OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were immediately reported to the local Seniors & People with Disability (SPD) office, injuries of unknown cause were promptly investigated to rule out abuse or reported to the SPD if abuse could not be ruled out, and failed to promptly investigate incidents of abuse or suspected abuse and document all required elements for 2 of 3 sampled residents (#s 2 and 3) whose incidents and injuries of unknown cause were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the MCC facility in 12/2024 with diagnoses including dementia. The resident’s clinical record from 10/11/25 to 01/17/26 was reviewed, and interviews with staff were conducted. The 12/26/25 quarterly evaluation identified Resident 2 had constant confusion with memory impairment; therefore, s/he was not a reliable historian and could not provide information for the events. The following was identified: * 11/16/25: Staff documented the resident was found in his/her roommate’s area of the room, sitting in their laundry basket, with redness and a laceration to the back and complaints of pain. There was no documented evidence the facility investigated the incident to include the time, date, place and individuals present, a description of the event as reported, response of staff at the time of the event, follow-up action, and an administrator's review. Survey requested the facility report the injury fall to the local SPD office, and confirmation was received on 01/26/26 at 11:17 am, after the team exited. * 12/04/25: Staff documented Resident 2 was missing a toenail. The facility lacked documented evidence the injury of unknown cause was investigated to rule out abuse as the cause of the injury or that it was reported to the local SPD office if abuse could not be ruled out. On 01/22/26, the injury of unknown cause was reported to SPD at the request of the surveyor. Confirmation of the report was received on 01/23/26 at 12:05 pm. * 12/18/25: Staff documented Resident 2 was involved in a resident-to-resident altercation. The facility reported the incident to the local SPD office on 12/22/25, not immediately as required. Additionally, the facility investigation of the resident-to-resident altercation lacked evidence of follow-up action and that an administrator review was completed as required. On 1/23/26 at 12:00 pm, Staff 3 (MCC Director) acknowledged resident-to-resident incidents needed to be immediately reported. * 01/13/26: Staff documented the resident was found on the floor in his/her room with a blanket “next to [him/her]” and unable to recall the incident. The facility incident report lacked documented evidence of follow-up action. On 01/22/26, Staff 3 confirmed no follow-up action was completed for this incident. On 01/23/26, the incident was reported to SPD at the request of the surveyor. Confirmation of the report was received on 01/26/26 at 11:13 am, after the survey team exited. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office, injuries of unknown cause were immediately investigated to rule out abuse or reported to the local SPD office if abuse could not be ruled out, and facility investigations included all required documentation was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3, Staff 5 (Human Resource Director), and Witness 1 (RN Consultant) on 01/23/26 at 2:20 pm. They acknowledged the findings. 2. Resident 3 was admitted to the assisted living facility in 08/2025 with diagnoses including heart failure and long-term use of anticoagulants. The resident’s clinical record, including 09/30/25 to 01/19/26 progress notes and incident reports were reviewed. The following was identified: * On 09/30/25 the facility documented in the progress note the resident had “a bruise” with dark purple bruising noted on the inside and outside of the left upper arm. The 09/23/25 incident report indicated “Resident does not know how it happened,” and the resident stated, “I did not fall or hit my arm on to something.” The bruising represented an injury of unknown cause. There was no documented evidence the facility immediately investigated the bruising and reasonably concluded and documented the injury was not the result of abuse or reported it as suspected abuse. * On 12/12/25 the facility documented in the progress note the resident was found sitting on the floor with bleeding from the back of his/her head. During the survey, documentation of an investigation related to the injury fall was requested. In an interview on 01/23/26 at 5:02 pm, Witness 1 (RN Consultant) reported that no investigation had been completed for the injury fall that included the time, date, place and individuals present, a description of the event as reported, response of staff at the time of the event, follow-up action, and an administrator's review. On 01/23/26 at 5:02 pm, survey requested the facility report the injury of unknown cause and the incident to the local SPD, and confirmation was received on 01/26/26 at 11:29 am, after the survey team exited. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office, injuries of unknown cause were immediately investigated to rule out abuse or reported to the local SPD office if abuse could not be ruled out, and facility investigations included all required documentation was discussed with Staff 1 (Associated ED), Staff 2 (Interim ED), Staff 4 (Resident Care Director/RN) and Witness 1 on 01/23/26 at 12:10 pm. They acknowledged the findings.

1. Resident 2's incidents dated 11/16/25, 12/4/25. 12/18/25, 1/13/26 were reported to SPD on 1/23/26. Resident 3's incidents dated 9/23/25, 12/12/25, were reported to SPD 1/23/26. 2.The Regional Director of Health & Wellness provided education to the Clinical Leadership Team and Direct Care Staff beginning on 2/13/26 regarding the need of identifying of abuse or suspected abuse, unwitnessed falls, injury of unknown cause and are immediately investigated to rule out abuse or suspected abuse,and determine cause if with injury or what occurred with the fall. Resident to resident incidents will be immediately reported and investigated. Training includes that investigations must include all required components which are the time, date, place, individuals present, description of event as reported, response of staff at time of event, follow up actions and Administrator review. Training for associates includes what incidents require investigation and reporting. A listing of incidents that require immediate investigation and reporting has been posted in the MedTech offices for visability. 3. The Assisted Living and Memory Care Program Directors, or designee, will conduct daily review of incident reports to identify if any reports require an investigation and reporting to the SPD office. Ongoing training will be provided to new associates in clinical leadership or new care associates during onboarding process. 4. The Executive Director, or designee, will audit incident reports and abuse reporting weekly ongoing for compliance with abuse reporting to verify compliance with abuse reporting requirements.The Administrator or designee will audit incident reports within 72 hours of the incident to monitor for ongoing compliance and appropriate follow-through. For incidents requiring an investigation, the audit will verify that all required investigative elements and reporting obligations have been completed.

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 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident’s needs, were readily available to staff, provided clear direction regarding the delivery of services, and were implemented, for 5 of 7 sampled residents (#s 1, 2, 3, 5, and 8) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC in 01/2026 with diagnoses including multi-system degeneration of the autonomic nervous system (a progressive neurological disease) and unspecified dementia. The resident’s clinical record was reviewed from 01/02/26 to 01/16/26, care observations were made, and family and staff interviews were conducted. The following was identified: The service plan, dated 01/02/26, was not reflective of the resident’s current status and lacked clear instructions for staff in the following areas: * Use of bilateral full-length side rails; * Left heel wound with documentation on who should provide services and what, when, how, and how often the services should be provided; and * Use of bilateral heel protection boots and when staff should don or doff them. During an observation of incontinence care with care staff on 01/22/26 at 1:45 pm, caregivers were observed lowering the full-length side rails to change the resident’s incontinence briefs and remove bilateral heel protection boots to facilitate bed mobility. Once cares were provided, the boots were donned, and side rails were placed in the up position. Resident 1 was wearing socks, and the wound was not visualized. Hospice nurses were providing cares to the wound, and it was identified in an outside provider note from 01/09/26. In an interview on 01/22/26 at 2:00 pm, Staff 16 (CG) confirmed having seen the wound on Resident 1’s left heel and stated it was “getting better.” The need to ensure service plans were reflective of the resident’s status and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 5 (Human Resources Director), and Witness 1 (RN Consultant) on 01/23/26 at 3:20 pm. They acknowledged the findings. 2. Resident 8 was admitted to the MCC in 03/2025 with diagnoses including type 2 diabetes mellitus. The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The following was identified: During the entrance interview on 01/20/26, facility staff reported service plans for the MC unit were stored in the service plan binder located in the MT office. Upon observation of the binder located in the MT office at 4:35 pm on 01/20/26, the service plan for Resident 8 was dated 04/26/25. On 01/22/26 at 10:55 am, Staff 3 (MCC Director) provided the requested quarterly service plan, dated 12/26/25. The need to ensure residents’ current service plans were readily available to staff was reviewed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3, Staff 5 (Human Resources Director), and Witness 1 (RN Consultant) on 01/23/26 at 3:20 pm. They acknowledged the findings. 3. Resident 3 was admitted to the assisted living facility in 08/2025 with diagnoses including heart failure. The resident's clinical record was reviewed from 02/04/25 to 01/15/26, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff in the following areas: * Bathing status included a preference for female staff; * Personal hygiene status; * Dressing status; * Activities; and * Anti-coagulant medication therapy. During the survey, multiple staff were interviewed, and they reported the resident required standby assistance or cueing with bathing and personal hygiene care. The need to ensure residents’ service plans provided clear direction to staff was discussed with Staff 1 (Associated ED), Staff 2 (Interim ED), and Witness 1 (RN Consultant) on 01/23/26 at 12:10 pm. They acknowledged the findings. 4. Resident 5 was admitted to the assisted living facility in 01/2025 with diagnoses including mild cognitive impairment of uncertain or unknown etiology, hypertension and chronic kidney disease. a. During the survey, facility staff reported service plans were stored in the service plan binder located in the med-room. Upon observation of the binder located in the medication room at 9:20 am on 01/21/26, the service plan for Resident 5 was dated 03/15/25. An updated service plan was not provided during this survey. b. The resident's clinical record was reviewed from 02/04/25 to 01/15/26, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff in the following areas: * Eating; * Emergency evaluation status; * Mobility; * Ability to use a key for the apartment; * Transfer status; and * Safety check status. During the survey, multiple staff were interviewed, and they reported the resident required additional cueing and increased safety checks due to increased confusion. The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 4 (Resident Care Director/RN) on 01/22/26 at 12:10 pm, and Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 5 (Human Resource Director) and Witness 1 (RN Consultant) on 01/23/26 at 12:10 pm. They acknowledged the findings. 5. Resident 2 was admitted to the MCC facility in 12/2024 with diagnoses including dementia. The resident’s clinical record was reviewed from 10/11/25 to 01/17/26, observations of the resident were made, and interviews with staff were conducted. The following was identified: a. During the entrance interview on 01/20/26, facility staff reported service plans for the MC unit were stored in the service plan binder located in the MT office. Upon observation of the binder located in the MT office at 4:35 pm on 01/20/26, the service plan for Resident 2 was dated 05/21/25. An updated service plan was not provided during this survey. b. The 05/21/25 service plan was not reflective of the resident’s current care needs, and/or lacked clear instructions in the following areas: * History of seizure activity and how staff should respond if one occurred; * Full assistance with meals; * Pain, including location and how pain was exhibited; * Preferences for waking up; * Eye protection needed when showering; and * Positioning in the facility recliner including ability to get in and out of the chair, elevation of the legs, location of the chair controller and supervision needed. On 01/22/26 at 1:15 pm, Staff 3 (MCC Director) indicated Resident 2 needed to wear shower glasses to protect his/her prosthetic eye when showering. The need to ensure residents’ current service plans were readily available to staff, were reflective of the residents’ status and care needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1(Associate ED), Staff 2 (Interim ED), Staff 3, Staff 5 (Human Resource Director) and Witness 1 (RN Consultant) on 01/23/26 at 02:20 pm. They acknowledged the findings.

1. Resident 1: On 2/18/26, Service Plan was updated to provide direction and reflect use of quarter side rails, left heel skin condition update with instructions for the use of bi-lateral heel protectors. Service Plan placed in Service Plan Binder. Resident 8: Service Plan was completed on 12/26/25. On 2/18/26, Service Plan was added to the Service Plan Binder. Resident 3: RN Assessment with Service Plan was updated 2/16/26, to reflect personal hygiene, bathing preferences, dressing and anti-coagulants. Service plan added to Service Plan Binder. Resident 5: Service Plan was already updated 11/4/25 with instructions for eating, transferring, mobility, ability to use key, cueing and increased safety checks status, and emergency evacuation status. Service Plan was placed in Service Plan binder on 2/11/26 for staff access to receive instructions on care to follow. Resident 2: Service Plan was updated and printed 2/18/26, to include Seizure Activity and how staff should respond;, full assistance with meals, pain evaluation to include location and how pain is exhibited, preferences for waking up, eye protection needed when showering; the recliner has been removed. Additional care instructions were documented on TSP completd 2/18/2026. On 2/18/26, Service Plan was updated to reflect use of quarter side rails, left heel skin condition update with instructions for the use of bilateral heel protectors. Service Plan placed in Service Plan Binder. 2. To ensure service plans are reflective of current care needs and clear instructions on providing required care, during the service planning process the Program Director will include caregivers and family, when applicable. All current Service Plans for Residents in Assisted Living and Memory Care were reviewed to verify that care needs/procedures are reflected and instructions on delivery of services are incorporated. All Service Plans are located in the Service Plan Binders in the chart rooms of each care area. Nurse, Program Director, or designee will place Service Plans in the binder upon updating .and notify care associates of changes and updates to the resident service plan 3. Updated Service Plans will be printed and placed immediately in the Service Plan Binders in Assisted Living and Memory Care Chart Rooms location readily available to staff by Program Directors or designee. The facility will conduct weekly audits to monitor that all Service Plans are present in Service Plan Binders for the next three months and then monthly thereafter. 4. The Program Director, or designee, will monitor for ongoing compliance by completing weekly audits of completed Service Plans that care needs/procedures are documented with instructions on delivery of services as identified in the evaluation.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. 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 observation, interview, and record review, it was determined the facility failed to determine, document, and communicate to staff what actions or interventions were needed for a resident following a short term change of condition and monitor the resident with weekly progress noted until resolved, for 3 of 6 sampled residents (#s 2, 3, and 8) with short term changes of condition requiring monitoring. Findings include, but are not limited to: 1. Resident 3 was admitted to the assisted living facility in 08/2025 with diagnoses including heart failure and long-term use of anticoagulants. The resident’s clinical record from 09/30/25 to 01/19/26 was reviewed and indicated the resident experienced multiple changes in condition. The following was identified: * On 10/20/25, the resident had changes to his/her medications including an increased dose of Lasix (diuretic) and potassium (supplement). There was no documented evidence staff were provided monitoring instructions for medication changes, and the changes had been monitored through resolution. * On 11/28/25, the resident had an injury fall. The progress note documented “now a skin tear and bruise on [his/her] left forearm.” There was no documented evidence staff were provided monitoring instructions for the injury, and the changes had been monitored at least weekly through resolution. * On 12/12/25, the resident had an injury fall. The progress note documented “bleeding from the back of [his/her] head.” There was no documented evidence staff were provided monitoring instructions for the injury from the fall, and the changes had been monitored at least weekly through resolution. * On 12/12/25, the resident had changes to his/her medications including an increased dose of torsemide (diuretic) and decreased blood pressure medication. There was no documented evidence the resident’s condition was monitored at least weekly through resolution, including monitoring for effectiveness or side effects of the medications. * 12/18/25, staff documented the resident had a bruise on the left leg. The resident was also prescribed a blood thinner medication twice a day. The facility initiated a temporary service plan on 12/18/25 to monitor for the changes in medication and skin injury. However, the facility failed to document monitoring of those conditions at least weekly through resolution. * 01/12/26, the facility initiated a temporary service plan on 01/12/26 to monitor changes in the resident’s medications, including an increased dose of torsemide (diuretic). There was no documented evidence the resident’s condition was monitored at least weekly through resolution, including monitoring for effectiveness or side effects of the medications. In an interview on 01/23/26 at 5:02 pm, Witness 1 (RN consultant) confirmed there was no documented evidence the facility provided monitoring instructions to staff regarding the changes in the resident’s condition, including changes noted on 10/20/25, 11/28/25 and 12/12/25. The need to ensure the facility monitored residents consistent with evaluated needs and service plan and documented weekly progress in the resident’s record until the condition resolved was discussed with Staff 1 (Associated ED), Staff 2 (Interim ED), Staff 4 (Resident Care Director/RN) and Witness 1 (RN Consultant) on 01/23/26 at 12:10 pm. They acknowledged the findings. 2. Resident 8 was admitted to the MCC facility in 03/2025 with diagnoses including type 2 diabetes mellitus. Resident 8’s clinical record from 10/10/25 through 01/20/26 was reviewed and revealed the following short-term changes of condition: * On 10/29/25, the resident cut his/her Aspira abdominal drain with a pair of scissors. There was no documented evidence the condition was monitored for maintenance of a clean dressing over the drain site and not storing sharp objects in the room through resolution. * On 10/31/25, the abdominal drain was replaced. There was no documented evidence the condition was monitored for pain, redness, and other signs and symptoms of infection through resolution. * On 11/16/25, the resident had a physical altercation with another resident. There was no documented evidence the condition was monitored through resolution. * On 11/27/25, the resident experienced uncontrolled abdominal pain with nausea and vomiting. There was no documented evidence resident-specific interventions were determined and communicated to staff or the condition was monitored at least weekly to resolution. * On 01/20/26, the resident had a verbal altercation with another resident. There was no documented evidence resident-specific interventions were determined and communicated to staff or instructions on what to monitor, such as signs of distress or irritation. During an interview on 01/23/26 at 3:20 pm, Witness 1 (RN Consultant) confirmed the lack of documented evidence staff were provided monitoring instructions and the resident had been monitored through resolution for the short-term changes of condition. The need to ensure the facility determined, documented, and communicated to staff what actions or interventions were needed for a resident following a short term change of condition, and monitored the resident with weekly progress noted until resolution was reviewed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 5 (Human Resources Director), and Witness 1 on 01/23/26 at 3:20 pm. They acknowledged the findings. 3. Resident 2 was admitted to the MCC facility in 12/2024 with diagnoses including dementia. The resident’s clinical record from 10/11/25 to 01/17/26 was reviewed and revealed the following: * 11/16/26: Staff created a TSP (Temporary Service Plan) for a fall. The progress notes indicated s/he had “redness and skin lacerations on back” as a result of the fall. There was no documented evidence staff had been provided monitoring instructions for the skin condition or had been monitored through resolution; * 12/03/25: Resident 2 had a seizure, was sent to the emergency department and returned the same day. The facility failed to monitor the condition through resolution; and * 12/18/25: Staff documented a resident-to-resident altercation with no documented evidence the resident behaviors were monitored through resolution. During an interview on 01/23/26 at 2:20 pm, Witness 1 (RN Consultant) confirmed the lack of documented evidence staff were provided monitoring instructions and the resident had been monitored through resolution for the short-term changes of condition. The need to ensure the facility monitored residents consistent with evaluated needs and service plan and documented weekly progress in the resident’s record until the condition resolved was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 5 (Human Resource Director) and Witness 1 (RN Consultant) on 01/23/26 at 02:20 pm. They acknowledged the findings.

1. Resident 3: Last Torsemide medication order change occurred on 2/10/26. The community updated the TSP and actions and/or interventions were communicated to staff. Resident's last fall was on 1/3/26. TSP for this date of fall was completed by the community nurse on 1/3/26. Status of resident's progress will be documented in resident medical record. Resident 8: On 2/18/26, Service Plan was updated to reflect the care and monitoring of abdominal drain to include Hospice Services that support the care, treatment of abdominal drain and provide updated progress notes. Service Plan and TSP address reporting pain, redness and other signs of infection around the drainage tube. Resident's IR Report of 1/20/26, was last documented verbal altercation. TSP was completed 1/20/26 providing documented interventions Resident 2: Experienced fall on 11/16/25. had a change of skin condition post-fall. On 2/13/26, a skin evaluation was completed. TSP and Service Plan were updated to reflect healed status, which was communicated to staff. Resident also has a history of seizure disorder, condition was updated in a TSP and Service Plan on 2/18/26, to provide post-seizure activity. The resident's last seizure episode was 12/4/25. 2. RN, Program Director or designee will review all residents for change of condition and update TSPs and Service Plans as appropriate. 3. RN, Program Director, or designee will monitor through participation in daily 24 hour change of shift meetings, report of documented changes of condition, medication evaluations, and medical events. 4. RN, Program Director or designee will monitor for ongoing compliance.

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 for 1 of 2 sampled residents (# 3) who experienced a significant weight gain. Findings include, but are not limited to: Resident 3 was admitted to the assisted living facility in 08/2025 with diagnoses including heart failure, dementia and chronic kidney disease. The resident’s clinical record from 09/30/25 to 01/19/26 was reviewed and revealed the following: Resident 3’s weight record was reviewed during the survey and revealed the following: * 09/12/25 – 156.9 pounds; * 10/12/25 – 168.4 pounds; and * 01/11/26 – 176.8 pounds. Review of the weight record indicated Resident 3 experienced a gain of 11.5 pounds, or 7.3 % of his/her body weight, between 09/12/25 and 10/12/25. This represented a significant change of condition for which an RN assessment of the weight gain was required. There was no documented evidence a facility RN completed an assessment which included findings, a description of the resident’s status and interventions made as a result of the assessment. In an interview on 01/23/26 at 5:02 pm, Witness 1 (RN consultant) confirmed that there was no RN assessment of the resident’s significant weight gain. The need to ensure an RN assessment was completed for the resident who experienced significant weight changes was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 4 (Resident Care Director/RN) and Witness 1 on 01/23/26 at 12:10 pm. They acknowledged the findings.

1. Resident #3- RN assessment and updated Service Plan was completed 2/16/2026 to include findings, resident status and interventions. Resident orders were updated in coordination with the provider and responsible party as a result of the completed assessment. On 2/16/26, the TSP and Service Plan were updated to reflect weights per provider instructions. The resdient will be monitored per provider orders and for weight changes of 5% weight gain or loss in 1 month, 7.5% weight gain or loss in a 3-month period and 10% weight gain or loss in a 6-month period. 2.All other residents have been reviewed for significant weight changes as per the criteria; 1 month = 5% wt gain or loss, 3 month = 7.5% wt gain or loss, and 6 months = 10% wt gain or loss. RN assessment of residents with significant weight changes for 2/2026 (were completed by 2/19/2026).To prevent recurrence of the violation, a process has been initiated for compliance with monthly weight capture and documentation into the EHR by the med tech, for review by the RN monthly or as required as per provider orders. The RN will run a report from the electronic health record to identify residents with significant weight loss or gain to promptly follow up with an assessment. The RN assessment will include the findings, the resident status and interventions initiated to address significant weight changes for 1 month, 3 month and 6 month periods. Education was initiated on 2/10/2026 to Med Techs and Caregivers on changes of conditions, including weight changes. 3. The Nurse, Program Director, or designee will monitor the entry of resident weights in the electronic health record during the first week of every month. During the second week of each month, the RN will review all recorded weights for any significant weight changes. Residents with provider orders for daily or weekly weight monitoring will be reviewed more frequently, as indicated. 4. 1. The Administrator will be responsible for the ongoing implementation and sustainability of the weight monitoring process by verifying that monthly weight entries are documented in the Electronic Health Record (EHR). The Administrator will also review the Registered Nurse’s monthly report and any associated follow up documentation during scheduled monthly Quality Assurance meetings.

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 411-054-0045 (1)(f)(B) RN Delegation and Teaching (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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (# 7) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to: Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant to OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. Resident 7 was admitted to the assisted living facility in 10/2024 with diagnoses including dementia and type 2 diabetes. During the acuity interview on 01/20/26, Resident 7 was identified to be administered insulin via injection multiple times daily by a facility UAP. Resident 7's MARs from 09/01/25 through 10/31/25 and 12/01/25 through 01/23/26 revealed insulin injections had been given by Staff 8 (MT/CG), Staff 9 (MT/CG), Staff 22 (MT/CG), and Staff 23 (MT/CG). Staff 23 was no longer employed at the facility. Review of the nursing delegation binder and the MAR revealed the following: * There was no documented evidence the initial nursing delegation was completed for Staff 22 and 23; * The initial nursing delegation for Staff 8 was dated 09/17/25. However, the MAR showed Staff 8 signed as having administered insulin to the resident on 09/11/25, 09/14/25, 09/15/25 and 09/16/25, which occurred prior to completion of the initial delegation; * The initial nursing delegation for Staff 9 was dated 10/17/25. However, the MAR showed Staff 9 signed as having administered insulin to the resident on 09/30/25, which occurred prior to completion of the initial delegation; and * The initial delegation for Staff 8 and 9 lacked documentation of the skills and abilities of each UAP, and did not include documentation of the rationale for deciding the task could be safely delegated to the UAP or whether the RN had previously authorized the same UAP to perform the same procedure or for how long the RN had worked with the UAP. The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by an RN in accordance with the OARs adopted by the OSBN in chapter 851, Division 047 was reviewed with Staff 4 (Resident Care Director/RN) on 01/23/26 at 5:40 pm. She acknowledged the findings. No further information was provided.

1. Resident 7: Delegating RN has completed education and training with to Staff 8, Staff 9, Staff 22 and all additional Med Techs for Insulin administration and accuchecks, on 2/13/26. Delegating Nurse completed all necessary components following a tracking log and Delegation Review Form to verify initial delegation was completed prior to insuin administration, first re-evluation within 60 days, subsequent evaluation up to 180 days and if there were any changes of condition requiring a new assessment. 2. All other residents with Insulin administration have been identified. Nurse Delegator was inserviced by Nurse Consultant/Nurse Delegator with Leaderstat on 2/13/2026 on delgation requirements and to follow all delegation requirements timely as listed under Section 1 above. Med Tech education was completed as of 2/13/26 following a tracking log and Delegation Forms for timeliness. Only Med Techs who have completed the required education and training will be permitted to administer insulin, including new hires. The onboarding process has been updated to include a scheduled training plan for new hires, to include when the RN education and delegation of tasks will occur to for timeliness and completion prior to delivery of delegated services. 3. Nurse Delegator will review delegation and supervision monitoring logs and and Delegation Review Forms and all new Med Tech hires will receive education on Insulin Administration and accucheck testing prior to medication administration. Education documentation will include skills, abilities and length of time RN Delegator has worked with Med Tech (UAP). Nurse Delegator will conduct ongoing audits of the supervision monitoring log, Delegation Review Forms and training needs weekly for the next three months. 4. Nurse Delegator will monitor for ongoing compliance.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by:

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers and failed to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care for 1 of 2 sampled residents (#4) who received home health services. Findings include, but are not limited to: Resident 4 was admitted to the assisted living facility in 02/2025 with diagnoses including Parkinsonism, Alzheimer’s disease, osteoporosis, and anxiety disorder. The resident’s clinical record, reviewed from 10/27/25 to 01/20/26, indicated the following: * Resident 4 returned to the facility on 12/09/25 following surgery and skilled rehabilitation for a hip fracture; and * Resident 4 was receiving PT and OT services in the facility. This was noted in the resident’s 12/09/25 service plan and confirmed in an interview on 01/22/26 with Witness 2 (Family). There was no documented evidence the outside service provider had left written information about the progress of the resident’s on-site services, including any clinical information necessary for facility staff to provide supplemental care. The need to coordinate on-site health services with outside service providers and ensure outside service providers left written information in the facility regarding the resident’s progress was reviewed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 4 (Resident Care Director/RN), and Staff 5 (Human Resources Director) on 01/23/26 at 12:36 pm. Staff 4 acknowledged the outside provider had not provided the facility with any written reports of Resident 4’s therapy and progress.

Michael Farrell1. Resident 4: Hospice Services were initiated and resident's Service Plan was updated indicating coordination of care with Hospice Provider on 2/12/26. Hospice provided updated orders and progress notes 2/13/26. 2. Facility will identify all residents receiving third party services through medical record review by RN, Program Director, or designee. All residents receiving third party services will have their Service Plan updated. 3. Third party providers will be educated that progress notes are required to be completed after services are rendered and prior to leaving Facility. Progress notes are to be left with the Program Director in-person or designated mailbox. The facility will conduct a weekly audit of third party Progress Notes for residents receiving services for the next three months. 4. The Nurse, Program Director or designee will monitor for ongoing compliance.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to: During the re-licensure survey, conducted 01/20/26 through 01/23/26, professional oversight of the facility's medication and treatment administration system was found to be ineffective based on deficiencies in the following areas: * C282: RN Delegation and Teaching; and * C302: Systems: Tracking Controlled Substances. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication and treatment administration was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 5 (Human Resources Director), and Witness 1 (RN Consultant) on 01/23/26 at 3:20 pm. They acknowledged the findings.

Please refer to citation 282 for plan of correction.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 3 and 8) whose MARs and Controlled Substance Disposition Logs were reviewed for accuracy. Findings include, but are not limited to: 1. Resident 8 was admitted to the MCC facility in 03/2025 with diagnoses including type 2 diabetes mellitus. The resident’s MAR dated 01/01/26 through 01/20/26, the Controlled Substance Disposition Log from 12/24/25 to 01/21/26, and physician orders were reviewed. The following was identified: Resident 8 had an order for oxycodone HCl, 2 tablets every 4 hours as needed for moderate to severe pain or shortness of breath. * The 01/01/26 – 01/20/26 MAR indicated the medication had been administered on five occasions until the order changed to “Pending Confirmation (D/C as of Jan 09, 2026).” The last recorded administration on the MAR was on 01/07/26. * The Controlled Substance Disposition Log contained 14 entries from 01/09/26 through 01/20/26; none of these administrations were reflected on the MAR. * The number of pills remaining on the Controlled Substance Disposition Log matched the number of pills left in the oxycodone HCl card. * On 01/22/26 at 2:50 pm, Staff 8 (MT/CG) confirmed he/she had administered the medication and not signed it out on the MAR on nine occasions. * Inconsistencies between the Controlled Substance Disposition Log and the MAR were reviewed with Staff 3 (MCC Director) and Witness 1 (RN Consultant) on 01/22/26 at 11:30 am. They reviewed the documentation and acknowledged the discrepancy. The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3, Staff 5 (Human Resources Director), and Witness 1 on 01/23/26 at 3:20 pm. They acknowledged the findings. 2. Resident 3 was admitted to the assisted living facility in 08/2025 with diagnoses including osteoarthritis of right hip and encounter for palliative care. The resident’s MAR dated 01/01/26 through 01/20/26, the Controlled Substance Disposition Log on 01/17/26, and physician orders were reviewed. The following was identified: Resident 3’ MAR directed 1mg hydromorphone be administered every four hours as needed for pain. The Controlled Substance Disposition Log showed the resident received 1 mg hydromorphone on 01/17/26. There was no documented evidence on the MAR that the dispensed medication was administered to the resident. In an interview on 01/23/26 at 12:10 pm, Witness 1 (RN consultant) did not provide any further information. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (Associate ED), Staff 2 (Interim ED), and Witness 1 (RN Consultant) on 01/23/26 at 12:10 pm. They acknowledged the findings.

1. Resident 3 received Hydromorphone on 1/17/26, in review of the count of Hydromorphone doses administered the count matched the narcotic log book.A narcotic count was completed on 1/23/26 and the count accurately reflected the narcotic log for all narcotics. The MAR could not be updated to reflect previous administrations, but correct counts were verified. The phyisican was contacted on 1/23/26 and discontinued the order. 2. Med Tech in-services were initiated on 1/22/26 by RN, to include controlled substance order review, administration and documentation . Education included the correct process for administering narcotics and documenting the decline in narcotic count. Further controlled substance log counts were reviewed in both areas of Assisted Living and Memory Care on 1/23/26. All narcotic counts on log sheets were correct. Documentation of controlled substance counts will be maintained and updated daily by the Nurse and Med Techs. Any discrepancies will be immediately reported to the RN or Program Director for prompt investigation and resolution. 3. Program Director, or designee, will conduct ongoing weekly review of the Controlled Substance Logs to verify they match the Medication Administration Record for the next three months and, if in compliance, then monthly for the following three months. 4. RN, Program Director, or designee, will monitor for ongoing compliance.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by 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 the facility RN, a PT, or an OT conducted a thorough assessment of a device with restraining qualities, the use of the device was included in the resident service plan, and the facility instructed caregivers on the correct use and precautions related to the use of the device, for 3 of 4 sampled residents (#s 1, 2, and 4) with devices with restraining qualities. Findings include, but are not limited to: 1. Resident 4 was admitted to the assisted living facility in 02/2025 with diagnoses including Parkinsonism, Alzheimer’s disease, osteoporosis and anxiety disorder. a. During an interview with Resident 4 on 01/23/26 at 12:10 pm, bilateral half-length side rails were observed on the resident’s bed. They were in the up position, securely fastened to the bed and there were no gaps between the bed mattress and the rails. In an interview at that time, Witness 2 (Family) reported the resident used the side rails to hold onto during ADL care in the bed. The use of the side rails was not documented in the resident’s current service plan, which was last updated on 12/09/25. b. In an interview on 01/23/26 at 11:11 am, Staff 6 (MT/CG) reported he had not received training on the use of the side rails. He also acknowledged he was not aware of the risks and precautions associated with the side rail use. In an interview on 01/23/26 at 11:57 am, Staff 20 (CG) reported she remembered only being verbally told that Resident 4 recently got side rails and Staff 21 (MT/CG) stated she remembered a Temporary Service Plan (TSP) instructing staff to ensure the side rails were secure when providing routine checks during the day. A copy of the TSP was not located in Resident 4’s clinical record and was not provided by the facility when requested. The facility failed to instruct caregivers on the correct use and precautions related to use of the device. The need to ensure the use of side rails was documented in the resident’s service plan and caregivers were instructed on their use was reviewed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 4 (Resident Care Director/RN), and Staff 5 (Human Resources Director) on 01/23/26 at 12:36 pm. They acknowledged the findings. No further information was provided. 2. Resident 1 was admitted to the MCC facility in 01/2026 with diagnoses including multi-system degeneration of the autonomic nervous system (a progressive neurodegenerative disease) and unspecified dementia. In the acuity interview on 01/20/26, Resident 1 was identified as being bed bound, dependent on two care staff for ADLs and transfers, and utilizing side rails for bed mobility. The resident’s clinical record from 01/02/26 to 01/16/26 was reviewed, observations were made, and staff and witnesses were interviewed. The following was identified: Observations of incontinence care were made on 01/22/26 at 1:45 pm, and the resident was observed to have bilateral full-length side rails in the up position. There was no documented evidence a facility RN, a PT, or an OT completed a thorough assessment for the full-length side rails. The resident’s 01/02/26 service plan did not provide information to staff related to the full-length side rails, including how to use the device with the resident and safety/maintenance items to watch for. Witness 3 (Family) on 01/21/26 at 12:05 pm stated Resident 1 moved into the facility with the bed with the full-length side rails attached, and he/she had agreed to it as a device for assistance with bed mobility. On 01/23/26 at 3:15 pm, Staff 3 (MCC Director) and Witness 1 (RN Consultant) acknowledged no assessment for the full-length side rails had been completed, and Resident 1’s service plan lacked documentation of the use of supportive devices with restraining qualities. The need to ensure the facility RN, a PT, or an OT conducted a thorough assessment of a device with restraining qualities and the use of the device was included in the resident’s service plan was reviewed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3, Staff 5 (Human Resources Director), and Witness 1 on 01/23/26 at 3:20 pm. They acknowledged the findings. 3. Resident 2 was admitted to the MCC facility in 12/2024 with diagnoses including dementia. The resident’s clinical record from 10/11/25 to 01/17/26 was reviewed, observations of the resident were made, and staff were interviewed. The following was identified: The resident’s 12/26/25 evaluation indicated Resident 2 needed supervision assistance and cues when in the recliner. Observations of the resident identified s/he used two facility recliners in the common area, with staff assistance, and allowed staff to recline the resident at a variety of angles. Staff sometimes placed the chair controller on the resident’s lap but sometimes tucked it into the left side pocket of the recliner out of the resident’s reach. In this latter instance, the resident’s ability to move freely was limited. Interviews with staff on 01/21/26 and 01/22/26 indicated the resident could “sometimes” use the control to raise or lower the footrest of the chair but would “sometimes” get out of the chair when the footrest was still in the up position. The resident was interviewed during the survey, but due to his/her cognitive status, was unable to respond directly to questions about the use of the recliner. The resident required full assistance for all ADL care including assistance with transfers and ambulation. Review of the resident's record showed no documented assessment of the recliners by a facility RN, a PT, or an OT. The resident’s 05/21/25 service plan did not provide information to staff related to the recliner including how to use the device with the resident and safety/maintenance items to watch for. The need for a RN, PT or OT to complete an assessment of any device with restraining qualities was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 5 (Human Resource Director), and Witness 1 (RN Consultant) on 01/23/26 at 02:20 pm. They acknowledged the findings.

1. On 2/13/26, Resident 1 had full side rails removed and quarter rails were applied after an updated Supportive Device with Restraining Qualities Assessment was completed by the RN. A TSP providing staff with instructions for use of the quarter side rails and updated Service Plan was entered providing staff directions for use of device on 2/13/26. On 2/13/26, Resident 4 had a side rail assessment completed for application of bilateral half side rails. TSP and Service Plan for the use of side rails were updated on 2/13/26, providing staff with directions for use of the bilateral half side rails. The two recliners located in the common area of Memory Care were removed on 2/13/2026, of which one was utilized by Resident 1. 2. An audit was initiated on 2/13/26, to identify any other residents with side rails or any other supportive device with restraining qualities. A room to room check on both Assisted Living and Memory Care has been conducted to visualize side rails or any other supportive devices with restraining qualities. 3. Residents identified as having a restraint or supportive device will have a completed assessment at initiation of device or change in condition. TSP and Service Plans will be updated by the RN or Program Director accordingly to reflect the utilization of the devices and providing staff with directions for use of the devices. 4. RN or Program Director will conduct a weekly audit of restraint and supportive devices for the next three months to monitor for ongoing compliance.

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 411-054-0037 (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 observation, interview, and record review, it was determined the facility failed to ensure the use of an acuity-based staffing tool (ABST) to develop and routinely update the facility’s posted staffing plan and failed to ensure the posted staffing plan contained the date(s) it was effective. Findings include but are not limited to: The facility’s ABST was reviewed on 01/23/26 at 12:30 pm with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 4 (Resident Care Director/RN) and Witness 1 (RN Consultant). The following was identified: The ABST for the assisted living floors showed the facility needed to schedule five staff for day shift, five staff for evening shift and two staff for overnight shift. Review of the staffing schedule from 01/18/26 through 01/24/26 indicated the facility was scheduling staff as required. However, the posted staffing plan for the assisted living floors indicated the facility was staffing four staff for day shift, four staff for evening shift and two staff for the overnight shift. The posted staffing plan for the assisted living did not accurately reflect the ABST, and it did not include the date it became effective. The need to ensure the results of an ABST were used to develop and routinely update the facility’s posted staffing plan and the staffing plan contained an effective date was discussed with Staff 1, Staff 2, Staff 5 (Human Resources Director) and Witness 1 on 01/23/26 at 3:45pm. They acknowledged the findings.

1. The Facility posted staffing plans based on the ABST for Assisted Living and Memory Care Departments, including documentation of the effective date 2/19/26, were posted in each area of care accessible to residents and families. 2. The Administrator verified staffing levels were appropriate utilizing the ABST and staffing levels were posted on 2/13/26. 3. The Program Director, or designee, will conduct a weekly review of the ABST and staffing plan to verify that the facility captures correct changes and staffing levels based on resident acuity and service needs, ADLs and cognitive support, Medication administration needs and safety considerations. 4. The Administrator, Program Director, RN or designee, are responsible for monitoring for on-going compliance.

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 411-054-0070 (3-4) 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: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 11, 12, 13, and 14) completed all required pre-service orientation training and 3 of 3 newly-hired direct care staff (#s 11, 12, and 13) completed required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed on 01/23/26 at 9:05 am with Staff 5 (Human Resource Director), and the following was identified: a. There was no documented evidence Staff 11 (MT), Staff 12 (CG), Staff 13 (MT), or Staff 14 (Dining Services), hired 11/25/25, 11/11/25, 10/08/25 and 11/13/25, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Infectious disease prevention training; * Home and Community-Based Services training; and * LGBTQIA2S+ training. b. There was no documented evidence Staff 11, Staff 12 and Staff 13 had completed one or more of the following pre-service dementia care training topics prior to beginning their job responsibilities: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 5, and Witness 1 (RN Consultant) on 01/23/26 at 02:20 pm. They acknowledged the findings.

1. The Human Resources Director initiated trainings on 2/6/26 for compliance with OAR 411-054-0077 for all associates reviewed during the survey. 2. On 2/6/26, the Human Resources Director conducted an audit of Direct and Indirect care staff pre-hire training records in Relias LMS to identify which staff are out of compliance for pre-hire training. 3. The Human Resources Director has identified pre-service training requirements mandated by the State of Oregon. Trainings are to be completed for direct and indirect care staff prior to working. HR Director has listing of all active employees and records of completed and trainings requiring completion within Relias LMS to include LGBTQ HCBS trainings with documentation listed on an activie spreadsheet electronically. Relias LMS Training certificates and Oregon Care Partner Certificates will be printed and uploaded and maintained electronically. All new hires will be maintained and followed with same tracking method prior to working on floor. 4. The HR Director will monitor for ongoing compliance and will audit training records weekly for the next 30 days. Ongoing record review will continue for all new hires.

OAR 411-054-0070 (3-4) 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: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 11, 12, 13) demonstrated competency in all assigned job duties within 30 days of hire; and 3 of 3 newly-hired staff (#s 15, 16 and 17) lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 01/23/25 at 9:05 am with Staff 5 (Human Resource Director) and revealed the following: a. There was no documented evidence Staff 11 (MT), Staff 12 (CG), Staff 13 (MT), Staff 15 (MT), Staff 16 (CG), Staff 17 (CG), hired 11/25/25, 11/11/25, 10/08/25, 11/14/25, 12/18/25, and 10/28/25, respectively, completed first aid and abdominal thrust training within 30 days of hire. b. Staff 11, Staff 12 and Staff 13 lacked demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; * Conditions which require assessment, treatment, observation, and reporting; and * Other duties as applicable (med pass, treatments). The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 5, and Witness 1 (RN Consultant) on 01/23/26 at 02:20 pm. They acknowledged the findings.

1. The Human Resources Director initiated trainings on 2/6/26 for compliance with OAR 411-054-0077 for all associates reviewed during the survey. 2. On 2/6/26, the HR Director reviewed employee records to identify missing trainings that are required within 30 days of hire for direct and indirect care staff. Identified staff that were and were not in compliance. 3. The Human Resources Director has identified training requirements required by the State of Oregon within 30 days of employment for driect and nondirect care staff. HR Director has listing of all active employees and records of completed and trainings requiring completion within Relias LMS maintained on a electronic spreadsheet. Relias Training certificates will be printed and uploaded and maintained electronically. All new hires will be maintained and followed with same tracking method. 4. The HR Director will audit training records weekly for the next 30 days to monitor for ongoing compliance. Ongoing record review will continue for all new hires.

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

OAR 411-054-0090 (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 provide fire and life safety instruction to staff on alternate months and failed to keep a written fire drill record that included all required information. Findings include, but are not limited to: Fire and life safety records were reviewed with Staff 1 (Associate ED) on 01/22/26 at 3:00 pm. The following was identified: a. The 16-story building consisted of two floors of licensed assisted living (AL) apartments, 13 floors of independent living apartments and a separate memory care unit on the ground floor. Fire drill records from 07/2025 through 12/2025 indicated the facility conducted fire drills where the origin of the fire was sometimes on an independent living floor, and the AL and MCC residents were not always included in the drill. The facility was not specifically documenting the following information for the assisted living and MCC units: * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; and * Number of occupants evacuated. b. In an interview on 01/22/26 at 3:00 pm, Staff 1 reported the facility had not been providing fire and life safety instruction to staff every other month as required. The need to ensure fire and life safety instruction was provided to staff on alternate months and a written fire drill record was kept that included all required information was reviewed with Staff 1, Staff 2 (Interim ED), Staff 3 (MCC Director), and Staff 5 (Human Resources Director) on 01/23/26 at 12:36 pm. They acknowledged the findings.

1. Director of Plant Operations conducted a Fire Drill for Assisted Living on 1/30/26. Documentation of the drill was uploaded to TELs system on 1/30/26, including all state-required components. 2. AL/MC Residents will be documented in the drill form to identify who participated in the drills. During the Monthly All-Staff meeting, fire safety will be discussed bi-monthly. 3. The facility has created a cadence of calendar events, with visibility to only department directors for licensed floors through the course of a year. The facility will perform unannounced AL/MC specific Fire Drills to include residents and staff, on alternating months to satisfy the requirement. The alarm will be activated on these floors for full participation amongst the residents. Based on location of the fire, there will either be evacuation out of the building, partial evacuation to a stairwell, behind a fire door or in the apartment to shelter in-place. A more detailed list of who participated in the Facility and what level of care they are in will be captured along with a list of those who do not participate and if there is a plan in place on how to evacuate them during an actual fire event. Bi-Monthly staff training will be completed by making it a standing agenda item in our Monthly All-Staff meeting, as well as during monthly Safety Committee Meetings. The Director of Plant Operations will conduct this segment of training and will cover topics regarding evacuation routes, shelter in-place as well as the P.A.S.S. process for utilizing fire extinguishers. 4. The Director of Plant Operations, or designee, will monitor for compliance with Fire Drill requirements utilizing the TELS system that will specifically call out for Licensed floor fire drills on a bi-monthly cadence.

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 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: In an interview on 01/22/26 at 3:00 pm, Staff 1 (Associate ED) reported the facility had not provided annual re-instruction to residents on fire and life safety procedures. He said the facility was planning to provide this instruction sometime in the next couple of months. No documentation of annual re-instruction for residents could be located. The need to ensure the facility had a process for re-instructing residents, at least annually, in general safety procedures was reviewed with Staff 1, Staff 2 (Interim ED), Staff 3 (MCC Director), and Staff 5 (Human Resources Director) on 01/23/26 at 12:36 pm. They acknowledged the findings.

1. The facility will host an annual Fire, Life, Safety Training Seminar for the residents. Curriculum will be captured and documented in a power point that will be available for review as needed. A sign-up sheet will be present to capture those who attend. The annual meeting for existing residents will be scheduled in March 2026. 2. The Facility will reach out to all members in the Facility to attend and will publish the curriculum for those who are unable to attend. 3. The annual Fire, Life, Safety, seminar for residents will occur in March with a schedule reminder will be implemented into our TELs system for annual training. A second training memory care specific training will be provided in the memory care unit. Director of Plant Operations will send out the curriculm to those residents unable to attend or who prefer not to attend will be informed via the community's communication tool and the curriculum will be available at the concierge desk. 4. The Director of Plant Operations, or designee, will save the content presented and the attendance sheet in the TELs system to document ongoing annual compliance.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: On 01/21/26 at 9:30 am the interior of the facility was toured, and the following observations were made: 1. Assisted Living Second Floor: * Scratches, smudges, and/or gouges were observed on doors and jambs of resident rooms 202, 203, 205, 208, 210, 219, 226, 229, 230, and 238 and the door to the “Refuse and Recycling” room; * The handrail outside room 239 was scraped and gouged to bare wood; * Carpets were stained outside room 238 and outside the kitchen door; * Trash cans in the “Refuse and Recycle” room were uncovered, allowing unbagged garbage to spill onto the floor; and * The hallway from room 236 to room 240 had a pervasive urine odor throughout the survey period. 2. Assisted Living Second Floor Laundry Room: * The large trash can was uncovered and overflowing with unbagged trash including soiled incontinence briefs and used latex gloves; * The counter beside the washing machines and dryers was littered with multiple pairs of used latex gloves (at least nine pairs), empty glove boxes, a scale, a pair of sneakers, and various resident clothing and linen items; * An accumulation of dust, lint, and debris was observed behind washing machines and dryers; * Used latex gloves and various resident clothing items were observed in unlocked upper and lower cabinets; and * The room had a pervasive urine odor that did not dissipate during the survey. 3. Assisted Living Third Floor: * Scratches, smudges, and/or gouges were observed on doors and jambs of resident rooms 301, 305, 309, 314, 319, 333, 338, the office, the “Refuse and Recycling” room, and the laundry room; * Carpets were stained outside rooms 301, 305, 338, outside the stairwell door, and outside the public restrooms across from room 335; * Baseboards outside room 301 were scratched and gouged; * The wall in the elevator foyer had a long, horizontal scratch on it; * Trash cans in the “Refuse and Recycle” room were uncovered and unbagged food receptacles were spilling onto the floor; and * An accumulation of dust, lint, and debris was observed behind washing machines and dryers in the laundry room. 4. Memory Care: * Scratches, smudges, and/or gouges were observed on doors and jambs of resident rooms 103, 104, 105, 108, 110, 111, and 113, and the staff room across from room 104; * Scratches and gouges to bare wood were observed on the handrails outside of, and across from, room 101; * Baseboards in the dining room were scratched and scuffed; * The wall opposite the serving line in the dining room had a long, horizontal scratch/dent; and * A recliner in the common area across was stained and the footrest did not securely fold into the body of the chair when not in use. 5. There were two doors in the MCC that required staff fobs or a keypad code to access. The keypad for the door that exited to the street was not operating properly to allow exit. On 01/23/26 at 1:40 pm, the need to ensure all interior materials and surfaces were kept clean and in good repair was reviewed with Staff 1 (Associate ED), who acknowledged the findings.

1. The surfaces such as baseboards, door jams, door frames and hand rails will be touched up/ repainted on the second floor. This includes the recycle/refuse room, the hand rail by unit 229, door jams and door frames around 202, 203, 205, 208, 210, 219, 226. Carpets were extracted outside of 238 and the dining room kitchen to remove the stains on 2/2/26. Housekeeping and the Care Staff will utilize the lids at all times for the waste bins. Housekeeping empties the garbage daily and the expectation will be to add supplemental collections to the licensed floors due to heavy use beginning on 2/2/26. The pervasive odor coming from the laudry room was mitigated on 2/2/26 by flushing all the lines and drains that the laundry equipment feed into to alleviate the odors. The Laundry Room cleanliness has been addressed by housekeeping and maintenance. Housekeeping wipes down all the surfaces, sweeping and mopping the floors and removing the trash. Maintenance will monitor the dust debris behind the dryers and clean as necessary. All Refuse/Recycling rooms have had their lids returned and the exepctation has been communicated to staff to leave the lids in place to help with odor control. Third floor smudges, scratches and gouges outside units 305, 301, 309, 314, 319, 338 and recycle/refuse rooms and laundry room doors are being addressed by maintenance. The Carpet smudges outside 338, 301, 305, across the public bathrooms and stairwell are being addressed by maintenance. Door Jambs, doors, railing scuffs and Memory Care Dining Room will be repainted by maintenance. Director of Plant Operations will work on getting the malfunctioning keypad up and online. They will work with the local security vendor to troubleshoot the issue and get it reprogrammed. 2. The Director of Plant Operations will be conducting an audit of the common areas to evaluate for stains, gouges, odors and other evironmental items throughtout the community. 3. The Director of Plant Operations will be utilizing a facility rounds tool to do routine audits of the facility grounds to review that surfaces are to standard. The regular use of this tool will verify areas are routinely maintained and do not fall below standard. 4. The Director of Plant Operations will be responsible for monitoring for ongoing compliance.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. 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 5 of 8 newly hired assisted living and MCC staff (#s 12, 13, 14, 16 and 17) whose training records were reviewed. Findings include, but are not limited to: Refer to C370 and Z155.

Refer to Citation C370 and Z155 for plan of Correction

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(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 C 231, C 363, C 370, C 372, C 420, C 422, and C 513.

Please refer to plan of corrections for C231, C363, C370, C372, C420, C422 and C513.

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 4 of 4 newly-hired MCC staff (#s 15, 16, 17, and 18) completed all required pre-service orientation training, and 3 of 3 newly-hired direct care MCC staff (#s 15, 16, and 17) completed all required pre-service dementia training topics and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 01/23/25 at 9:05 am with Staff 5 (Human Resource Director) and revealed the following: a. There was no documented evidence Staff 15 (MT), Staff 16 (CG), Staff 17 (CG), and Staff 18 (Housekeeper), hired 11/14/25, 12/18/25, 10/28/25 and 08/13/25, respectively, had completed one or more of the following pre-service orientation topics before beginning any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious disease prevention; * HCBS training; and * LGBTQIA2S+ training. b. There was no documented evidence Staff 15, Staff 16 and Staff 17 completed one or more of the following pre-service dementia training topics: * 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; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. c. Staff 17 was missing additional pre-service dementia training topics: * 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; and * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment. d. There was no documented evidence Staff 18 completed the following pre-service dementia training topics: * 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; and * 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. e. There was no documented evidence Staff 15, Staff 16, and Staff 17 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; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Other duties, including medication pass and treatments. The need to ensure the required pre-service training was completed by staff prior to beginning job and staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 1 (Associate ED), Staff 2 (Interim ED), Staff 3 (MCC Director), Staff 5, and Witness 1 (RN Consultant) on 01/23/26 at 02:20 pm. They acknowledged the findings.

1. On 2/6/26, Human Resources Director reviewed training records for compliance with Memory Care staff training requirements for Dementia. 2. On 2/6/26, the HR Director identified missing trainings that are required for Dementia within 7 days for staff hired for Memory Care and within 30 days of hire for direct and indirect care staff. Staff were entered on an electronic spreadsheet for tracking and training is being scheduled for each identified staff. 3. The Human Resources Director has identified training requirements required by the State of Oregon within 7 days of employment for staff hired to work in Memory Care and within 30 days of hire for all other direct care and indirect care staff. HR Director has listing of all active employees and records of completed and trainings requiring completion within Relias LMS maintained on a electronic spreadsheet. Relias Training certificates will be printed and uploaded and maintained electronically. All new hires will be maintained and followed with same tracking method. The HR Director will audit training records weekly for the next 30 days to monitor ongoing compliance for completion of required training for staff hired in Memory Care and for all other direct and indirect care staff within 30 days of employment. 4. The HR Director will monitor for compliance for all new hires.

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 C 260, C 270, C 280, C 282, C 290, C 300, C 302, and C 340.

.Refer to plan of corrections for C260, C270, C280, C282, C290, C 300, C302, C340.

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: