OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were free from verbal, mental, or physical abuse and provide a safe and homelike environment for 2 of 2 sampled residents (#s 1 and 2) who were roommates. Resident 2 experienced ongoing physical and verbal abuse and expressed ongoing fear related to living with Resident 1. Findings include, but are not limited to: Resident 2 moved into the MCC in 04/2025 with diagnoses including dementia. Resident 1 was admitted to the MCC in 06/2026 with diagnoses including Alzheimer’s disease and schizophrenia. Resident 2’s 05/08/26 service plan and Interim Service Plans (ISPs) related to altercations with the resident’s roommate were reviewed, as well as progress notes dated 06/23/26 through 07/15/26. Resident 1’s clinical record, dated 06/23/26 through 07/15/26, was also reviewed. The following was identified: Resident 2 and Resident 1 shared a room beginning on 06/23/26. A 06/24/26 incident report documented, “[Resident 2] entered [his/her] shared room and used the bathroom. When [Resident 2] exited the bathroom, [Resident 1] observed him/ her, balled [his/ her] fists, walked toward [him/her] and yelled, ‘Get out of here, you’re trespassing!’ A caregiver who was assisting [Resident 2] immediately redirected [him/her] away while another caregiver redirected [Resident 1], preventing physical contact.” Following the incident, staff documented Resident 1’s behaviors continued to escalate, necessitating calls to emergency medical services and law enforcement before Resident 1 could be safely transported to the hospital. Resident 1 remained under observation at the hospital until 07/02/26, when s/he returned to the facility and back to the room shared with Resident 2. A 07/03/26 ISP documented Resident 1’s return from the hospital with diagnoses including “anxiety and agitation.” Staff were instructed to “monitor for anxiety,” and “continue to monitor interactions w/ other residents.” There were no resident-specific instructions or interventions for staff on how to maintain Resident 2’s safety and sense of a homelike environment while s/he continued to share a room with Resident 1. On 07/05/26, an incident report documented, “[Staff 17 (CG)] entered [the room] and observed [Resident 1] standing near the foot of the bed. [Resident 1] suddenly struck [Resident 2] in the face with [his/her] fist, causing [Resident 2] to fall to the floor. [Resident 1] then continued attempting to strike [Resident 2]. . . . [Resident 2] stated that [Resident 1] had assaulted [him/her] and expressed that [s/he] was going to kill [Resident 1] if they remained in the same room.” Resident 1 and Resident 2 were sent to the emergency department to have their injuries evaluated and treated, and both returned to the facility early the next day, to their shared room. Resident 2 sustained a facial injury with a nosebleed, injury to the back of the head/neck area, left elbow skin tears, and bruising to his/her hands. On 07/06/26, an ISP for Resident 2 was created by Staff 3 (Health and Wellness Director/ RN), detailing the incident and subsequent injuries and instructed staff to “maintain separation from [Resident 1] at all times.” She also documented, “[Resident 2] reports fear of roommate and concern that another assault could occur. Resident declined to sleep in [his/her] room following the incident and remained in common area overnight.” There was no further documented evidence the facility placed the residents in separate rooms or determined interventions to ensure Resident 2 felt safe in his/her living space and was provided a homelike environment. Staff documented on 07/08/26 the following incident in the residents’ shared room: “[B]ehavior observed: resting in chair, got up walked over to [Resident 2] raised hands with a fist balled, caregiver stepped in between [Resident 1] and [Resident 2].” No interventions were established to address the continued aggression of Resident 1 toward Resident 2. Resident 1 and Resident 2 continued to share a room and Resident 2 continued to avoid being in his/her room while Resident 1 was there, because s/he did not feel safe. In a 07/07/26 progress note, staff documented, “[R]esident spent most of the time in the Activity Room watching TV. [S/he] only went to bed just before 4:10 am.” In a 07/08/26 progress note, staff documented, “[R]esident only went to bed about 2:45 am.” On 07/14/26, staff documented, “[Resident 2] was asleep in [his/her] room and when [Resident 1] saw [Resident 2], [s/he] got upset and wanted [him/her] out of the room despite telling [Resident 1] that [s/he] was sharing a room with [Resident 2]. [Resident 1] was still adamant about [Resident 2] out of the room. . . . in order to ensure the safety of [Resident 2], care staff helped [him/her] to the Activity Room. [Resident 2] remained in the Activity Room since 3:00 am till end of shift.” At approximately 7:00 am that same morning, Resident 2 was transported to the emergency department due to complaints of chest pain and shortness of breath. The resident returned to the facility later that day with a new diagnosis of atrial fibrillation and no new orders. Staff 14 (CG) was interviewed on 07/14/26 at 9:07 am and stated Resident 2 was a “homebody” who enjoyed sitting or napping in his/her recliner and looking out the window. She stated Resident 2 had insomnia and was most comfortable in bed when having difficulty sleeping. She added that since the altercation on 07/05/26, Resident 2 did not want to sleep in the room because s/he was afraid of Resident 1 and had instead been coming out to the common area to sleep. Staff 18 (CG), on 07/14/26 at 10:43 am, reported Resident 2 had repeatedly voiced fear and anger at having to live with Resident 1. Resident 2 had been observed falling asleep in the common area until 2:00 am or 3:00 am due to concerns over being in the shared room with Resident 1. She stated Resident 2’s normal routine prior to the altercation on 07/05/26 had been to go to his/her room about an hour after dinner and rest or sleep until about 6:00 am or 7:00 am. On 07/15/26 at 9:28 am, Staff 1 (MCC Administrator) stated she was not aware Resident 2 was still not sleeping in his/her room. She was also not aware of the incident on 07/08/26 or the details regarding Resident 2’s transport to the hospital on 07/14/26 with chest pains following another verbal altercation with Resident 1 in their shared room. Resident 2 experienced ongoing physical and verbal altercations in his/her home and expressed ongoing fear. The facility failed to ensure Resident 2 was free from verbal, mental, or physical abuse and was provided a safe and homelike environment, placing the resident’s health and safety at risk. The need to provide a safe and homelike environment and ensure residents were free from verbal, mental, or physical abuse was reviewed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/15/26 and 07/16/26. They were providing one-to-one supervision for Resident 1 until an alternative placement could be secured, and instructed staff on additional resident-specific interventions for Resident 2 to provide him/her with privacy in common areas while sleeping, as well as a tablet for entertainment.

1. Actions to correct the rule violation: Resident 1 has been discharged from the facility and will not return. Resident 2 will remain in a safe sleeping arrangement and will not be placed with a roommate who presents a known safety risk. The Health and Wellness Director/Registered Nurse (HWD/RN) will assess Resident 2 for injuries, fear, sleep disruption, and psychosocial effects; notify the provider and representative as indicated; and update the service plan with resident-specific safety and emotional-support interventions. The MCC Administrator will review other roommate pairings for conflict, fear, repeated redirection, or incompatibility and will implement immediate protective measures when concerns are identified. The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. 2. System correction to prevent recurrence: The facility will implement a Resident-to-Resident Aggression and Roommate Safety protocol. Any threat, intimidation, physical contact, repeated conflict, or expression of fear will trigger immediate separation, protection of the affected resident, nurse assessment, required reporting, investigation, provider/representative notification, and an interdisciplinary review before residents are returned to shared space. Roommate compatibility will be reviewed before placement and after a behavioral change, hospitalization, altercation, or significant change of condition. All staff in-service of resident rights completed 7/28/26. 3) Audit of resident rights continued compliance completed weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report a physical injury of unknown cause to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to immediately notify the local Department office of any incident of suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse, investigate all reports of abuse or suspected abuse, and document the investigation as required for 2 of 2 sampled residents (#s 1 and 4) who experienced resident-to-resident altercations and/or an injury of unknown cause. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 06/2026 with diagnoses including Alzheimer’s disease and schizophrenia. The resident’s clinical record from 06/23/26 through 07/13/26 was reviewed, and the following was identified: a. A 06/23/26 facility investigation description documented, “[Resident 1] approached a group of residents in the living room watching TV,” and after a brief exchange of words, “balled [his/her] fists and struck [Resident 3]. [Resident 3] then returned punches.” On 07/14/26 at 9:45 am, Staff 1 (MCC Administrator) confirmed she had not reported the incident to the local Department office because she did not recall Resident 3 getting hit. She acknowledged the description of Resident 3 being “struck” by Resident 1 and provided documented evidence of the report to the local department office on 07/14/26 at 10:34 am. b. A progress note dated 07/08/26 documented, “Behavior observed: resting in chair, got up walked over to [Resident 2] raised hands with a fist balled, caregiver stepped in between [Resident 1] and [Resident2].” On 07/15/26 at 9:28 am, Staff 1 stated she was not aware of the 07/08/26 incident and had not completed an investigation of the incident, nor had she reported it to the local Department office. The surveyor requested Staff 1 report the incident to the local Department office. Confirmation of the report was received on 07/16/26 at 9:10 am. The need to ensure any incident of abuse or suspected abuse was promptly investigated and immediately reported to the local Department office if abuse could not be ruled out was reviewed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings. 2. Resident 4 moved into the MCC facility in 04/2026 with diagnoses including dementia. Observations made during the survey identified Resident 4 as primarily nonverbal. The resident’s 05/01/26 through 07/13/26 clinical record was reviewed. The following was identified: a. The following resident-to-resident altercations were identified: * On 06/13/26 at 4:50 pm, staff documented Resident 4 had “swatted” an unsampled resident’s shoulder. There was no documented evidence the 06/13/26 altercation was immediately reported to the local Department office as required. At the request of survey, the facility reported the above incident and provided verification of reporting on 07/16/26 at 11:30 am. * On 06/15/26 Staff 1 (MCC Administrator) documented Resident 4 had “gotten into another incident with a different resident.” During an interview on 07/16/26 at 10:20 am, Staff 1 did not recall the situation of the incident and what other resident was involved. She confirmed the incident had not been reported to the local Department office as required, and there was no documented evidence the facility promptly investigated the incident, including documenting the time, date, place, and individuals present; a description of the event as reported; the response of staff at the time of the event; follow-up action; and the Administrator’s review. b. Staff documented on 05/19/26 Resident 4 had a skin tear “on [his/her] right forearm” and “still looks raw.” An incident investigation was requested during the survey. On 07/16/26 at 10:20 am, Staff 1 reported no incident investigation had been completed regarding the injury. The injury to Resident 4's forearm represented an incident which should have been reported to the local Department office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. There was no documented evidence the facility either reported the incident or immediately investigated the incident and ruled out abuse. At the request of survey, the facility reported the above injury of unknown cause and provided verification of reporting on 07/15/26 at 1:37 pm. The need to ensure incidents of suspected abuse were immediately reported to the local Department office and all reports of suspected abuse and injuries of unknown cause were promptly investigated and reported to the local Department office if abuse could not be ruled out was discussed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings.

1. Actions to correct the rule violation: Resident 1 has been discharged from the facility and will not return. The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. MCC administrator self reported identified incidents to adult protective services on 7/16/2026. Current residents involved in open events will be assessed for injury, fear, retaliation risk, and needed protective measures. 2. System correction to prevent recurrence: The facility will use a written abuse-reporting decision guide and an incident tracking log. Staff will immediately report suspected abuse to the administrator/designee and the appropriate outside agency. When facts are unclear, the event will be treated as suspected abuse until an immediate investigation documents that abuse is reasonably ruled out. The administrator/designee will be available 24 hours a day for reporting decisions. Incident reports may not be closed until reporting verification, protective actions, investigation elements, and administrator review are documented. All staff in-service of individual service plans completed 7/28/2026. 3) Individual service plan audits completed weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

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

OAR 411-054-0040 (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 and document what action or intervention was needed for short-term changes of condition, communicate the action or intervention to staff on each shift, monitor the resident consistent with the resident’s evaluated needs, and document weekly progress until the condition was resolved for 2 of 2 sampled residents (#s 1 and 4) with changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the MCC facility in 04/2026 with diagnoses including dementia. The resident's 05/01/26 through 07/13/26 clinical record was reviewed. a. For the following changes of condition, the facility failed to communicate to staff what action or intervention was needed for a resident following a change of condition: * On 06/04/26 an RN assessment for a “progressive decline” was completed and identified the intervention to “offer food/fluids frequently…” There was no documented evidence the facility communicated the intervention to staff on each shift. * On 06/22/26 Resident 4 had a fall out of bed. The incident form identified an intervention which included to “reposition resident higher in bed and toward the center during bedtime care and with each overnight safety check as needed…” There was no documented evidence the intervention was communicated to staff on each shift. * On 06/28/26 Resident 4 was found on the floor “grasping the armrest of a nearby dining chair…” The investigation report identified an intervention instructing staff to cue the resident when the resident was attempting to sit in a chair and “encourage the resident to fully position [himself/herself] in front of the chair before sitting down” with “hands-on” assist as needed. There was no documented evidence the fall intervention was communicated to staff on each shift. b. For the following changes of condition, the facility failed to document the status of the condition at least weekly until resolved or failed to document whether the condition was resolved: * 05/01/26 – New move-in; * 05/02/26 – Refusal of multiple medications; * 05/08/26 – Skin tear on the top of his/her left hand; * 05/19/26 – Skin tear on right forearm; * 05/22/26 – New medication risperidone (for agitation) 1 mg/mL nightly; * 05/26/26 – Skin tear on left middle finger; * 06/05/26 – Witnessed fall; * 06/08/26 – Protein shakes three times a day; * 06/13/26 – Resident-to-resident altercation; * 06/15/26 – Resident-to-resident altercation; * 06/15/26 – Increase risperidone 1 mg/mL to twice a day; * 06/18/26 – Discontinue atorvastatin (for high cholesterol) and metformin (for diabetes); * 06/22/26 – Unwitnessed fall; * 06/22/26 – Redness on left shoulder; * 06/28/26 – Found on floor, with emergency room visit; * 06/29/26 – Progress notes indicated “bruising found on the left hip and left inner thigh”; * 07/01/26 – New medication potassium chloride (for low potassium); and * 07/02/26 – Discontinue medication memantine (for cognitive decline). During an interview on 07/16/26 at 10:20 am, Staff 1 (MCC Administrator) stated Staff 3 (Health and Wellness Director/RN) monitored and resolved significant changes of condition and skin issues, while Staff 1 resolved all other changes of condition. The need to ensure interventions for short-term changes of condition had been determined, documented, and communicated to staff on all shifts, and the resident was monitored, with progress noted weekly through resolution, was reviewed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings. No further documentation was provided. 2. Resident 1 moved into the MCC in 06/2026 with diagnoses including Alzheimer’s disease and schizophrenia. The resident’s 06/23/26 through 07/13/26 clinical record was reviewed. For the following changes of condition, there was no documented evidence of weekly progress monitored to resolution: * 06/23/26 - New move-in; * 06/24/26 - Skin tear to left elbow; * 07/03/26 - Discontinuation of lisinopril; and * 07/03/26 - Addition of the following medications: sennoside, tamsulosin, amlodipine, brexpiprazole, apixaban, losartan, quetiapine, melatonin, lorazepam, finasteride, and divalproex. In an interview with Staff 1 (MCC Administrator) on 07/16/26 at 10:20 am, she stated Staff 3 (Health and Wellness Director/ RN) would discontinue monitoring of skin issues, but it was Staff 1’s responsibility to discontinue alerts for all other short-term changes of condition. The need to ensure short-term changes of condition were monitored with weekly progress until the condition resolved was reviewed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The HWD/RN and MCC Administrator reviewed and corrected assessment and service plan for Resident 4 on 7/31/2026. Resident 1 was sent out to hospital and admitted 7/18/2026 and will not be returning to the facility. The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. 2. System correction to prevent recurrence: A change-of-condition tracker will be maintained with the resident, condition, start date, assigned owner, interventions, shift communication, weekly review date, provider notification, and closure date. For each active condition, the record will identify the action or intervention, who must perform it, how it will be communicated to each shift, monitoring frequency, provider-notification criteria, weekly progress, and the date and basis for resolution. Service plans will be updated when the change affects ongoing care. Staff will receive current written instructions before the next shift assignment. The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. New falls, injuries, medication changes, refusals, skin concerns, weight changes, behavioral events, hospital returns, and new admissions will be reviewed in the daily clinical meeting. Alerts will remain open until a licensed nurse or designated leader documents resolution or transition to the service plan. All staff in-service completed 7/28/2026 3) Evaluation and re-evaluation audits completed weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are 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:

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 1 of 1 sampled resident (# 4) who experienced a significant weight loss. Findings include, but are not limited to: Resident 4 moved into the MCC facility in 04/2026 with diagnoses including dementia. The resident's 05/01/26 through 07/13/26 clinical record and 06/2026 through 07/2026 weight records were reviewed, observations of the resident and interviews with staff were conducted, and the following was identified: The following weights were recorded by the facility: * 06/08/26: 183 pounds; and * 07/03/26: 167.5 pounds. Resident 4 experienced an unexplained weight loss of 5.5 pounds, or 8.47% of his/her total body weight, in one month. This severe weight loss constituted a significant change of condition that required an RN assessment. In a progress note dated 07/02/26, Staff 1 (MCC Administrator) identified the weight loss, notified the PCP and requested a mechanical soft diet, and established interventions. There was no documented evidence the facility RN conducted an assessment. Resident 4 was reweighed on 07/14/26 at the request of the survey team and had lost an additional two and a half pounds, weighing 165.0 pounds. On 07/16/26, Staff 2 (ED) reported the resident was reweighed on 07/16/26 and was 169.0 pounds, a four pound weight gain in two days. Observations during the survey, from 07/13/26 through 07/16/26, identified the following: * Resident 4 was primarily nonverbal and would often respond to staff’s questions by closing his/her eyes, turning his/her head, or nodding; * During meals, the resident would immediately push the plate away when served; * Staff would prepare a bite of food onto the fork or spoon, and the resident would often take a bite, and other times would turn away when feeding assistance was offered; * Staff provided a nutritional protein drink at every meal observed and the resident drank 100%; * Of the four meals observed, the resident ate no more than 10% of the main meal but would drink 100% of the beverages and dessert offered. During an interview on 07/16/26 at 10:20 am, Staff 1 acknowledged notifying the physician and indicated she let the RN know about the significant weight loss. The need to ensure significant changes of condition were assessed timely by the facility RN, including documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings. No further documentation was provided.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The HWD/RN will complete and document a comprehensive assessment of Resident 4's weight loss, intake, hydration, swallowing/chewing ability, feeding assistance, medications, functional status, and risk factors. The provider and resident representative will be notified, and orders or referrals for dietitian, speech therapy, laboratory testing, supplements, or other treatment will be obtained as indicated. The service plan, nutrition plan, and staff instructions were revised and completed 7/31/2026. The HWD/RN will review other residents with recent weight loss or other significant changes to verify that required RN assessments were completed. 2. System correction to prevent recurrence: The facility will adopt clinical trigger criteria requiring RN assessment for significant weight change, repeated poor intake, repeated falls, acute functional decline, repeated behavioral escalation, hospital return with changed status, or other major deviation from the latest evaluation using a change of condition log and review of progress notes during clinical meetings. The RN assessment will be completed promptly, generally within 24 hours of identification, and will document findings, interventions, provider notification, follow-up, and service-plan changes. All staff in-service completed 7/28/2026. 3) Change of condition and monitoring audit completed weekly with tracking log and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols during meal service. Findings include, but are not limited to: 1. On 07/13/26 at 5:20 pm during dinner service, a staff member in the MCC kitchenette was asked to remove the crusts on a sandwich served to Resident 2, who had orders for a mechanical soft diet. The staff member proceeded to slice the crusts from the sandwich using bare hands. She was also observed cutting the crusts off another grilled sandwich, touching the bread with bare hands. On 07/14/26 at 12:15 pm during lunch service, a staff member could not find a knife and proceeded to cut an apple with a spoon without first performing hand hygiene and wearing gloves. Another staff member was observed preparing ready-to-eat food without wearing gloves. 2. On 07/14/26 at 10:27 am, a rolling cart transported a tray of uncovered desserts from the main kitchen to the MCC kitchenette. The need to establish and maintain effective infection prevention and control protocols was reviewed with Staff 1(MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. Food-service and direct-care staff who prepare, portion, transport, or assist with food will receive immediate retraining on hand hygiene, glove use, prevention of bare-hand contact with ready-to-eat food, clean utensil use, and covered food transport. Appropriate knives, utensils, gloves, and covered transport containers will be available in the MCC kitchenette. Staff observed using an unsafe practice will stop, discard affected food, perform hand hygiene, and prepare a replacement. All staff in-service of infection control protocol completed 7/28/2026 2. System correction to prevent recurrence: The Dining Services Director will implement a meal-service infection-control checklist covering hand hygiene, glove changes, ready-to-eat food handling, clean utensils, protected transport, and sanitation of preparation areas. New staff/agency competency will be observed before independent food handling. Food-handler credentials will be tracked before assignment to food preparation. Infection control specialist assigned for Memory Care. 3) Infection prevention and control audit completed weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure treatment orders were carried out as prescribed for 2 of 2 sampled residents (#s 2 and 4) who had modified diet orders. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 06/2026 with diagnoses including dementia. The resident’s clinical record, dated 06/23/26 through 07/13/26, and a signed order for modified diet textures, dated 12/23/25, were reviewed. The following was identified: Resident 2 had a diet order for mechanical soft diet texture and thin liquids. The resident’s 05/08/26 service plan indicated the order was to improve the ease and safety of chewing due to “multiple missing or broken teeth.” On 07/13/26 at 5:20 pm, Resident 2 was served a tuna sandwich with the crusts still on the bread. The crust was not fork-mashable and easy to chew and, therefore, not reflective of the resident’s mechanical soft diet order. Resident 2 was observed taking two bites of the sandwich before the surveyor requested the crusts be removed from the sandwich and the sandwich cut into bite-sized pieces. The need to ensure orders were carried out as prescribed was reviewed with Staff 1(MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings. 2. Resident 4 moved into the MCC facility on 04/2026 with diagnoses including dementia. The resident’s clinical record, dated 05/01/26 through 07/13/26, was reviewed, observations of the resident and interviews with staff were conducted, and the following was identified: Resident 4 had a diet order dated 07/07/26 for mechanical soft diet texture. The request was initiated by the facility following a significant weight loss because the resident was unable to consistently feed him/herself independently and had a decline in nutritional intake. The order was to “promote safer eating and improve intake.” On 07/13/26 at 5:19 pm, Resident 4 was served cut up pieces of a grilled cheese sandwich with the crusts still on the bread. The crust was not fork-mashable and easy to chew and, therefore, not reflective of the resident’s mechanical soft diet order. The resident immediately pushed the plate away and did not eat the sandwich during dinner. On 07/14/26 at 11:37 am, Resident 4 was served cut up taco meat with melted cheese, rice, and corn salad. The corn in the salad had fibrous skins, was difficult to chew and posed a choking hazard, and was not mechanical soft consistency. Observations identified the resident did not take any bites of the corn. On 07/14/26 at 5:02 pm, Resident 4 was served cut up pieces of beef stroganoff in a sauce over noodles and mixed vegetables that included corn. The resident pushed the plate toward the center of the table, refused to eat the meal served, and at 5:16 pm was provided a supplement drink and a bowl of noodles. Observations of the meals that did not follow a mechanical soft diet as ordered were reviewed with Staff 19 (Vice President of Operations) on 07/15/26 at 11:48 am, and she acknowledged training would immediately take place for all staff in the kitchen, as well as direct care staff who provided assistance to the residents for meals and snacks, to ensure they were following the diet textures as ordered. On 07/15/26 at 5:04 pm, Resident 4 was served cut up meatball casserole with mashed potatoes and cut up green beans topped with gravy. The meal was mechanical soft and followed physician’s orders. The need to ensure orders were carried out as prescribed was reviewed with Staff 1(MCC Administrator), Staff 2 (ED), and Staff 19 on 07/16/26 at 12:00 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The HWD/RN and Dining Services Director will verify current diet orders for each resident and create an updated diet roster and resident-specific meal card. Residents 2 and 4 will receive meals that meet mechanical-soft standards, including appropriate bread, vegetables, meat, portion size, and feeding assistance. Staff who prepare, plate, serve, or assist with meals will complete texture-modification training and a return demonstration. Food that does not match the order will be replaced before it is served. Put specific covers over modified diet plates in warmer to identify to care staff. Primary care physician changed resident 2 diet order to cut up bite size regular food. All staff in-serviced 7/28/2026. Executive Chef in-serviced 8/6/2026. 2. System correction to prevent recurrence: Diet orders will be entered into a central diet roster and cross-checked against the MAR/order record, service plan, kitchen list, and meal card. A change in diet order will be communicated to dietary and direct-care staff before the next meal. The Dining Services Director will maintain approved texture examples and a pre-service review of modified diets. The HWD/RN will reconcile diet orders weekly and after each new order. All staff in-service completed. 3) Health services audit completed weekly and results will be reviewed in QAPI weekly. Diet orders will be audited weekly and any discrepancies will be addressed immediately. 4) MCD, ED and/or designee are 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:

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 4) who had documented medication refusals. Findings include, but are not limited to: Resident 4 moved into the MCC facility on 04/2026 with diagnoses including dementia. The resident's 06/02/26 through 07/13/26 MARs and progress notes, dated 05/01/26 through 07/13/26, were reviewed and revealed the resident refused to consent to orders for the following medications: * Chlorthalidone (for water retention) on six occasions; * Vitamin C (supplement) on six occasions; * Atorvastatin (for high cholesterol) on three occasions; * Ferrous Sulfate (for low iron) on three occasions; * Memantine twice daily (for cognitive decline) on six occasions; * Metformin (for diabetes) on seven occasions; * Multivitamin (supplement) on four occasions; and * Risperidone (for agitation) on one occasion. There was a signed order, dated 03/25/26, for staff to notify the prescriber when the resident missed “any” scheduled medication or treatment. During an interview on 07/15/26 at 2:59 pm, Staff 7 (MT/CG) stated the facility's process was to document the refusal in the MAR, notify the physician, and put the resident on alert charting each time the resident refused a medication. On 07/16/26 at 12:00 pm, Staff 1 (MCC Administrator) confirmed the prescriber had not been notified of the above refusals. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1, Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The HWD/RN will notify Resident 4's prescriber of the documented refusals and request direction regarding continued orders, refusal thresholds, and follow-up. The prior 30 days of MARs were reviewed for other missed or refused medications, and prescribers were notified when required. Resident-specific causes of refusal and helpful approaches will be added to the service plan and medication instructions. Have added interventions into care plan to decrease refusal amounts. 2. System correction to prevent recurrence: Medication staff will document each refusal in the MAR and progress note, notify the HWD/RN or on-call leader, follow the prescriber's notification parameters, and place the resident on change-of-condition monitoring when indicated. A daily exception report will identify refusals, omissions, and missed treatments. The HWD/RN will sign off after notification and follow-up are completed. All staff in-service for nursing services including documentation and follow up completed 7/28/26 3) Nursing services audit completed weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff documented that non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medication for 1 of 1 sampled resident (#1) who had orders for PRN psychotropic medications. Findings include, but are not limited to: Resident 1 moved into the MCC in 06/2026 with diagnoses including Alzheimer’s disease and schizophrenia. The resident’s signed prescriber orders and 06/23/26 through 07/13/26 MAR and progress notes were reviewed, and the following was identified: * Resident 1 had orders for PRN lorazepam 2 mg tablet, take one every 4 hours for anxiety. Staff administered the medication eight times between 06/23/26 and 07/02/26. * On 07/03/26, Resident 1’s order changed to: PRN lorazepam 2 mg tablet, take one every 8 hours for anxiety or sleep. Staff administered the medication eleven times between 07/03/26 and 07/13/26. There was no documented evidence that staff attempted non-pharmacological interventions with ineffective results prior to administering the PRN lorazepam. The need to ensure PRN psychotropic medications were administered only after documented non-pharmacological interventions had been tried with ineffective results was reviewed with Staff 1(MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings.

1. Actions to correct the rule violation: Resident 1 has been discharged from the facility and will not return. Therefore, the facility will not administer further PRN psychotropic medication to Resident 1. The HWD/RN will complete a retrospective review of Resident 1's PRN psychotropic administrations to identify documentation, intervention, or notification gaps and will use the findings for staff education and system correction. For current residents with PRN psychotropic orders, the HWD/RN will verify indication, dose, frequency, duration, resident-specific parameters, and required non-pharmacological approaches. Medication staff will receive training and competency validation before administering PRN psychotropic medication. The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. 2. System correction to prevent recurrence: The MAR and PRN documentation process will require the behavior/clinical symptom, non-pharmacological interventions attempted, response to each intervention, reason medication remained necessary, medication effect, adverse effects, and required provider notification. PRN psychotropic medication will not be administered for convenience or without resident-specific parameters. The HWD/RN will review frequent use for possible reassessment or order revision. All staff in-service for medication administration completed 7/28/2026 3) Medication administration audit will be completed weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT, or OT, failed to instruct caregivers on the correct use of and precautions for the device, and failed to document the use of the device in the resident's service plan for 1 of 1 sampled resident (#4) who had a side rail on his/her bed. Findings include, but are not limited to: Resident 4 moved into the MCC facility on 04/2026 with diagnoses which included dementia. On 07/14/26 at 10:50 am, the resident's bed was observed to have a fixed side rail on one side of the bed. There was no documented evidence that the device with restraining qualities had been assessed by an RN, PT or OT, instruction had been provided to caregivers on the correct use of and precautions for the device, and documentation of the use of the rails had been included in the resident's service plan. During an interview on 07/15/26 at 3:22 pm, Staff 3 (Health and Wellness Director/RN) acknowledged she had not completed an assessment, instructed caregivers on the correct use of and precautions for the side rail, or documented use of the side rail in the resident’s service plan. The?need to ensure?the?facility had an RN, PT, or OT conduct a thorough assessment of a supportive device with restraining qualities,?provide instruction to caregivers on the correct use of and precautions for the device,?and include use of the device in the resident service plan was discussed with Staff 1 (MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on?07/15/26?at?12:00 pm. They acknowledged the findings.?

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The side rail for Resident 4 will be removed until an RN, PT, or OT completes the required assessment and less-restrictive alternatives are evaluated. All staff restraint in-service completed 7/28/2026. Resident 4 was not using the side rail so it was removed once assessed that she was not utilizing it for mobility. 2. System correction to prevent recurrence: A supportive-device approval checklist will be required before a side rail, positioning device, or other device with restraining qualities is placed in use. The checklist will include clinical assessment, alternatives considered, consent, staff instructions, service-plan entry, manufacturer guidance, and quarterly review date. Maintenance may not install or leave such a device in place without clinical authorization. When use is clinically appropriate, the resident or legal representative will receive the risks and benefits, consent will be documented, caregivers will be trained on correct use and precautions, and the device will be added to the service plan with quarterly review. The HWD/RN will inspect resident rooms for other devices with restraining qualities and complete the same review. 3) Restraint audit completed weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an adequate number of direct care staff were scheduled and available on the overnight shift to meet the 24-hour scheduled and unscheduled needs of each resident and failed to meet the fire safety evacuation standards as required by the fire authority. Findings include, but are not limited to: 1. The MCC’s acuity-based staffing tool was reviewed on 07/15/26 at 3:06 pm. The posted staffing plan indicated there were two direct care staff scheduled for each overnight shift. The survey investigation indicated two residents required the assistance of two care staff for transfers. During the time when one staff was on meal or rest breaks, only one direct care staff was available for residents requiring two-person assistance. The facility failed to meet the scheduled and unscheduled needs of each resident requiring two staff for transfers and ADL assistance during that time. 2. At the time of survey, 07/13/26 through 07/16/26, the facility was home to 18 residents. On 07/14/26 at 3:00 pm, Staff 4 (Maintenance Director) stated the facility did not evacuate residents in the MCC during fire drills, and he did not know if two staff could safely evacuate the residents, as it had never been practiced. The need to ensure there were an adequate number of direct care staff on the overnight shift to meet the 24-hour scheduled and unscheduled needs of each resident and meet fire safety evacuation requirements was reviewed with Staff 1 (MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The ED and MCC Administrator will revise the overnight schedule so two direct-care staff remain available to residents at every point in the shift, including meal and rest breaks. Coverage may include an additional qualified staff member, overlapping shifts, or paid on-duty breaks that do not reduce resident coverage. Residents requiring two-person transfers will be identified on shift assignments. The facility will conduct an evacuation-capability drill with the Maintenance Director and consult the Fire Authority when needed to confirm staffing and evacuation methods. Updated staffing plan and increased staffing level for NOC shift to 2 caregivers and 1 medication technician. 2. System correction to prevent recurrence: The posted staffing plan will account for ABST time, unscheduled needs, two-person assistance, breaks, building layout, and evacuation capability. The scheduler may not publish a schedule below the posted plan. Call-offs will trigger the contingency staffing plan and leadership notification. Shift leads will document staffing at the start of shift and after any staffing change. Will conduct evacuation drill 8/19/2026. 3) ABST audits are completed weekly to ensure appropriate staffing is available. Results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) accurately captured care time and care elements staff were providing to residents for 2 of 2 sampled residents (#s 2 and 4) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the MCC facility on 04/2026 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the 05/24/26 service plan and Resident 4’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Supervising, cueing, or supporting while eating; * Ambulating, escorting to meals/activities; * Repositioning in bed or a chair; * Transferring in and out of bed or chair; and * Bowel and bladder management. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1(MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings. 2. Resident 2 moved into the MCC in 04/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the 05/08/26 service plan and Resident 2’s ABST data were completed. The following area was not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks, fall prevention. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The MCC Administrator and HWD/RN will complete a 100% review of resident ABST entries against current service plans, staff interviews, observations, and actual care records. Resident 4's eating support, escorts, repositioning, transfers, bowel/bladder care, and other provided care will be accurately timed. Resident 2's safety checks and fall-prevention time were added 7/16/2026. Resident 4 care elements updated 7/31/2026. The posted staffing plan were recalculated after corrections. All staff in-service completed 7/28/2026 2. System correction to prevent recurrence: An ABST-to-service-plan crosswalk will be completed at admission, quarterly review, and significant change. Care time will be resident-specific rather than based on an average. Staff who complete ABST entries will receive training on direct-care elements, unscheduled care, documentation sources, and reconciliation with the posted staffing plan. All staff in-service completed 7/28/2026 3) ABST audit completed weekly and during updates/changes in resident needs and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated and reviewed before move-in and at least quarterly for 2 of 4 sampled residents (#s 1 and 2) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 06/2026 with diagnoses including Alzheimer’s disease and schizophrenia. The resident’s ABST evaluation was reviewed and showed it was not created until seven days after the resident moved in. 2. Resident 2 moved into the MCC in 04/2025 with diagnoses including dementia. Resident 3’s individual ABST evaluation noted it was last reviewed and updated on 01/29/26. The resident’s service plan was updated on 05/08/26. There was no documented evidence the ABST was updated at the same time the quarterly service plan was updated, as required. The need to ensure the ABST was updated and reviewed before move-in and at least quarterly was reviewed with Staff 1 (MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The MCC Administrator will complete or update the ABST for each resident and verify that the date aligns with the admission review, significant-change review, or quarterly service-plan update. The affected resident records were corrected. No new resident will move in until the pre-admission ABST is completed and staffing impact is reviewed. 2. System correction to prevent recurrence: A due-date tracker will link admission, service-plan, ABST, and significant-change dates. The admission checklist will require ABST completion before move-in. Quarterly service-plan packets will not be closed until the ABST is reviewed and signed. The staffing plan will be updated when ABST totals change. 3) ABST audit completed weekly and during updates/changes in resident needs and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

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

OAR 411-054-0090 (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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months from fire drills and written fire drill records included all required elements in accordance with the Oregon Fire Code. Findings include, but are not limited to: 1. Six months of fire drill records were reviewed with Staff 4 (Maintenance Director) on 07/14/26 at 3:00 pm. The fire drill documentation failed to address the following: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. During the review of fire drill records, Staff 4 stated the above information was not documented on the fire drill forms because the facility never practiced moving residents out of the unit; all MCC drills were simulations. 2. In an interview on 07/16/26 at 11:00 am, Staff 2 (ED) stated she was unable to locate any documentation regarding fire and life safety instruction to staff other than fire extinguisher training conducted in 01/2026. The need to ensure fire and life safety instruction was provided to staff on alternating months from fire drills and written fire drills records included all required elements was reviewed with Staff 1 (MCC Administrator), Staff 2, and Staff 19 (Vice President of Operations) on 07/16/26 at 12:37 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The Maintenance Director and ED will conduct documented fire and life-safety instruction and a drill using the facility's approved evacuation method. The drill record will document date/time, simulated origin, route, alarm activation, staff participating, residents/occupants evacuated or moved to the approved point of safety, evacuation time, resistance or problems, and corrective follow-up. The Fire Authority will be consulted when clarification or an alternative plan is needed. All staff in-service completed 7/28/26. Fire drill conducted 8/5/2026 and staff received re-training on 8/5/2026. 2. System correction to prevent recurrence: A 12-month calendar will alternate unannounced fire drills with fire/life-safety instruction and rotate day, evening, and night shifts. A standardized drill form containing each required element will be used. The ED will review and sign each drill or training record within three business days. Identified evacuation barriers will trigger staffing, assignment, room, or equipment changes. 3) Fire and life safety audits completed monthly including drills, training, signage and inspections, and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

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. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers. Residents were unable to contact staff to request help when needed, constituting a threat to their health, safety, and welfare. Findings include, but are not limited to: The MCC was composed of eight shared resident units and three single-occupancy units. During the acuity interview on 07/13/26 at 2:04 pm, Staff 15 (CG) and Staff 8 (MT/CG) stated the pull cords in resident bathrooms did not work and there was no system for residents to call for assistance from their rooms. Resident 8 stated the call system had not been operable since she had started her employment with the facility approximately two years ago. She also stated there were two residents in the facility who attempted to use the pull cords in their bathrooms to call for assistance and would question staff as to why no one ever responded. On 07/13/26 at 3:18 pm, Staff 1 (MCC Administrator) and Staff 2 (ED) reported the pull cord system in resident bathrooms was working, but the facility did not have enough pagers to connect care staff to the system. The facility failed to ensure residents had a working call system, which left residents unable to call for assistance when needed and placed the residents’ health, safety, and welfare at risk. On 07/13/26 at 3:52 pm, a written plan of correction was requested of Staff 1, to be submitted by 4:30 pm. The plan of correction was accepted at 5:15 pm on 07/13/26. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. On 07/14/26 at 11:00 am, Staff 4 (Maintenance Director) reported he had been able to procure three pagers for staff to use and pull cords in all MCC resident rooms were programmed to audibly notify staff of activation. However, upon inspection, one private room did not send an alert to the pager system. Staff 4 was requested to perform a full audit of MCC rooms to ensure all pull cords were connected to the pagers. At 12:00 pm, he stated all pull cords had been programmed to link to staff pagers. The need to have an operational call system that connected residents to the care staff or staff pagers was discussed with Staff 1 and Staff 2 on 07/16/26. They acknowledged the findings.

1. Actions to correct the rule violation: On July 14, 2026, the facility obtained three pagers, programmed the bathroom pull cords to the pagers, and completed a function audit as documented in the survey report. The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The Maintenance Director will verify each resident-room and bathroom pull cord activates an audible alert and the assigned staff pager. Each shift will have a designated pager holder, a back-up pager, and a documented handoff. Any failed device will trigger immediate repair, increased staff checks, and use of an alternate means for the resident to request help until repair is verified. 2. System correction to prevent recurrence: The facility will maintain a call-system inventory, test log, pager assignment sheet, battery/charging schedule, spare equipment, and vendor contact information. New devices, repairs, programming changes, and room changes will be function-tested before use. Staff will be trained to respond promptly and report failed alerts. 3) Alarm audits will be conducted weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for 4 of 4 sampled residents (#1, 2, 3, and 4) and multiple unsampled residents who shared a bathroom. Findings include, but are not limited to: On 07/13/26 at 2:42 pm, observations of the shared bathroom between roommates in Rooms 122 and 123 revealed no locking mechanism for the residents to lock the doors from inside the bathroom. On 07/14/26 at 10:37 am, Staff 4 (Maintenance Director) acknowledged the majority of the shared bathroom door handles were updated and did not have locks. Staff 4 confirmed residents throughout the facility were not able to lock their shared bathroom doors from inside their bathrooms for privacy. On 07/16/26 at 12:00 pm, the need to ensure each individual had privacy in his or her own unit, including privacy when using shared bathrooms between roommate units, was discussed with Staff 1 (MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. Bathroom locks were installed 8/10/2026. 2. System correction to prevent recurrence: The environmental inspection checklist will include functioning privacy locks, emergency-release capability, door alignment, and staff access. Replacement hardware may not remove resident privacy capability unless an approved alternative is in place. Work orders involving resident doors or locks will receive a privacy review before closure. 3) Monthly audits to ensure locks are functioning correctly will be completed and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 3 of 4 sampled newly hired staff (#s 9, 15, and 16) whose training records were reviewed. Findings include, but are not limited to: Refer to Z155.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. Staff 9, 15, and 16 will complete the Department-approved LGBTQIA2S+ course and required resident-rights orientation. Training completion and knowledge validation will be documented. A staff member with missing pre-service requirements will not work independently with residents until the required training is complete and documented. 2. System correction to prevent recurrence: The Business Office/HR designee will use a pre-service clearance checklist that includes resident rights, abuse reporting, infection prevention, food-handler requirements when applicable, HCBS, and Department-approved LGBTQIA2S+ training. The MCC Administrator must sign the checklist before a new employee begins job duties. The training matrix will show due dates, completion dates, and supporting certificates. 3) Staff training audits to ensure completion and continued education will be completed 3 times weekly and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

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

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to: During the relicensure survey, conducted 07/13/26 through 07/16/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. 1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area: * OAR 411-054-0200 (11) - Call System The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. 2. Refer to deficiencies in the report.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The ED and MCC Administrator will implement a 90-day compliance stabilization plan assigning an owner, action, due date, evidence, and audit method to each survey tag. Leadership will verify resident protection, staffing, training, clinical systems, environmental safety, dietary practice, fire safety, and call-system function. Corporate clinical and operations support will validate high-risk corrections and assist with barriers. Changed schedule to ensure administration is on site seven days per week. Elderwise consulting began (date). 2. System correction to prevent recurrence: A compliance dashboard will be reviewed at a weekly QAPI meeting. Department heads will report completion evidence, audit findings, root causes, and corrective follow-up. The ED will conduct leadership rounds and validate that reported corrections are present in practice and documentation. Repeat or high-risk findings will trigger a focused root-cause review and revised action plan. 3) Weekly audits and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. 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 observation, 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 C200, C231, C295, C360, C362, C363, C420, and C555.

1. Actions to correct the rule violation: Resident 1 has been discharged from the facility and will not return. The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The facility will complete the corrective actions listed for C0200, C0231, C0295, C0360, C0362, C0363, C0420, and C0555. The ED will verify evidence for resident protection, abuse reporting, infection control, staffing, ABST accuracy and timing, fire/life safety, and call-system operation before closing this tag. 2. System correction to prevent recurrence: The facility will maintain a regulatory crosswalk linking Division 57 responsibilities to the applicable Division 54 requirements. Department heads will complete focused audits in their assigned area, and the ED will validate the results through QAPI and leadership rounds. 3) Weekly audits and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

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 411-057-0155(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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 9, 15, and 16) completed all required pre-service orientation and dementia training topics; and 4 of 4 newly hired direct care staff (#s 9,15, 16, and 17) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 07/15/26 at 2:16 pm with Staff 1 (MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations), and the following was identified: a. There was no documented evidence Staff 9 (CG/MT), Staff 15 (CG) and Staff 16 (CG), hired 11/07/25, 04/11/26, 05/12/26, respectively, had completed one or more of the following pre-service orientation training topics before completing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Food handler’s certificate; * Infectious disease prevention; * HCBS course; and * LGBTQIA2S+ course. b. There was no documented evidence Staff 9, Staff 15, and Staff 16 had completed the pre-service dementia training in one or more of the following required topics prior to beginning their job responsibilities: * Dementia disease process, including progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating, and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia, including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach; * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 9, 15, 16, and Staff 17 (CG), hired 06/16/26, demonstrated competency in one or more of the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documenting, and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure the required pre-service training was completed by staff in the time frames specified in the rules and staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 1, Staff 2, and Staff 19 on 07/16/26 at 12:00 pm. They acknowledged the findings.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. Staff 9, 15, 16, and 17 will complete the missing required training and competency validation. Training will cover resident rights, abuse reporting, food-handler requirements when applicable, infection prevention, HCBS, LGBTQIA2S+, dementia disease process, communication and response to distress, meaningful activities, nutrition/hydration, wandering and elopement, person-centered care, environmental factors, family roles, changes of condition, personal care, supportive devices, service plans, normal aging, and reporting requirements. Staff with incomplete competency will receive direct supervision and will not independently perform an unvalidated task. Staff 9,15, 16 and 17 will complete required training by 8/21/2026. 2. System correction to prevent recurrence: The facility will use a memory-care training matrix and new-hire competency packet. Pre-service requirements must be completed before job duties or independent care, and role competencies must be validated within 30 days. The MCC Administrator and qualified trainer will sign each competency. Schedules will identify employees who remain under direct supervision. 3) Weekly audits and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

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. 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 observation, 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, 280, C303, C305, C330, and C340.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The facility will complete the corrective actions listed for change-of-condition monitoring, timely RN assessment, modified diets, medication refusals, PRN psychotropic medication, and supportive devices. The HWD/RN will complete a focused review of current residents for open clinical alerts, significant changes, diet orders, repeated refusals, PRN psychotropic use, and devices with restraining qualities. 2. System correction to prevent recurrence: A monthly clinical compliance review will reconcile provider orders, assessments, service plans, MAR/TAR records, change-of-condition tracking, nutrition plans, behavior interventions, and supportive-device documentation. High-risk exceptions will be addressed in the daily clinical meeting and tracked to closure. 3) Weekly audits and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

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:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 1 of 2 sampled residents (#4) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Resident 4 moved into the MCC facility on 04/2026 with diagnoses including dementia. Observations made during the survey, from 07/13/26 through 07/16/26, identified the resident was primarily nonverbal, required intermittent feeding assistance from staff, and did not consume more than 10% of his/her meals. During the acuity interview on 07/13/26, Resident 4 was noted to have had a significant weight loss and to have an order for a mechanical soft diet texture. Residents 4’s current service plan was reviewed during survey. The service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop an individualized nutrition and hydration plan based on the resident's preferences and needs that was documented in the resident's service plan was discussed with Staff 1 (MCC Administrator), Staff 2 (ED), and Staff 19 (Vice President of Operations) on 07/16/26 at 12:00 pm. They acknowledged the findings and no further documentation was provided.

1. Actions to correct the rule violation: The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The HWD/RN has developed an individualized nutrition and hydration plan for Resident 4 that addresses preferences, mechanical-soft texture, feeding approach, cueing and assistance, positioning, adaptive equipment needs, supplements, fluids, preferred foods, meal alternatives, intake documentation, weight frequency, and provider-notification thresholds, this is included in her change of condition completed 7/31/2026. Current residents will be reviewed for similar missing nutrition instructions. 2. System correction to prevent recurrence: Nutrition and hydration will be a required section of each memory-care service plan. The section will be updated at admission, quarterly, after a diet-order change, significant weight change, repeated poor intake, swallowing concern, or change in feeding ability. Dietary and direct-care staff will have access to the same current instructions. The provider, dietitian, speech therapist, and representative will be involved as indicated. 3) Weekly audits and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability, and design to prevent resident injury or aid in elopement. Findings include, but are not limited to: The secured courtyard of the memory care community was toured on 07/13/26 at 2:40 pm. Several pieces of outdoor furniture, including a bench and multiple tables, were observed in the courtyard to which residents had free access. The furniture was easily movable and not of sufficient weight to prevent injury or elopement. On 07/13/26 at approximately 5:06 pm the outdoor courtyard was toured with Staff 1 (MCC Administrator). Staff 1 acknowledged the furniture was not of sufficient weight and stated she would have them removed. The need to maintain outdoor furniture of sufficient weight was discussed with Staff 1, and she acknowledged the findings.

1. Actions to correct the rule violation: Resident 1 has been discharged from the facility and will not return. The facility-wide corrective actions, system changes, staff training, and monitoring described below remain applicable to current and future residents. The easily movable bench and tables will be removed from resident access, secured, or replaced with furniture of sufficient weight, stability, and design. The Maintenance Director and MCC Administrator will inspect the courtyard perimeter, gates, furniture, and items that could be climbed, thrown, or moved to aid elopement. Furniture was secured (date). 2. System correction to prevent recurrence: The daily environmental round will include courtyard furniture stability, condition, placement, fence clearance, gate function, and elopement risk. New outdoor furniture will be approved by the Maintenance Director and MCC Administrator before placement. 3) Weekly audits and results will be reviewed in QAPI weekly. 4) MCD, ED and/or designee are responsible.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: