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 promptly investigate injuries of unknown cause and report to the local SPD office if abuse could not be ruled out for 2 of 2 sampled residents (#s 1 and 2) reviewed for injuries of unknown cause. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 11/2022 with diagnoses including dementia. Resident 1’s progress notes were reviewed from 04/17/25 through 07/21/25 and the following was identified: * On 07/01/25, Staff 2 (RN) documented “Right shin opening. Staff provided first aid…” An incident investigation was requested during the survey. On 07/22/25 at 4:30 pm, Staff 2 stated no immediate investigation was completed to reasonably rule out abuse, and there was no documented evidence the incident was reported to SPD. The facility was asked to report the injury to the local SPD office on 07/23/25. Confirmation was received on 07/24/25. The need to investigate injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 (Administrator) on 07/24/25. He acknowledged the findings. 2. Resident 2 moved into the MCC in 06/2023 with diagnoses including dementia. Resident 2’s progress notes were reviewed from 04/17/25 through 07/21/25 and the following was identified: * Staff 2 (RN) documented in facility progress notes on 05/15/25 that the resident’s right arm “has a smaller skin tear – cleaned and bandaged…” An incident investigation was requested on 07/23/25 at 10:45 am. During an interview with Staff 2 (RN) on 07/23/25 at 1:50 pm, she stated the facility had not completed an investigation of the injury to rule out abuse, nor reported it to the local SPD office. The facility was asked to report the injury to the local SPD office on 07/23/25. Confirmation was received on 07/24/25. The need to investigate injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 (Administrator) on 07/24/25. He acknowledged the findings.

1 and 2.In the case of ruling out injuries of unknown origin or abuse. The facility is taking the following corrective action. There has been a "to do task" for admin set up to review staff observations on week days to identify if there are any entries of unknown origin that cannot be ruled out as abuse. We anticipate that our staff will file an incident report or make any observation of any injuries, including but not limited to: bruises, skin tears, cuts etc. If abuse cannot be ruled out Administration will report to APS 3-4.The administrator and nurse will be reviewing and watching for unknown injury on a daily basis.

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 411-054-0050(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 maintain infection prevention and control protocols related to dining services. Findings include, but are not limited to: On 07/22/25 between 9:55 am and 12:15 pm, interviews with staff and observations of the facility kitchen, food preparation, and food service were conducted, and the following was identified: a. Multiple direct care staff were observed to cook and/or serve residents meals without the use of a protective barrier over potentially contaminated clothing. b. At 10:30 am, a CG was observed helping a resident eat. During the observation, the CG touched the resident’s food with bare hands then handed it to the resident to eat. c. At 11:10 am, a CG entered the kitchen. She made toast for a resident. The CG handled the bread with bare hands while preparing it for the resident. The need to ensure the facility maintained effective infection prevention and control protocols to provide a safe and sanitary environment when preparing resident meals and during meal service was reviewed with Staff 1 (Administrator) on 07/22/25 at 12:15 pm. He acknowledged the findings.

1-2. Staff will receive training on the expectation to wear protective barrier while providing dining services for our residents. The expectation is that when staff enter the kitchen with the intention to prepare or serve any food, that they will wash their hands, put on gloves and put on a protective barrier such as an apron to protect from any cross contamination and protect the residents. Staff will also be expected to wear gloves when serving, preparing food and assisting residents with eating. Administration has supplied several aprons to wear when entering kitchen. 3-4.This will be monitored by the administration and continued training will occur by our trainer at hire, and quarterly reviews.

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 411-057-0140(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 C231 and C295.

Please refer to correction actions on tags C231 and C295 as previously done.

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: