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 ensure incidents of abuse were immediately reported to the local Department office for 1 of 1 sampled resident (#1) who was reviewed for behaviors that negatively impacted other residents. Findings include, but are not limited to: Resident 1 was admitted to the MCC in 03/2026 with diagnoses including dementia. Staff reported in the acuity interview on 04/06/26 that the resident had multiple physical and verbal altercations with other residents since admit. The resident’s 03/03/26 to 04/06/26 clinical record was reviewed, and the following verbal resident-to resident altercations were identified: * 03/11/26 at 7:00 pm; * 03/11/26 at 7:15 pm; * 03/13/26 at 7:15 pm; * 03/13/26 at 8:30 pm; * 03/14/26 at 12:30 pm; * 03/31/26 at 1:45 pm; * 03/31/26 at 2:00 pm and * 04/05/26 at 7:30 pm. There was no documented evidence the facility immediately reported the above incidents to the local Department office. In an interview at 2:09 pm on 04/07/26, Staff 1 (Campus Administrator) confirmed the above resident-to-resident altercations had not been reported. At the request of survey, the above incidents were reported, and confirmation was received at 3:56 pm on 4/7/26. The need to ensure incidents of abuse were immediately reported to the local Department office was discussed with Staff 1, Staff 2 (MCC Administrator), Staff 3 (Wellness Director/RN), and Staff 4 (Assistant Wellness Director/LPN) at 1:20 pm on 04/08/26. They acknowledged the findings.

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 ensure residents were monitored consistent with evaluated needs and service plan and/or failed to ensure actions or interventions were determined for short-term changes of condition and residents were monitored with weekly progress noted to resolution for 2 of 5 sampled residents (#s 1 and 5) whose resident-to-resident altercations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including dementia. Staff reported in the acuity interview on 04/06/26 that the resident had multiple physical and verbal altercations with multiple sampled and unsampled residents since admit. The resident’s 03/03/26 to 04/06/26 clinical record was reviewed, and the following was identified: Resident 1 was involved in several resident-to resident altercations, including physical and verbal, was frequently found urinating in inappropriate areas and dressed inappropriately in common areas, was resistant to care, and made frequent attempts to enter other residents’ rooms. Interventions listed on the current service plan, dated 03/31/26, included: * Staff to use a one-person approach when redirecting; * Keep eye contact and stay calm; and * Give resident tasks and other busy work. There was no documented evidence the facility monitored the resident consistent with evaluated needs and service plan, including whether interventions were effective and what new interventions were attempted. In an interview at 9:18 am on 04/08/26, Staff 4 (Assistant Wellness Director/LPN) confirmed the lack of monitoring consistent with Resident 1’s evaluated needs and service plan. The need to ensure residents were monitored consistent with evaluated needs and service plan was discussed with Staff 1 (Campus Administrator), Staff 2 (MCC Administrator), Staff 3 (Wellness Director/RN), and Staff 4 at 1:20 pm on 04/08/26. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 12/2025 with diagnoses including dementia. The resident’s 03/08/26 service plan and 03/11/26 to 04/06/26 observation notes were reviewed. Resident 1’s clinical record was also reviewed. The following was identified: * Staff documented in Resident 1’s clinical record on 03/11/26: “during swing [Resident 5] reported [Resident 1] going into [his/her] room being aggressive…[Resident 5] said [Resident 1] didn’t hit [him/her] but [Resident 5] was afraid [s/he] would…[Resident 5] has been in distress since the event”; and * Staff documented in Resident 5’s clinical record on 03/13/26: “[Resident 5] was in [his/her] room asleep when [Resident 1] went in [his/her] room…[Resident 5 said] [s/he] grabbed [his/her] arm…I examined [Resident 5, and s/he] has a bruise on [his/her left] arm.” There was no documented evidence the facility determined actions or interventions for the above resident-to-resident altercations, and there was no documented evidence the facility monitored Resident 5, with progress noted at least weekly to resolution, for the altercations and the resultant bruise. In an interview at 9:18 am on 04/08/26, Staff 4 (Assistant Wellness Director/LPN) confirmed actions and interventions were not determined, and the resident was not monitored for the above short-term changes of condition. The need to ensure actions or interventions for short-term changes of condition were determined and residents were monitored, with weekly progress noted to resolution, was discussed with Staff 1 (Campus Administrator), Staff 2 (MCC Administrator), Staff 3 (Wellness Director/RN), and Staff 4 at 1:20 pm on 04/08/26. They acknowledged the findings.

