identified a lack of temporary service plans and an alert charting system to document changes in condition, including documentation of the resolution of those changes, when she was hired. The need to ensure the facility determined and documented what action or intervention was needed for short-term changes of condition, communicated the action or intervention to staff on each shift, monitored the resident consistent with the resident’s evaluated needs, and documented weekly progress until the condition was resolved was reviewed with Staff 1 (General Manager) and Staff 4 (Regional Director of Operations) on 08/26/26 at 2:07 pm. They acknowledged the findings. No further information was provided. 2. Resident 6 was admitted to the facility in 06/2026 with diagnoses including a left side above-the-knee amputation and cerebrovascular accident (stroke). The resident’s clinical record from 06/29/26 through 08/21/26 was reviewed, observations of the resident were made, and interviews with the resident and facility staff were conducted. The facility failed to determine specific actions or interventions needed for the resident, communicate the determined actions or interventions to staff, or document weekly progress until the conditions were resolved for the following short-term changes of condition: * 06/29/26 – New move-in; * 07/04/26 – Skin tear to the right leg; * 07/06/26 – Cellulitis to right lower extremity and new antibiotic, doxycycline; and * 08/11/26 – Multiple blisters and cellulitis to right lower extremity and new antibiotic, cephalexin. In an interview on 08/25/26 at 1035 with Staff 2 (Resident Care Director/LPN), she confirmed there was no documented evidence the facility had determined actions or interventions, communicated the actions or interventions to staff on each shift, or monitored the resident’s skin tear to the right leg, cellulitis to right lower extremity and new antibiotic, cephalexin and multiple blisters to right lower extremity and new antibiotic, doxycycline. The need to ensure the facility determined and documented what action or intervention was needed for short-term changes of condition, communicated the action or intervention to staff on each shift, monitored the resident consistent with the resident’s evaluated needs, and documented weekly progress until the condition was resolved was reviewed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10:30 am. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 11/2025 with diagnoses including paraplegia. The resident’s clinical record, dated 05/14/26 through 08/24/26, was reviewed and the following was identified: a. There was no documented evidence the facility determined what action or intervention was needed for the resident and communicated the determined action or intervention to staff on each shift on 05/26/26 and 06/25/26 relating to verbalizations of suicide. b. There was no documented evidence the facility determined what action or intervention was needed for changes of condition, communicated the determined action or intervention to staff on each shift, and monitored the condition through resolution for the following: * 05/25/26 - Signs and symptoms of depression; * 05/26/26 - Inappropriate comments to female staff members; * 06/17/26 - Two new medications; * 06/18/26 - Upper respiratory infection; and * 06/21/26 – A new antibiotic. On 08/25/26 at 3:18 pm, Staff 2 (Resident Care Director/LPN) confirmed there was no documented evidence the facility determined and documented actions or interventions and communicated the actions or interventions to staff on each shift relating to Resident 1’s verbalizations of suicide. In the same interview, Staff 2 also confirmed there was no documented evidence the facility had determined actions or interventions, communicated the actions or interventions to staff on each shift, or monitored the resident’s depression, behaviors, medication changes, and upper respiratory infection through resolution. The need to ensure the facility determined and documented what action or intervention was needed for short-term changes of condition, communicated the action or intervention to staff on each shift, and monitored the resident through resolution was discussed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10:47 am. They acknowledged the findings. 4. Resident 2 was admitted to the facility 12/2024 with diagnoses including chronic kidney disease. Review of the resident's clinical record, including alert charting from 05/24/26 through 08/24/26, the 07/14/26 service plan, and interim service plans (ISPs) from 05/24/26 through 08/24/26 were completed during the survey. On 7/13/26 an alert charting note documented “back to the community from rehabilitation.” On 7/16/26 an alert charting note documented Resident 2 had “returned from long stint of increased falls resulting in broken right wrist. [S/he] has full-time caregiver, staff taken over administration of medications, removed from alert charting.” The increased falls, wrist fracture, hospitalization, six-week stay in a rehabilitation facility, and increased care needs at return to the facility constituted a significant change of condition for which an RN assessment was required. There was no evidence Resident 2’s change of condition was evaluated and referred to the facility RN for assessment. In interview on 10/25/26 at 10:00 am, Staff 2 (Resident Care Director/LPN) confirmed there was not a documented referral to the facility RN to complete a significant change of condition assessment. The need to ensure significant changes of condition were evaluated and referred to the facility RN for assessment was discussed with Staff 1 (General Manager), Staff 2, and Staff 4 (Regional Director of Operations) on 08/27/26 at 1:00 pm. They acknowledged the findings.

1. Corrective actions for cited examples/residents: The RCD or facility nurse will review the cited changes of condition for Residents 1, 2, 5, and 6 and complete any current evaluation, referral, intervention, service-plan update, staff communication, monitoring, and resolution documentation still applicable. Resident 2's significant change following hospitalization and rehabilitation will be reviewed by the facility nurse, and the evaluation and service plan will be updated as needed. Current unresolved short-term changes will have resident-specific interventions communicated to every shift and weekly progress documented until resolution. 2. System correction to prevent recurrence: The facility will implement a change-of-condition process that requires staff to report changes promptly, the licensed nurse to classify the change as short-term or significant, and resident-specific interventions to be documented and communicated to all shifts. Significant changes will be referred to the facility RN for assessment. Short-term changes will remain on alert charting or an interim service plan until the condition is resolved, with weekly progress notes and a documented closure. Inservice to be completed for all care staff on Change of Condition Interpretive Guidelines, when to report, and how to report. 3. Monitoring and evaluation frequency: The RCD or facility nurse will review the change-of-condition log and alert charting each business day and follow unresolved changes at least weekly, as required by the resident’s condition and the facility process. The GM will sample completed change-of-condition records each month for timely assessment, staff communication, nurse referral when required, documented monitoring, and resolution. Findings will be tracked and corrected, and the review will remain part of ongoing quality oversight. 4. Responsible person: The RCD and facility nurse are responsible for clinical implementation and monitoring. The GM will oversee compliance and monthly audits.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers, ensuring staff were informed of new interventions, the service plan was adjusted if necessary, and reporting protocols were in place for 3 of 5 sampled residents (#s 3, 5, and 6) who were receiving outside services. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 07/2026 with diagnoses including emphysema and was receiving hospice services. Review of the clinical record from 07/20/26 through 08/16/26 noted the following: In a progress note on 07/22/26, staff documented hospice ordered the facility to obtain the resident's blood pressure "every [three] days, call hospice if systolic (top number) blood pressure is below 90 or above 180.” On 08/27/26 at 10:02 am, Staff 3 (RCC) confirmed there was no documented evidence the facility was obtaining Resident 3's blood pressure every three days. The need to ensure staff were informed of outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10:47am. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 01/2025 with diagnoses including hypertension, type 2 diabetes, and gout and was identified during the acuity interview on 08/24/26 as receiving home health services. Review of the resident’s chart from 06/29/26 through 08/21/26 included the following recommendations made by the home health provider: * 06/29/26 – Standby assistance with ambulation for now “very unsteady”; * 07/02/26 – “use cane/walker for fall prevention”; and * 07/20/26 – “stay upright 30 minutes after meal.” There was no documented evidence the facility communicated these recommendations to direct care staff or that the service plan was adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (General Manager) and Staff 4 (Regional Director of Operations) on 08/26/26 at 2:07 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 06/2026 with diagnoses including a left side above-the-knee amputation and cerebrovascular accident (stroke). Review of the resident’s chart from 07/14/26 through 08/12/26 identified the following home health nurse recommendations: 07/14/26 – “We have no nurse to see [the resident] Friday as I am off. If someone can do wc [wound care] then we will see [him/her] Monday and Thursday. For showers please wrap leg.“ There was no documented evidence the facility communicated these recommendations to direct care staff or that the service plan was adjusted to ensure continuity of care. In an interview on 08/25/26 at 10:35 am, Staff 2 (Resident Care Director/LPN) stated there was no documentation to show the wound care requested by home health to be done on Friday 07/17/26 had been completed and that it had not been communicated to staff to wrap the leg during showers. The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10:30 am. They acknowledged the findings.

1. Corrective actions for cited examples/residents: The RCD or facility nurse will reconcile outside-provider recommendations for Residents 3, 5, and 6 with the current record and service plan. Resident 3's blood-pressure monitoring and provider notification parameters will be placed in the appropriate record and assigned for completion. Resident 5's mobility, fall-prevention, and post-meal positioning recommendations will be communicated to direct-care staff and added to the service plan. Resident 6's wound-care and shower instructions will be clarified with the outside provider, communicated to staff, and reflected in the service plan and treatment documentation. 2. System correction to prevent recurrence: All hospice, home-health, therapy, and other outside-provider communications will be routed to the RCD or facility nurse for review. The reviewer will document receipt, identify required actions, update orders and service plans as applicable, notify direct-care staff, and confirm follow-through. A provider communication log will track the date received, intervention, responsible staff member, service-plan update, and completion. 3. Monitoring and evaluation frequency: The RCD or facility nurse will review outside-provider communications as received and check the communication log each business day for outstanding actions. Each month, the RCD or designee will sample records of residents receiving outside services to verify that recommendations were reviewed, implemented as appropriate, communicated to staff, and reflected in the service plan. Gaps will be documented and followed through to resolution; the GM will review trends and completion monthly. 4. Responsible person: The RCD and facility nurse are responsible for coordination with outside providers and record updates. The GM will review audit results monthly.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a system for tracking controlled substances for 1 of 2 sampled residents (#4) whose record was reviewed for controlled substances. Findings include, but are not limited to: Resident 4 was admitted to the facility in 12/2025 with diagnoses including spinal stenosis. The resident’s current signed orders, 08/01/26 through 08/24/26 MAR, and controlled substance disposition log entries were reviewed, and the following was identified: The resident had orders for tramadol 50 mg, administer one tablet twice a day PRN for pain. The controlled substance disposition log showed staff administered the medication 33 times. On seven occasions, the MAR lacked a corresponding entry. On 08/24/26 at 4:00 pm, the discrepancies were reviewed and the need to ensure a system for tracking controlled substances was discussed with Staff 1 (General Manager), Staff 2 (Resident Care Director/LPN), and Staff 4 (Regional Director of Operations) on 08/25/26 at 4:00 pm. They acknowledged the findings.

1. Corrective actions for cited examples/residents: The RCD or facility nurse will reconcile Resident 4's controlled-substance disposition log, MAR, physician orders, and available medication count. The seven cited administrations without corresponding MAR entries will be reviewed, documented according to facility policy, and reported or followed up as required. All residents receiving controlled substances will be audited for matching MAR entries, disposition records, and medication counts. 2. System correction to prevent recurrence: Medication staff will be retrained to document each controlled-substance administration on both the MAR and controlled-substance record at the time of administration. Shift-to-shift controlled-substance counts and discrepancy reporting will be completed according to the facility's pharmacist- or RN-approved system. Discrepancies will be escalated to the licensed nurse and GM immediately and resolved with documented follow-up. 3. Monitoring and evaluation frequency: Medication staff will complete and verify controlled-substance counts at each shift change according to the facility’s approved process. The RCD or designee will review discrepancies as they arise and sample controlled-substance records and corresponding MAR entries each month. Any variance will be escalated promptly, investigated, and documented through resolution. The GM will review audit findings and follow-up monthly. 4. Responsible person: The RCD or facility nurse is responsible for medication-system oversight. The GM will verify completion of audits and corrective follow-up

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 2 and 5) reviewed for medication administration. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility 12/16/24 with diagnoses including chronic kidney disease. The resident's 08/01/26 to 08/24/26 MAR and physician orders dated 08/19/26 were reviewed, and the following was identified: a. The following signed physician order was not included on the MAR and was not being administered: * “Acetaminophen 650 mg every 8 hours (for pain management) administration time 6:00 AM, 2:00 PM, 10:00 PM.” b. Physician orders dated 08/19/26 documented: * Amlodipine 5mg (blood pressure medication) “Hold for blood pressure less than 110 or heart rate less than 60”; and * Propranolol 10mg (blood pressure medication) “hold for systolic blood pressure less than 110 or heart rate less than 60.” On 08/11/26 the Amlodipine and the Propranolol were given at 8:00 AM; however, there was no documented evidence the blood pressure or heart rate were checked prior to administration. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (General Manager), Staff 2 (Resident Care Director/LPN), and Staff 4 (Regional Director of Operations) on 08/27/26 at 1:00 pm. They acknowledged the findings. 2. Resident 2. Resident 5 was admitted to the facility in 01/2025 with diagnoses including hypertension, type 2 diabetes, and gout (a painful type of inflammatory arthritis). Review of Resident 5’s clinical record, including the 08/01/26 through 08/24/26 MAR and signed physician orders dated 02/27/26, identified the following: a. A physician order indicated to check blood sugar level daily. However, the MAR showed the facility did not obtain the blood sugar level results on three occasions on 08/01/26, 08/07/26, and 08/13/26; b. A physician order indicated to administer Colchicine 0.6 mg twice a day for gout. However, the MAR showed the medication was not administered on 40 occasions due to the medication not being available or other unspecified reasons; and c. A physician order indicated to administer Rybelsus 14 mg daily for diabetes. However, the MAR showed the medication was not administered on four occasions due to the medication not being available. On 08/26/26 at 11:35 am, Staff 6 (CG/MA) stated Colchicine and Rybelsus were not currently available, and the facility had faxed the pharmacy regarding the need for refills. The facility was informed there were no remaining refills, and they were informed the medications had been discontinued. However, there was no signed physician’s order indicating those two medications had been discontinued nor was there any documentation provided to support the discontinuation. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (General Manager) and Staff 4 (Regional Director of Operations) on 08/26/26 at 2:07 pm. They acknowledged the findings. ?

1. Corrective actions for cited examples/residents: The RCD or facility nurse will reconcile current signed orders, MARs, pharmacy profiles, and medication supply for Residents 2 and 5. Resident 2's acetaminophen order and blood-pressure and heart-rate hold parameters will be accurately entered and implemented. Resident 5's blood-sugar monitoring and medication orders will be clarified with the prescriber and pharmacy; medications will not be treated as discontinued without a signed order. Missed or unavailable medications will be reviewed and followed up according to facility policy. All current residents' orders and MARs will be audited for similar discrepancies. 2. System correction to prevent recurrence: A licensed nurse will verify every new or changed medication and treatment order against the MAR and pharmacy profile before implementation. The verification will include medication, dose, route, frequency, administration times, hold parameters, monitoring requirements, and supply availability. Medication aides will promptly report unavailable medications, omitted doses, missing parameters, and conflicting information to the licensed nurse for documented follow-up with the pharmacy or prescriber. 3. Monitoring and evaluation frequency: The RCD or facility nurse will verify new and changed medication and treatment orders before implementation, review medication exceptions each business day, and sample resident MARs each month for agreement with current signed orders, pharmacy profiles, monitoring parameters, and available supply. Discrepancies will be escalated and corrected promptly, with follow-up documented. The GM will review trends and completion monthly. 4. Responsible person: The RCD and facility nurse are responsible for order reconciliation and medication audits. The GM will review trends and verify corrective action monthly.

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 were accurate regarding following resident-specific parameters and instructions for PRN medications for 2 of 2 sampled residents (#s 1 and 4) whose MARs were reviewed for PRN pain medication. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2025 with diagnoses including spinal stenosis. The resident’s 08/01/26 through 08/24/26 MAR and physician’s orders were reviewed. The following was identified: Resident 4 had two PRN medications for pain: * Acetaminophen 500 mg tablet, one tablet every 6 hours as needed for pain; and * Tramadol 50 mg tablet, one tablet twice a day as needed for pain. Parameters were added to the MAR with “special instructions” to administer acetaminophen PRN for “verbalized pain on a pain scale of 1-4” and administer tramadol for “pain scale of 5-10,” with additional instructions to use acetaminophen “for pain 1-4 first.” According to the MAR provided on 08/24/26, the resident was administered PRN tramadol 26 times and acetaminophen had not been administered. There was no documented evidence the unlicensed staff had indicated the resident’s pain level prior to administering the tramadol. The need to ensure the MAR was accurate regarding resident-specific parameters and instructions for administration of PRN pain medication was reviewed with Staff 1 (General Manager) and Staff 4 (Regional Director of Operations) on 08/26/26 at 2:35 pm. They acknowledged the findings. Example #2: Julian 2. Resident 1 was admitted to the facility in 11/2025 with diagnoses including paraplegia. The resident’s 07/01/26 through 08/24/26 MARs were reviewed and the following was identified: Resident 1 had two PRN medications prescribed for pain: * Acetaminophen 500 mg, take two tablets by mouth every eight hours as needed for pain and/or fever greater than 100 or headache; and * Acetaminophen with Codeine 300/30 mg, take one tablet by mouth every four hours as needed for extreme pain. Parameters were added to the MAR relating to the acetaminophen with Codeine with “special instructions” to administer the PRN acetaminophen first. “If PRN Tylenol is ineffective and [the resident] is complaining of severe pain or pain on a scale of 5 – 10 okay to use.” According to the MARs provided on 08/24/26, the resident was administered PRN acetaminophen with Codeine without administering the PRN acetaminophen first for three out of four administrations. In addition, there was no documented evidence the unlicensed staff had indicated the resident’s pain level prior to administering the acetaminophen with Codeine. The need to ensure the MAR was accurate regarding resident-specific parameters and instructions for administration of PRN pain medication was reviewed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10:47 am. They acknowledged the findings.?

1. Corrective actions for cited examples/residents: The RCD or facility nurse will review Residents 1 and 4's PRN pain orders, MAR instructions, and documentation. PRN parameters will be clarified with the prescriber when needed and accurately reflected on the MAR. Medication staff will be instructed to document the resident's pain level or other indication before administration, follow first-line medication instructions, and document the resident's response and effectiveness. Current PRN medication records for all residents will be reviewed for clear parameters and accurate documentation. 2. System correction to prevent recurrence: The facility will standardize PRN MAR entries to include the indication, resident-specific threshold or parameter, required first-line intervention, time administered, and follow-up effectiveness. Medication aides will be retrained on following the exact prescriber order and MAR instructions and on contacting the licensed nurse when directions are unclear or cannot be followed. 3. Monitoring and evaluation frequency: The RCD or facility nurse will review PRN administration exceptions as they arise and sample PRN MAR entries each month for the documented indication, ordered parameter, first-line intervention when applicable, administration, and follow-up effectiveness. Missing or unclear information will be clarified with the prescriber when needed and addressed with the staff member. Findings and follow-up will be tracked and reviewed by the GM monthly. 4. Responsible person: The RCD or facility nurse is responsible for MAR accuracy, staff training, and audits. The GM will monitor completion and trends monthly.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on?observation, interview,?and record review, it was determined the?facility?failed to have an?RN, PT, or OT conduct a thorough assessment of a supportive device with restraining qualities,?failed to document other less restrictive alternatives evaluated prior to the use of the device,?and failed to provide?instruction to caregivers on the correct use and precautions related to use of the device?in the resident's service plan?for 2 of 2 sampled residents (#s 1 and 6) who had devices with restraining qualities.??Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2026 with diagnoses including a left side above-the-knee amputation and cerebrovascular accident (stroke). On 08/25/26 at 2:00 pm, the resident’s bed was?observed?to?have bilateral half side rails in the raised position. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, the facility had documented other less restrictive alternatives evaluated prior to the use of the device, and?instruction to caregivers?had been provided?on?the?correct use and precautions related to the use of the device.? In an interview on 08/26/26?at 8:45 am, Staff 2 (Resident Care Director/LPN) stated she wasn’t aware the resident had side rails and an assessment hadn’t been done by an RN, PT, or OT. She confirmed the facility also hadn’t documented less restrictive alternatives?evaluated prior to the use of the device?or instructed caregivers on the correct use and precautions related to the use of the device. The?need to ensure?the?facility had an RN, PT, or OT conduct a thorough assessment of a supportive device with restraining qualities,?document other less restrictive alternatives evaluated prior to the use of the device,?and?provide instruction to caregivers on the correct use and precautions related to use of the device?was reviewed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10:30 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2025 with diagnoses including paraplegia. On 08/25/26 at 10:00 am, the resident’s bed was?observed?to?have a left half side rail in the raised position. In an interview on 08/26/26?at approximately 9:30 am, Staff 3 (RCC) stated she was not aware that the side rails needed to be assessed if they came with a hospital bed. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, the facility documented other less restrictive alternatives?prior to use of the device, and?instruction to caregivers?had been provided?on?the?correct use and precautions related to the use of the device.?? The?need to ensure?the?facility had an RN, PT, or OT conduct a thorough assessment of a supportive device with restraining qualities,?document other less restrictive alternatives evaluated prior to the use of the device,?and?provide instruction to caregivers on the correct use and precautions related to use of the device?was reviewed with Staff 1 (General Manager), Staff 4 (Regional Director of Operations), and Staff 13 (Regional Director of Health Services) on 08/27/26 at 10: 47 am. They acknowledged the findings.? ?

1. Corrective actions for cited examples/residents: The side rails used by Residents 1 and 6 will not continue as supportive devices with restraining qualities unless the required process is completed. An RN, PT, or OT will assess each device; the resident's request or approval and risks and benefits will be documented as applicable; less restrictive alternatives will be evaluated; caregivers will receive resident-specific instructions on correct use and precautions; and the service plan will be updated. All resident rooms and records will be reviewed to identify any other devices with restraining qualities and correct them through the same process. 2. System correction to prevent recurrence Before a side rail or other supportive device with restraining qualities is used, the RCD must receive and verify the required clinical assessment, alternatives review, resident approval when applicable, service-plan documentation, and caregiver instruction. New move-in and equipment-change checklists will include a supportive-device review. Staff will be trained not to use or raise such devices without documented authorization and instructions. 3. Monitoring and evaluation frequency: The RCD or designee will review supportive devices when initiated or changed and sample current device records each month to verify the required assessment, resident approval when applicable, alternatives review, service-plan directions, and caregiver instruction. Each device will also be reevaluated at the required service-plan review and when the resident’s condition or equipment changes. Missing requirements will be addressed before continued use, and the GM will review audit results and follow-up monthly. 4. Responsible person: The RCD and assessing RN, PT, or OT are responsible for required assessments and instructions. The GM will verify that audits and service-plan reviews are completed.

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 1 of 3 newly hired staff (#9) completed all required pre-service orientation training within the required time period and 2 of 3 newly hired direct care staff (#s 8 and 10) completed all required pre-service dementia training within the required time period. Findings include, but are not limited to: Staff training records were reviewed on 08/26/26 with Staff 4 (Regional Director of Operations), and the following was identified: a. There was no documented evidence Staff 9 (CG), hired on 03/08/26, had completed the following training after hire (or during the previous 24 months): * Infectious disease prevention training. b. There was no documented evidence Staff 8 (CG), hired on 05/08/26, and Staff 10 (CG), hired on 01/04/26, had completed the required pre-service dementia care training topics after hire (or in the past 24 months): * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for staff to complete all required pre-service infection control training and for direct care staff to complete pre-service dementia training prior to beginning their job responsibilities was discussed with Staff 1 (General Manager), Staff 2 (Resident Care Director/LPN), and Staff 4 (Regional Director of Operations) on 08/27/26 at 1:00 pm. They acknowledged the findings.

1. Corrective actions for cited examples/staff: Staff 9 will complete and provide documentation of approved infectious-disease prevention training. Staff 8 and Staff 10 will complete and provide documentation of approved pre-service dementia training covering the required topics. Until required training is verified, affected staff will not independently perform duties for which the missing pre-service training is required. All active employee training files will be audited and any missing required pre-service training or documentation will be corrected. 2. System correction to prevent recurrence: A pre-service training checklist will be completed before any new employee begins job responsibilities. The checklist will include position description, resident rights and required Department-approved training, abuse reporting, emergency procedures, approved infectious-disease training, HCBS training, food handling when applicable, dementia training for direct-care staff, resident-specific orientation, and competency supervision as applicable. The GM or designee will verify credentials and certificates before releasing the employee to independent assignment. 3. Monitoring and evaluation frequency: The GM or designee will verify required training and documentation before each new employee begins applicable job responsibilities and will review onboarding files until required items are complete. The GM will sample active training files quarterly and follow up on missing or expiring documentation. Any staff member lacking required pre-service training will not perform the affected duties independently until training is verified. Findings and corrective follow-up will be documented. 4. Responsible person: The GM is responsible for the pre-service training system and file audits. The RCD will verify clinical and direct-care training requirements before staff provide resident care.