Wiley Creek Memory Care

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

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled Resident (#s 3 and 5) whose initial evaluations were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility on 04/06/26, and Resident 5 was admitted on 04/08/26. Resident 3 and 5’s move-in evaluations, dated 04/05/26 and 04/06/26, respectively, were reviewed. There was no documented evidence that one or more of the following elements were addressed: * Customary routines for sleeping, eating, and bathing; * List of current diagnoses; * List of medications and PRN use; * Personality, including how the person copes with change or challenging situations; * Ability to use call system; * Transportation; * Nutrition habits, fluid preferences and weight, if indicated; * List of treatments; * Indicators of nursing needs including potential for delegated nursing tasks; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Smoking, ability to smoke safely; * Alcohol and drug use; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature. The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Memory Care Director), Staff 2 (RN), Staff 4 (Resident Care Coordinator) on 04/15/26. They acknowledged the findings.

1) Resident #3 and Resident #5 evaluations were immediately reviewed and updated to include all required elements per OAR. Missing areas were completed, including routines, mental health, cognition, ADLs/IADLs, risk indicators, preferences, and environmental factors. 2)A standardized move-in evaluation checklist aligned with OAR requirements has been implemented. A hard stop process is in place: no resident will move in without ED or RN review confirming the evaluation is complete. All staff responsible for completing evaluations have been re-trained on required elements and documentation expectations. RN or designee will review 100% of move-in evaluations within 24 hours of completion. 3) 100% of move-in evaluations will be audited prior to move-in and within 24 hours after move-in. 4) Executive Director, RN, Resident Care Manager

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

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.

Based on interview and record review, it was determined the facility failed to ensure MARs included resident-specific parameters and instructions for PRN medications for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility on 01/2024 with diagnoses including dementia. The resident’s MAR, dated 03/01/26 to 04/12/26, and corresponding prescriber orders were reviewed. The MAR failed to include sequential parameters for PRN anxiety medications: * Lorazepam 0.5 mg; and *Haloperidol 5 mg. On 04/14/26, the need to ensure MAR’s included clear medication parameters was discussed with Staff 1 (Memory Care Administrator) and Staff 2 (RN). They acknowledged the findings. 2. Resident 4 moved into the facility on 04/13/2026 with diagnoses including dementia. The resident’s MAR, dated 03/01/26 to 04/12/26, and corresponding prescriber orders were reviewed. a. The MAR failed to include sequential parameters for PRN bowel medications: * Senna-Time 8.6 mg; and *Bisacodyl Suppository 10 mg. b. The MAR failed to include sequential parameters for PRN agitation medications: * Haloperidol 5mg; and * Lorazepam 0.5mg. c. The MAR failed to include sequential parameters for PRN skin redness and irritation medications: * Destin daily defense 13% cream; and * Desenex 2% powder. On 04/14/26, the need to ensure MAR’s included clear medication parameters was discussed with Staff 1 (Memory Care Administrator) and Staff 2 (RN). They acknowledged the findings. 3. Resident 1 was admitted to the facility in 02/2024 with diagnoses including Alzheimer’s dementia with agitation. Review of the resident's 03/01/26 through 04/13/26 progress notes, MAR and physician communications, and the signed physician orders showed the following: * Haloperidol 1mg/0.5ml every four hours as needed for agitation, delirium, and nausea; and * Lorazepam 1mg every four hours as needed for anxiety. The parameters on the MAR instructing staff how the resident would exhibit behaviors for use of the medications were the same or similar symptoms, including, “Fearful, calling out/yelling, pacing, aggression/hitting, kicking.” Both medications were administered on multiple occasions for “anxiety or agitation.” The MAR lacked resident-specific parameters for when to administer the psychotropic medications. On 04/15/26 at 9:10 am, Staff 2 (RN) reviewed the MAR and verified the parameters/instructions for administration were unclear due to the exhibiting symptoms or behaviors being very similar. The need to ensure medication/treatment administration records included clear, resident-specific parameters and instructions for PRN psychotropic medication use was discussed with Staff 1 (Memory Care Director), Staff 2, and Staff 4 (Resident Care Coordinator) on 04/15/26 at 11:00 am. The staff acknowledged the findings. 4. Resident 3 was admitted to the facility in 04/2026 with diagnoses including dementia, anxiety, and agitation. Review of the resident's 03/01/26 through 04/13/26 progress notes, MAR, physician communications, and the signed physician orders showed the following: a. * Haloperidol 1mg/0.5ml every four hours as needed for agitation, delirium, and restlessness; and * Lorazepam 1mg every four hours as needed for anxiety, shortness of breath, or nausea. The parameters on the MAR that instructed staff on how the resident would exhibit the behaviors for administration of each medication were the same or similar symptoms, including, “Fearful, yelling, physical aggression/hitting, kicking.” The lorazepam was administered on one occasion since admission for “anxiety.” The MAR lacked resident-specific parameters/clear instructions for administration of the PRN psychotropic medications. b.* Acetaminophen 500mg, give two tablets twice daily as needed for pain; and * Morphine Sulfate 10mg/1ml every hour as needed for shortness of breath or moderate to severe pain. The parameters on the MAR that instructed staff on how the resident would exhibit pain for administration of each medication were the same or similar symptoms, including, “Grimacing, guarding of body parts.” Neither medication had been administered since admission. The MAR lacked resident-specific parameters/clear instructions for administration of the PRN pain medications. On 04/15/26 at 9:10 am Staff 2 (RN) reviewed the MAR and verified the parameters for administration were unclear due to the exhibiting symptoms and/or behaviors being very similar. The need to ensure medication administration records included clear instruction and resident-specific parameters for administration of PRN psychotropic and pain medication use was discussed with Staff 1 (Memory Care Director), Staff 2, and Staff 4 (Resident Care Coordinator) on 04/15/26 at 11:00 am. The staff acknowledged the findings.

1)Resident 1, Resident 2, Resident 3, and Resident 4: -The RN reviewed all current physician orders and MARs for each identified resident. -The RN contacted the legally recognized prescribers to obtain clarified, resident-specific PRN parameters, including: -Clear symptom differentiation (e.g., anxiety vs. agitation vs. pain vs. delirium). -Stepwise or sequential instructions where multiple PRN medications are ordered for the same condition (e.g., first-line vs. second-line use). -Measurable indicators when applicable (e.g., pain scale ratings, behavioral descriptors). -MARs were updated immediately to reflect: -Distinct, non-overlapping parameters for each PRN medication. -Clear instructions for use, including when to administer, when to hold, and when to notify the RN or prescriber. -Licensed nurse or qualified staff were re-educated on the updated MAR instructions prior to next medication pass. 2) -The RN will review all new admissions, re-admissions, and new or updated physician orders to ensure PRN medications include clear, resident-specific parameters before use. -Prescribers will be contacted promptly if PRN instructions are unclear, incomplete, or overlapping. -Medication administration staff will receive focused re-education on: -The importance of following resident-specific PRN parameters. -Differentiating symptoms prior to administration. The RN or designee will provide ongoing guidance and real-time clarification to staff when questions arise regarding PRN medication use. 3) The RN or designee will ensure: -Staff correctly identify resident symptoms prior to administering PRN medications. -Staff follow the clarified, resident-specific parameters. -Staff demonstrate understanding of sequencing when multiple PRN medications are ordered. -Immediate feedback and coaching will be provided during observations to reinforce correct practices. 4.) Executive Director/ RN / Resident Care Manager

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.

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Six months of fire drill records were reviewed on 04/13/26, and revealed the following: a. Fire drills were not conducted every other month at different times of the day, evening and night shifts. b. Fire drills lacked documentation of one or more of the following components: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. c. The facility failed to provide fire and life safety instruction to staff on alternate months. The need to ensure fire drills were conducted according to the Oregon Fire Code, with all required components documented, and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1 (Memory Care Director) on 04/13/26. She acknowledged the findings.

1) All current fire drill documentation was reviewed and corrected to include required elements: Escape route used. Problems encountered/resident participation. Evacuation time. Staff on duty and occupants evacuated. A new fire drill was conducted to ensure full compliance with all documentation requirements, including use of an alternate exit route. Fire and life safety staff training was completed immediately to ensure the alternating month requirement is back in compliance. 2) Implemented a standardized fire drill form that includes all required OAR elements no sections can be missed. Established a set annual schedule: Fire drills every other month (varying shifts) Fire/life safety training on alternating months Added a pre-drill checklist to ensure: Alarm activation,Alternate exit route used. Full evacuation process to point of safety. ED/designee will review and sign off on every drill for completeness. Maintenance Director and leadership were re-trained on Oregon Fire Code requirements and documentation expectations. 3) 100% of fire drills will be reviewed at time of completion for accuracy and completeness. Monthly calendar will be reviewed to ensure alternating schedule compliance. Fire drill records will be audited: Monthly for 3 months Quarterly thereafter. Any missing elements will be corrected immediately with re-training as needed. 4) Executive Director/ Maintenance Director/Designee/RCC/Leadership Team

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

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420.

See tag C420

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 8, and 11) completed all pre-service orientation training, all required pre-service dementia trainings, and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (ED) on 04/14/26 at 9:00 am. The following was identified: Staff 7 (CG) was hired 03/02/26, Staff 8 (CG) was hired 02/03/26, and Staff 11 (MT) was hired 02/02/26. a. There was no documented evidence Staff 7, Staff 8, and Staff 11 completed orientation in: * Abuse reporting requirement; and * Fire safety and emergency procedures. Additionally, there was no documented evidence Staff 8 and Staff 11 completed Resident rights and values of CBC care. b. There was no documented evidence Staff 7, Staff 8, and Staff 11 completed pre-service dementia training in: * Environmental factors that are important to resident ' s well-being; * Family support and the role the family may have in the care of the resident; and * The use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 7, Staff 8, and Staff 11 had demonstrated competency within 30 days of hire in: * Changes associated with normal aging. Additionally, there was no documented evidence Staff 11 had demonstrated competency in role of service plans in providing individualized care and providing assistance with ADL’s. On 04/14/26, the need to ensure staff completed all required pre-service orientation, pre-service dementia trainings, and had documented evidence of competency within 30 days of hire was discussed with Staff 1 (Memory Care Administrator). She acknowledged the findings.

1) The facility reviewed the training records for Staff 7, Staff 8, and Staff 11. Immediate corrective actions were taken, including: -All missing orientation topics were completed and documented, including: -Abuse reporting requirements -Fire safety and emergency procedures -Resident rights and values of community-based care (as applicable) All required pre-service dementia training topics were completed and documented, including: -Environmental factors affecting resident well-being -Family support and involvement in care o Use of supportive devices with restraining qualities Each staff member completed required competency evaluations, including: -Changes associated with normal aging -Role of service plans in individualized care (as applicable) -Assistance with ADLs (as applicable) -Competency was observed, verified, and documented by a qualified staff person prior to continued independent work. 2) The Memory Care Director or designee will ensure all newly hired staff complete: -Required orientation training prior to performing job duties -All pre-service dementia training prior to independently providing care A training tracking process will be utilized to verify completion of: -Required orientation topics -Pre-service dementia training topics -Competency demonstrations for assigned duties -Staff will not work independently until all required training and competency verification is completed and documented. -The Memory Care Director or designee will review each new hire’s training progress and follow up on any incomplete items. 3) The Memory Care Director or designee will review new hire training records and competency documentation to ensure: -All required orientation and pre-service dementia training is completed -Competency is demonstrated and documented within required timeframes Any missing or incomplete training or competency documentation will be addressed promptly. 4) Memory Care Director / Administrator: -Ensures all staff meet training requirements prior to working independently -Monitors completion of orientation, dementia training, and competency documentation Registered Nurse (RN) or Qualified Designee: -Completes and documents competency evaluations Provides training and guidance related to resident care tasks Resident Care Manager/ Designee: -Tracks staff training completion -Maintains training records and ensures documentation is current and available

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252 and C310.

See tag C310 and C252

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.