OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to: Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control. Resident 1 was admitted to the MCC in 2013 with diagnoses including incontinence. On 03/10/26 at 9:20 am, the surveyor obtained permission and observed a CG provide ADL care to Resident 1. During the observation, the CG donned gloves, helped the resident onto the toilet, removed the resident’s soiled pants and placed them on the bathroom floor, and wiped urine from the resident’s perineum. Wearing the same soiled gloves, the CG touched the resident's clean clothing, clean incontinence brief, bathroom door handle, sink handles, key/lock to bins in bathroom, wheelchair handles, and a walkie-talkie. After care was completed, the CG removed the soiled gloves and walked to the common bathroom in the hallway to wash her hands. The need to ensure staff consistently used effective universal precautions was discussed with Staff 1 (Executive Director) and Staff 2 (MCC Administrator) on 03/11/26 at 11:00 am. They acknowledged appropriate infection control practices were not implemented.

1. All direct care staff will be assigned an online Oregon Care Partners class on infection control and prevention with a 4.30.2026 due date. An in-person training will be conducted and documented with all direct care staff regarding proper infection control, PPE use and general sanitation protocols when providing personal care to residents. 2. MCA will conduct regular observations of direct care staff including Care Partners and Med Techs to ensure that proper infection prevention protocol and PPE use is being followed. Additional 1:1 training will be provided to direct care staff by MCA as necessary if any deficiencies are noted. 3. MCA will conduct and record obervation of 2 direct care staff including 1 Care Partner and 1 Med Tech on a monthly basis. Results will be discussed during monthly QA meeting with Community Administrator and MCA present. 4. MCA will be responsible for monitoring infection control and ensuring that additional training is provided as needed with assistance from Community Administrator.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. 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 the environment was kept in good repair. Findings include, but are not limited to: Observations of the facility on 03/09/26 and 03/10/26 revealed the following: * Rooms 3, 5, 6, 7, and 10 had scraped doors and/or jambs; * The common bathroom, located near the television room, had several scrapes to the door jamb. The wall adjacent to the toilet had several small holes near the toilet paper holder; * The kitchenette had peeling paint above the sink. The laminate backsplash was coming apart from the wall; and * Room 5 had gouged wall corners near both closets. The bathroom had a scraped door and jamb, discolored caulking and flooring surrounding the toilet, gouged paint and missing drywall near the shower and sink, and cove base coming apart from the wall in several places. The surveyor toured the environment with Staff 1 (Executive Director), Staff 2 (MCC Administrator), Staff 3 (Memory Care Coordinator), and Staff 4 (Maintenance) on 03/11/26 at 10:00 am. They acknowledged the above areas needed to be repaired.

1. With a due date of 4.30.2026, Apartment doors # 3, 5, 6, 7, and 10 will be re-painted. New toilet paper holder will be purchased for common area bathroom and holes will be patched. Damage to Apartment #5 and bathroom including gouged wall, missing drywall by shower, peeling cove base, and discolored caulk will be repaired. Backsplash in Dining area will be repaired. 2. Condition of doorjambs, common areas, apartments etc. will be monitored during regular walk-throughs with Maintenance Director and Community Administrator to evaluate ongoing condition of physical environment. Work orders will be entered by Community Administrator detailing any new damage or issues that need repair. 3. Monthly walk-throughs will be completed to ensure all areas of the community are in good repair. Results will be presented monthly at QA meetings, with issues being addressed through the work-order process as they arise. 4. Maintenance director will monitor and Campus Administrator will ensure completion.

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 411-057-0140(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 C160 and C513.

Please see each related POC regarding noted violations: (C160 & 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 2 of 4 newly hired caregiving staff (#s 6 and 7) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records, reviewed on 03/10/26, revealed the following: a. Staff 6 (MT/Care Partner) was hired on 09/25/25. There was no documented evidence Staff 6 demonstrated competency in job duties within 30 days of hire and prior to working independently in the following areas: * Providing assistance with ADLs; and * Medication Administration. The surveyor informed Staff 2 (MCC Administrator) that Staff 6 could not administer medications until documented training was completed. She acknowledged and stated documented medication training would be completed for Staff 6 before she administered medications. b. Staff 7 was hired on 01/29/26. There was no documented evidence Staff 7 demonstrated competency in job duties within 30 days of hire and prior to working independently in the following areas: * Providing assistance with ADLs. The need to ensure newly hired staff completed required trainings within 30 days of hire was reviewed with Staff 1 (Executive Director) and Staff 2 on 03/11/26 at 11:00 am. They acknowledged the findings. ?

1. Demonstrated competency evaluation and checklist has been completed with identified staff. Full audit to be conducted by 04.15.26 to identify any missing demonstrated competency evaluations. Competency evaluations to be completed with staff no later than 04.30.2026. 2. System correction moving forward: CPs will not be placed on the floor independently until competency evaluation and checklist is completed. 3. Training system will be evaluated monthly at 1:1 meetings between MCA and Community Administrator. Tracking of checklist to completed by the community's MCA. 4. Community Administrator and MCA to be responsible for ensuring that team members do not work independently without required training checklist. MCA will be responsible to track competency checklist completion, pre-service and annual training.

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: