Print Inspection: RL014337

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 or the local AAA (Area Agency on Aging) of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#2) reviewed for an incident of suspected abuse. Findings include, but are not limited to: Resident 2 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment. The resident’s 06/24/26 through 09/21/26 clinical record was reviewed, and interviews with staff were conducted. The following was identified: Staff documented in an incident report, dated 08/28/26, Resident 2 “stated a caregiver who had entered [his/her] room the previous day had been ‘very aggressive’ with [him/her].” The resident described the caregiver as “a tall, young woman who had been ‘looking for something’.” Resident 2 pointed at “the caregiver’s pink staff lanyard and stated the individual had also been wearing a pink lanyard.” The resident's statement represented suspected abuse which the facility was required to report to the local Department office or AAA. On 09/22/26 at 12:43 pm, Staff 2 (Nurse Manager) stated the incident had not been reported to the Department. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local Department office or AAA was reviewed with Staff 1 (Assisted Living Manager), Staff 2 and Staff 3 (RN) 09/23/26 at 2:10 pm. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse Corrective Action: 1. All Residents have the potential to be affected by this practice. The allegation of abuse will be reported to APS on 10/14/2026 for regulatory compliance. 2. Leadership and direct care staff will be educated on the facility's Abuse Reporting and Investigation Policy, including mandatory reporting requirements by 10/31/2026 . An Abuse Reporting Checklist will be implemented to assist with identifying reportable events on 10/31/2026. 3. Incident reports in September and October will be audited to ensure there are no additional reports unsubmitted by the RCF Manager, Nurse Manager, or designee by 10/31/2026 for reporting determination.The RCF Manager or designee will audit incident reports weekly for four weeks and monthly for two months thereafter to ensure reportable events are identified and managed according to policy. Findings will be reviewed through the Quality Improvement process, and additional education will be provided by the RCM Manager/Nurse Manager or Designee as needed. 4: The RCf Manager/Nurse Manager or Designee will be responsible.

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, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a short-term change of condition and failed to note weekly progress of the condition until resolution for 1 of 3 sampled residents (#2) who experienced a change of condition that required monitoring. Findings include, but are not limited to: Resident 2 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment. The resident’s 06/24/26 through 09/21/26 clinical record was reviewed, and interviews with staff were conducted. The following was identified: Staff documented in an incident report, dated 08/28/26, Resident 2 “stated a caregiver who had entered [his/her] room the previous day had been ‘very aggressive’ with [him/her].” On 09/22/26 at 12:43 pm, Staff 2 (Nurse Manager) confirmed the facility had not determined, documented and communicated to staff what actions or interventions were needed for the resident following the statement of “aggressive” treatment and had not noted weekly progress through resolution. The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed for a resident following a short-term change of condition, noting weekly progress of the condition until resolved was reviewed with Staff 1 (Assisted Living Manager), Staff 2 and Staff 3 (RN) 09/23/26 at 2:10 pm. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring. Corrective Action: 1: All Residents have the potential to be affected by this practice. A change of conditon progress note will be created for the allegation of agression for resident #12 on 10/14/2026. Measures outlined below will be implemented to ensure compliance with change of condition requirements. 2: Leadership and direct care staff will be educated on the facility's Change of Condition policy and documentation requirements by 10/31/2026, specifacally who made expression of agression abuse and neglect. A Change of Condition Monitoring Form will be implemented on 10/31/2026 to ensure resident-specific interventions are documented, communicated to staff on all shifts, and monitored through weekly progress notes until resolution. 3: The RCF Manager Nursing Manager, or designee will audit change of condition reports for who expressed allegations of abuse and neglect in the Months of September and October by 10/31/2026 to ensure there are no other residents affected. Monitoring: The Nurse Manager will audit clinical dashboards and bring changes of condition to daily Stand Up Meetings. Findings will be reviewed through the facility's Quality Improvement process, and additional education will be provided as needed. 4:The RCF Manager/Nurse Manager or Designee will be responsible.

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 orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) whose prescriber orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the assisted living facility in 07/2026 with diagnoses including Parkinson’s disease and restless leg syndrome. The resident’s 07/06/26 through 09/21/26 clinical record was reviewed, and interviews with staff were conducted. The following was identified: a. Resident 3 had an order dated 08/03/26 for ropinirole, 1 mg tablet at night three hours before bedtime for restless leg syndrome. The additional directions for the three hours prior to bedtime were not transcribed to the MAR. The medication was scheduled to be administered at 9:00 pm on the MAR. On 9/23/26 at 3:45 pm Staff 5 (CG Preceptor) stated Resident 3 went to bed around 8:30 pm. The service plan dated 08/05/26 indicated the resident’s preferred bedtime was 7:00 pm. On 09/23/26 at 3:50 pm, the MAR was reviewed with Staff 11 (CG) and showed the administration time ranged from 8:00 pm through 9:41 pm. b. Resident 3 had an order dated 08/24/26 for a lidocaine patch, add: to be placed on for 12 hours and off for 12 hours for pain as needed. Review of 09/2026 MAR indicated Resident 3 received the patch on two occasions. There was no documented evidence the patch was removed 12 hours after administration as ordered. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Assisted Living Manager), Staff 2 (Nurse Manager) and Staff 3 (RN) on 09/23/26 at 3:10 pm. They acknowledged the findings. No additional information was received. 2. Resident 2 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment and unspecified dementia. The resident’s 06/24/26 through 09/21/26 clinical record was reviewed, and interviews with staff were conducted. The following was identified: Resident 2 had a physician order dated 06/24/26 directing staff to monitor nine separate behaviors on “each shift.” Five of the nine behaviors were transcribed onto the resident’s 09/2026 MAR/TAR. The following behaviors for staff to monitor had not been transcribed: * Delusions; * Hallucinations; * Paranoia; and * Being physically threatening to others. Due to the orders not being transcribed onto Resident 2’s MAR/TAR, the facility failed to follow the physician’s orders. On 09/22/26 at 11:58 am, Staff 2 (Nurse Manager) confirmed there was no documented evidence staff were monitoring the four behaviors and the facility did not have a physician's order to discontinue the monitoring. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Assisted Living Manager), Staff 2 and Staff 3 (RN) on 09/23/26 at 2:10 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders Corrective Action: 1. All residents have the potential to be affected. For Resident 2 and 3, orders and the service plan will be put in place by 10/14/2026 2: Leadership, nursing, and medication administration staff will be educated on physician order transcription and order verification procedures by 11/15/2026. An Order Confirmation and Discontinuation Reference Guide will be created by 11/15/2026 to ensure all medication and treatment orders are accurately transcribed to the MAR/TAR and carried out as ordered. The RCF Manager, Nurse Manager, or designee will review new and updated physician orders within one business day to verify accurate transcription and implementation. 3. The RCF Manager, Nurse Manager, or designee will audit new physician orders weekly for four weeks and monthly for two months thereafter to ensure orders are accurately transcribed, implemented, and carried out as prescribed. Findings will be reviewed through the Quality Improvement process, and additional education will be provided by the RCF manager, Nurse Manager or Designee 4: The RCM Manager/Nurse Manager or Designee will be responsible.

OAR 411-054-0070 (3-4) Staffing Requirements and Training ? Pre-service Temporary rule language in effect until 02/05/2027 (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 per OAR 411-054-0090 and 411-054-0093. (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 verify 1 of 1 newly hired non direct care staff (#10) completed all required pre-service orientation training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were reviewed on 09/22/26 with Staff 4 (Human Resources Director), and the following was identified: There was no documented evidence Staff 10 (Nutritional Aide), hired 07/22/26, completed the following required pre-service orientation topics prior to beginning job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; and * Infectious disease prevention. The need to ensure all newly hired staff completed all required pre-service orientation training prior to beginning job responsibilities was discussed with Staff 1 (Assisted Living Manager), Staff 2 (Nurse Manager) and Staff 3 (RN) on 09/23/26 at 3:10 pm. They acknowledged the findings.

OAR 411-054-007 Staffing Requirements and Training Pre-Service Corrective Action: 1. All Residents have the potential to be affected by this practice. Measures outlined below will be implemented date below, to ensure required pre-service orientation training is completed and documented prior to employees beginning assigned job duties. 2. Staff #10 has been assigned all missing training and will have it completed within 14 days. A full audit of all staff working in this level of care will be completed by 10/23/26 and if any other training deficincies are identified, existing staff will have 30 days to complete training. 3. Leadership staff responsible for hiring, onboarding, and staff training will be by implemented by 11/15/2026 and educated on pre-service orientation requirements. Pre-Service Orientation Training plan was created within Oregon Care Partner's training management portal and all new hires associated with the AL floor will be added to this training pre-hire. All hiring and department training managers will be responsible for verifying completion of all required orientation topics prior to an employee beginning job responsibilities. Employee training records will be reviewed by the Human Resources team, or designee prior to assignment of independent job duties. Monitoring: The Human Resources Director, or designee will audit all new hire files weekly for four weeks and monthly for two months thereafter to ensure required pre-service training is completed and documented prior to beginning job responsibilities. Findings will be reviewed through the Quality Improvement process and additional education will be provided as needed. 4: The HR manager or Designee will be responsible.

OAR 411-054-0200 (5) Resident Units (5) RESIDENT UNITS. Resident units may be limited to a bedroom only, with bathroom facilities centrally located off common corridors. Each resident unit shall be limited to not more than two residents.(a) Resident units must have a lockable door with lever type handles, effective 01/15/2017. This applies to all existing and new construction.(b) For bedroom units, the door must open to an indoor, temperature controlled common-use area or common corridor. Residents may not enter a room through another resident's bedroom.(c) Resident units must include a minimum of 80 square feet per resident, exclusive of closets, vestibules, and bathroom facilities and allow for a minimum of three feet between beds;(d) All resident bedrooms must be accessible for individuals with disabilities and meet the requirements of the building codes. Adaptable units are not acceptable.(e) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident's small valuable items and funds. Both the administrator and resident may have keys.(f) WARDROBE CLOSET. A separate wardrobe closet must be provided for each resident's clothing and personal belongings. Resident wardrobe and storage space must total a minimum volume of 64 cubic feet for each resident. The rod must be adjustable for height or fixed for reach ranges per building codes. In calculating useable space closet height may not exceed eight feet and a depth of two feet.(g) WINDOWS.(A) Each sleeping and living unit must have an exterior window that has an area at least one-tenth of the floor area of the room. A CF must have at least one exterior window with a minimum size of 8 square feet per resident.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(h) RESIDENT UNIT BATHROOMS. If resident bathrooms are provided within a resident unit, the bathroom must be a separate room and include a toilet, hand wash sink, mirror, towel bar, and storage for toiletry items. The bathrooms must be accessible for individuals who use wheelchairs.(i) UNIT KITCHENS. If cooking facilities are provided in resident units, cooking appliances must be readily removable or disconnect-able and the RCF must have and carry out a written safety policy regarding resident-use and nonuse. A microwave is considered a cooking appliance. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide a lockable storage space (e.g., drawer, cabinet, or closet) in each resident unit for the safekeeping of a resident's small valuable items and funds. Findings include, but are not limited to: During interviews and tours of sampled resident apartments from 09/21/26 to 09/22/26, Residents 1 and 3 reported their apartments did not have a lockable storage space. The surveyors did not observe a lockable storage space in these apartments. In an interview on 09/22/26 at 12:32 pm, Staff 2 (Nurse Manager) stated the facility recommended a locked storage space to residents who self-administered their own medication but did not offer one to all residents. The need to provide a lockable storage space in each resident unit was reviewed with Staff 1 (Assisted Living Manager), Staff 2 and Staff 3 (RN) on 09/23/26 at 2:50 pm. They acknowledged the findings.

OAR 411-054-0200(5) Resident Units Corrective Action: Lockable Storage 1. All residents have the potential to be affected by this practice. Lockable storage will be available to each resident by October 21, 2026. 2. The RCF manager will implement a Resident Unit Compliance Checklist by 10/31/2026 to verify required lockable storage space. The RCF Manager, Nurse Manager, or designee will verify the presence of a lockable storage space during move-in, apartment inspections, and resident unit reviews. 3. The RCF Manager or designee will audit resident units weekly for four weeks and monthly for two months thereafter to verify the availability of lockable storage space in each resident unit. Findings will be reviewed through the Quality Improvement process, and corrective action will be taken as needed. 4: The RCF Manager/Nurse Manager or Designee will be responsible.