1. APS reports were made of each example immediately. Incident reports were created and each example were placed on monitoring. 2.Immediate assessment of any reported or observed change. Documentation of findings in the resident record . Timely notification of PCP and family. An Alert Charting Tool/Checklist has been implemented to ensure: Clear monitoring parameters and Consistent staff follow-through. Shift-to-shift communication has been reinforced to include: Reporting of all changes in condition and Review of residents on alert status. Behavior Monitoring completed each shift to identify behaviors and intervention that were attempted. Weekly behavior monitoring to be completed by wellness director/assistant wellness director. Incident and change-of-condition reviews will be conducted daily by the clinical team or designee. 3.3. The Administrator/Assistant Wellness Director/RCC will conduct: Daily Clinicals with the wellness team. Weekly audits of change-of-condition documentation for 4 weeks. Monthly audits of incidents and monitoring. Audits will include: Timeliness of assessment, documentation completeness, PCP and family notification and implementation of monitoring interventions. All staff will be re-educated on recognizing and reporting changes in condition, documentation requirements, monitoring and alert charting procedures. 4.Responsible Person(s) Memory Care Administrator, Wellness Director/ Assistant Wellness Director, Resident Care Coordinator / Designee.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 10, 11, 12, and 13) demonstrated satisfactory performance in all job areas within the first 30 days of hire. Findings include, but are not limited to: Staff training records were requested and reviewed with Staff 1 (Campus Administrator) at 11:00 am on 03/07/26. The following was identified: There was no documented evidence Staff 10 (MT), hired 01/30/26, Staff 11 (CG), hired 02/17/26, Staff 12 (MT), hired 02/18/26, and Staff 12 (MT), hired 02/24/26, demonstrated performance in abdominal thrust. The need to ensure newly hired staff demonstrated performance in all assigned job duties within 30 days of hire was discussed with Staff 1, Staff 2 (MCC Administrator), Staff 3 (Wellness Director/RN), and Staff 4 (Assistant Wellness Director/LPN) at 1:20 pm on 04/08/26. They acknowledged the findings.

1.All identified staff with incomplete or missing 30-day competencies were immediately scheduled for competency evaluation. Competencies were completed, validated, and documented. Any staff found not competent in required areas received immediate retraining and re-evaluation prior to continuing resident care duties. 2.The facility implemented a 30-Day Competency Tracking System, which includes: A centralized log of all new hires with due dates, business office manager to send out reminders weekly on Wednesdays, all new hires are to complete an orientation phase. The Administrator/RCC will: Assign responsibility for competency completion and sign-off and ensure competencies are scheduled during orientation. A standardized Competency Checklist Tool will be used for all new hires to ensure consistency and completeness. Staff will not be permitted to work independently beyond the required period without completed competencies. 3. The Business Office Manager/RCC will conduct: Weekly audits of new hire files for 4 weeks and monthly audits thereafter. Audit log will be completed during these times. Audits will verify: Timely completion of 30-day competencies and proper documentation and signatures. Any identified issues will result in immediate corrective action. Management staff responsible for onboarding will be re-educated on: Oregon requirements for 30-day competencies, Documentation standards, Tracking and compliance expectations. Ongoing education will be incorporated into new supervisor training. 4. Responsible Person(s) Memory Administrator, Business office manager, Wellness Director/Assistant Wellness Director, Resident Care Coordinator and/or lead med tech.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

OAR 411-057-0140(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 interview and record 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 C231 and C372.

1.The community will review the identified resident(s) to ensure all applicable licensing rules are being followed, including those related to abuse reporting, service planning, and care delivery. Any identified gaps will be corrected, and care plans will be updated as needed. 2. The community will implement a system-wide compliance oversight process to ensure adherence to all applicable Oregon Administrative Rules. This will include: re-education of all staff on applicable licensing rules, including: abuse reporting requirements, service plan requirements, and health care service delivery requirements. Leadership will implement a structured review process to ensure: incidents are identified and reported appropriately, service plans are accurate and followed, and health care services are provided in accordance with resident needs. The community will utilize a daily clinical meeting to review: incidents, changes in condition, and resident care needs to ensure compliance with applicable rules A “when in doubt, report” approach will be implemented to ensure compliance with abuse reporting requirements. The community will ensure ongoing compliance with all applicable Oregon Administrative Rules, including timely abuse reporting and provision of health care services in accordance with resident needs and service plans. 3. The Memory Care Administrator or designee will conduct weekly compliance audits for 4 weeks, followed by monthly audits for 2 months, to ensure adherence to Oregon Administrative Rules. 4. Responsible Person(s) Memory Administrator, Business office manager, Wellness Director/Assistant Wellness Director, Resident Care Coordinator and/or lead med tech.

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:

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 interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270.

1.The identified resident(s) will be assessed to ensure all health care services are being provided in accordance with the service plan and current needs. Any gaps in care will be addressed immediately, and service plans will be reviewed and updated as needed. Staff will be notified of care expectations and will provide services as outlined in the updated service plan. 2. The community will implement a clinical oversight and accountability process to ensure health care services are provided in accordance with OAR 411-057-0160(2)(b). This will include: Re-education of all staff on: providing care in accordance with the service plan, recognizing and responding to changes in condition, and completing assigned care tasks each shift. The Administrator, Wellness Director, Assistant Wellness Director, or designee will implement routine review of: service plans, task completion, and resident care needs. A process will be implemented to ensure: health care services are provided as assigned, changes in condition are identified and addressed, and service plans are updated when interventions are not effective. Leadership will conduct a daily review of resident care needs and service delivery to ensure appropriate care is being provided. 3. The Memory Care Administrator, Wellness Director/Assistant Wellness Director, or designee will conduct weekly audits of health care service delivery for 4 weeks, followed by monthly audits for 2 months, to ensure compliance with OAR requirements. 4. Responsible Person(s) Memory Care Administrator, Wellness Director/Assistant Wellness Director, Resident Care Coordinator or Designee.

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: