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, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 3 of 4 sampled residents (#s 4, 7, and 8) and multiple unsampled residents who required modified diets. The facility’s failure to provide modified diet textures placed residents at risk of aspiration, choking, and/or death. Findings include, but are not limited to: During the acuity interview on 09/21/26 at 9:43 am, staff identified twelve residents who required mechanical soft diet textures. A thirteenth resident with orders for mechanical soft diet was identified once the sample was selected. Three of these residents required full feeding assistance. Also identified during the acuity interview were two residents who had orders for pureed diet textures. Once the sample was selected, a third resident was identified with pureed diet orders. One of these residents required full feeding assistance. 1. Resident 4 was admitted to the MCC in 05/2022 with diagnoses including Alzheimer’s disease, abnormal weight loss, and dysphagia (difficulty swallowing). During the acuity interview on 09/21/26 at 9:43 am, the resident was identified as requiring finger foods. Resident 4’s 06/21/26 – 09/21/26 clinical record was reviewed and the following was identified: A signed physician’s order dated 07/02/26 indicated the resident’s diet was “mechanical soft texture, thin consistency, add gravy as tolerated.” According to the National Dysphagia Diet (NDD), mechanical soft diet consists of foods that are modified by chopping, grinding, blending, or pureeing so they require less chewing effort. Food should be cut into pieces no larger than 1.25 cm by 1.25 cm. During a lunch observation on 09/21/26 at 1:00 pm, Resident 4 was served the following food items: * Grilled cheese sandwich with crusts on the bread, cut into 1.5 cm to 2.0 cm pieces; * Diced steamed carrots; and * Half of a peeled banana. The grilled cheese sandwich pieces were not moistened with sauce or gravy, and the banana was not cut into 1.25 cm pieces as per the prescribed diet order. Resident 4 ate 100% of the meal with his/her hands, ignoring the provided silverware. On 09/21/26 at 1:20 pm, Staff 12 (Personal Care Assistant: PCA) stated food was sent from the kitchen in separate pans for regular diet, mechanical soft diet, and pureed diet textures. The PCA then referred to a list posted on the inside of the kitchenette cabinet door to determine which diet was served to each resident. For lunch on 09/21/26, the regular diet pan contained whole grilled cheese sandwiches. The mechanical soft diet pan contained 1.5 cm to 2.0 cm pieces of grilled cheese sandwiches with crusts on the bread; the sandwich pieces were not moistened, nor was gravy or any other moistening agent sent up from the kitchen to pour onto the food items. Staff 12 confirmed she had not received any training on preparation of mechanical soft diet textures. On 09/21/26 at 1:15 pm, Staff 8 (Dietary Services Manager) stated she had not had any training in preparation of mechanical soft diet textures and had been requesting instruction since her date of hire approximately three months ago. The facility failed to ensure Resident 4 received the prescribed mechanical soft diet order and failed to ensure staff had been trained on the preparation of the prescribed diet texture, which placed the resident at risk for choking, aspiration, and/or death. An immediate plan of correction was requested from Staff 1 (Interim ED) on 09/21/26 at 3:30 pm. The plan of correction was received and accepted by the survey team on 09/21/26 at 5:07 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1, Staff 2 (Regional Nurse/ Health Services Director), Staff 3 (Regional Director of Operations), Witness 5 (LPN/ Health Services Director), and Staff 24 (Senior ED) on 09/21/26 at 3:30 pm. They acknowledged the findings. 2. Resident 8 was admitted to the MCC in 06/2023 with diagnoses including Alzheimer’s dementia and dysphagia (difficulty swallowing). The resident was identified in the acuity interview on 09/21/26 at 9:43 am as requiring mechanical soft diet texture and full feeding assistance. The resident’s signed physician orders, dated 05/05/26, indicated the resident required a “mechanical soft (IDDSI level SB6/ soft and bite-sized)” diet and had aspiration precautions. According to the International Dysphagia Diet Standardization Initiative (IDDSI), Level 6 food should be soft, tender, and moist throughout, with pieces no larger than 1.5 cm by 1.5 cm. Food should be easily mashed with a fork. During a lunch observation on 09/21/26 at 1:00 pm, Resident 8 was served the following food items: * Grilled cheese sandwich with crusts on the bread, cut into 1.5 cm to 2.0 cm pieces; * Diced steamed carrots; and * A bowl of lentil soup. The grilled cheese sandwich pieces were not moistened with sauce or gravy and were not cut to the appropriate size as per the prescribed diet order. The resident’s spouse assisted with feeding him/her 75% of the soup, 100% of the carrots, and 50% of the sandwich. On 09/21/26 at 1:20 pm, Staff 12 (Personal Care Assistant: PCA) shared how food was delivered from the kitchen for residents: separate pans were sent from the kitchen for regular diet, mechanical soft diet, and pureed diet. The PCA then referred to a list posted on the inside of the kitchenette cabinet door to determine which diet was served to each resident. For lunch on 09/21/26, the regular diet pan contained whole grilled cheese sandwiches. The mechanical soft pan contained 1.5 cm to 2.0 cm pieces of grilled cheese sandwiches, crusts still on the bread; the sandwich pieces were not moistened, nor was gravy or any other moistening agent sent up from the kitchen for the mechanical soft option. Staff 12 confirmed she had not received any training on preparation of IDDSI Level 6 diet textures. On 09/21/26 at 1:15 pm, Staff 8 (Dietary Services Manager) stated she had not had any training in preparation of the IDDSI Level 6 diet texture and had been requesting instruction on altered diet textures since her date of hire approximately three months ago. The facility failed to ensure Resident 8 received the prescribed mechanical soft diet order and failed to ensure staff had been trained on the preparation of the prescribed diet texture, which placed the resident at risk for choking, aspiration, and/or death. An immediate plan of correction was requested from Staff 1 (Interim ED) on 09/21/26 at 3:30 pm. The plan of correction was received and accepted by the survey team on 09/21/26 at 5:07 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1, Staff 2 (Regional Nurse/ Health Services Director), Staff 3 (Regional Director of Operations), Witness 5 (LPN/ Health Services Director), and Staff 24 (Senior ED) on 09/21/26 at 3:30 pm. They acknowledged the findings. 3. Resident 7 was admitted to the MCC in 03/2025 with diagnoses including moderate vascular dementia with anxiety and dysphagia (difficulty swallowing). The resident was identified in the acuity interview on 09/21/26 at 9:43 am as requiring a mechanical soft diet texture and nectar thickened liquid. The resident’s signed physician orders, dated 05/05/26, indicated the resident required a “mechanical soft (IDDSI level SB6/ soft and bite-sized)” diet, “Nectar liquids (mildly thick)” and had aspiration precautions. According to the International Dysphagia Diet Standardization Initiative (IDDSI), Level 6 food should be soft, tender, and moist throughout, with pieces no larger than 1.5 cm by 1.5 cm. Food should be easily mashed with a fork. During a lunch observation on 09/21/26 between 12:43 pm and 1:05 pm, Resident 7 was served the following food items: * Chopped grilled cheese sandwich, crusts on the bread, cut into 1.5 cm to 2.0 cm pieces; * Diced, cooked carrots; and * A bowl of lentil soup. The chopped grilled cheese sandwich pieces were not moistened with gravy, sauce, or other topping and were not cut to the appropriate size as per the prescribed diet order. Staff 14 (MT) confirmed Resident 7 was on a mechanical soft diet, and the chopped grilled cheese sandwich was prepared for the resident. The resident was able to eat independently and consumed 100% of the meal. The facility failed to ensure Resident 7 received the prescribed mechanical soft diet order and failed to ensure staff had been trained on the preparation of the prescribed diet texture, which placed the resident at risk for choking, aspiration, and/or death. An immediate plan of correction was requested from Staff 1 (Interim ED) on 09/21/26 at 3:30 pm. The plan of correction was received and accepted by the survey team on 09/21/26 at 5:07 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1, Staff 2 (Regional Nurse/ Health Services Director), Staff 3 (Regional Director of Operations), Witness 5 (LPN/ Health Services Director), and Staff 24 (Senior ED) on 09/21/26 at 3:30 pm. The staff acknowledged the findings.

• • Immediate POC was given to State on 9/21/2026 • The Regional Nurse or designee conducted a comprehensive review of the records for Residents #4, #7, and #8, addressing concerns identified, including ensuring appropriate physician communication and follow-up. • The HSD or Designee identified and reviewed current residents requiring modified diets and/or thickened liquids, addressing concerns identified. • As per Conditions, State Approved Consultant retained on 9/27/2026 and assisting onsite with review of systems. • As per Conditions, Registered Dietician retained and assisting onsite with review of modified diets, meal service processes, and implementation of corrective actions. • The Meal Service Process for modified diets was reviewed by leadership team, State Approved Consultant and Registered Dietician, a revised Meal Service Plan was developed. Diet orders were reviewed across EHR system and Menu system to ensure aligned to NDD Food Textures. • ED or Designee re-educated DSM, Dietary Staff, HSD, RCC, Med Techs, PCAs, and Activities on Modified Diets and Meal Service Plan. Modified Diet training on National Dysphagia Diet (NDD) Food Textures Included; Levels, Definitions, Preparation and Appearance. • ED or Designee will review modified diet compliance via observation weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and record review, it was determined the facility failed to create an environment in which residents were treated with dignity and respect and received services in a manner that protected privacy and dignity for 1 of 5 sampled residents (# 9) and multiple unsampled residents. Findings include, but are not limited to: 1.During the survey on 09/21/26, between 12:07 pm and 1:05 pm, there were approximately 14 residents in the dining and common area. At approximately 12:43 pm, staff served lunch to the residents in the dining and common area. The lunch included a cup of lentil soup, grilled sandwich, and diced, cooked carrots. Most of the residents were provided metal silverware. Approximately four residents were provided plastic silverware, including spoons and forks. At 12:51 pm, when asked why plastic silverware was used for those residents, Staff 14 (MT) reported, “I know, we don’t have enough [silverware] today.” The need to ensure the residents received care with dignity and in a manner that supports a homelike environment was discussed with Staff 1 (Interim ED), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 2:45 pm. The staff acknowledged the findings. 2. During the survey on 09/22/26, between 9:17 am and 10:00 am, an unsampled resident was observed walking through the facility while approximately 10 residents were present in the common and dining area. The unsampled resident had a urine collection bag hanging from the side of the walker, which was visible and appeared to be full of urine. The urine collection bag was not covered. At approximately 9:30 am, the resident approached the surveyor and asked for help. The surveyor was able to determine the resident needed assistance with emptying the urinary collection bag. The surveyor asked Staff 13 (Personal Care Attendant) to assist the resident. On 09/24/26 at approximately 9:55 am, the same unsampled resident was observed walking around the facility with a urine collection bag hanging from the side of the walker. The urine collection bag was not covered, and urine was visibly present in the bag. Approximately seven residents were present in the common and dining area. One resident was observed finishing breakfast while another resident was just beginning breakfast. Staff were observed setting up breakfast for the residents. The need to ensure the residents received care with dignity and in a manner that supports a homelike environment was discussed with Staff 1 (Interim ED), Staff 3 (Regional Director of Operations) and Staff 24 (Senior ED) on 09/24/26 at 2:45 pm. The staff acknowledged the findings. 3. Resident 9 was admitted to the MCC in 06/2026 with diagnoses including Alzheimer's disease and type 2 diabetes mellitus. S/he was subsequently admitted to hospice services on 09/08/26 with admitting diagnoses of mixed Alzheimer’s and vascular dementia. Resident 9 resided in a shared double-occupancy room. Throughout the duration of the survey, the door to Resident 9’s room was observed to be open at all times. On 09/23/26 at 1:53 pm, Resident 9 was observed using the bathroom independently while the bathroom door was half-open. On 09/23/26 at 2:03 pm, Resident 9 was visited by Witness 2 (Family member) who stated, “I asked them [the facility] many times to keep the door closed. For privacy and to keep other residents away.” Witness 2 indicated other residents were seen in Resident’s 9 room on “numerous occasions.” On 09/21/26 at 12:47 pm, another sampled resident was observed wheeling him/herself into Resident 9’s room and going through Resident 9’s personal belongings on the tray table while Resident 9 was laying in bed with eyes closed. The resident remained in Resident 9’s room until 1:05 pm. The need to create an environment in which residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 3:26 pm. They acknowledged the findings.

• The Regional Nurse or Designee reviewed Resident #9’s interventions regarding the desire to keep their room door closed, updated and service plan accordingly, and addressed concerns identified. • HSD or Designee identified and reviewed current residents who expressed a desire to keep their room door closed, reviewed interventions, updated service plans as appropriate, and addressed concerns identified. • ED or Designee reviewed silverware inventory ordered appropriate quantity to ensure silverware was available. • HSD or Designee identified and reviewed residents requiring urine collection bags for dignity with regard to urine collection bags, addressing concerns identified with service plan updated. • ED or Designee conducted walk through of community for resident care with dignity that supports a homelike environment, addressing concerns identified. • ED or Designee re-educated HSD, RCC, Med Techs, PCAs, Activities on requirement to create an environment in which residents receive care & services in a manner that protect privacy and dignity; training included residents that prefer door closed & interventions in place, proper silverware not plastic utensils are used, and urine collection bags have covers. • ED or Designee re-educated Dietary Staff on the requirement to use proper silverware rather than plastic utensils to maintain a homelike dining environment. Training included promptly notifying the ED or HSD if silverware is unavailable. • ED or Designee will conduct care and service privacy & dignity audits via rounding, observation, and/or interviews with staff/residents/families for compliance weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible

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 residents’ service plans were reflective of current care needs and provided clear instruction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the MCC in 05/2022 with diagnoses including Alzheimer’s disease, abnormal weight loss, and dysphagia (difficulty swallowing). The resident was identified in the acuity interview on 09/21/26 at 9:43 am as requiring finger foods and having altercations with other residents. The resident’s 06/21/26 to 09/21/26 clinical record was reviewed, observations of the resident were made, and interviews with staff were conducted. Resident 4’s service plan, dated 06/24/26, did not provide clear instruction to staff in the following areas: * The resident’s preference to eat with her hands and how staff should ensure proper hand hygiene at mealtimes; * Behaviors related to taking food from nearby residents; and * Altercations with other residents as a result of wandering into their units and/or taking food from their plates. On 09/23/26 at 11:13 am, Staff 10 (Personal Care Attendant) stated Resident 4 had been involved in multiple altercations with other residents, primarily verbal, related to him/her taking food from their plates. Staff would try to redirect Resident 4 away from other residents and try to find a table s/he could sit by herself during meals. Multiple observations were made of Resident 4 eating with his/her hands, including diced chicken with gravy, creamed spinach, and steamed carrots. Staff were not observed providing the resident with hand hygiene prior to the meal or afterward. The need to ensure service plans were reflective of residents’ current care needs and provided clear instruction to staff regarding the delivery of services was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/ Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 4:11 pm. They acknowledged the findings. 2. Resident 3 was admitted to the MCC in 05/2026 with diagnoses including Alzheimer’s disease. The resident’s 06/23/26 to 09/22/26 clinical record was reviewed, interviews with the staff were conducted, and observations were made. The service plan, dated 09/02/26, was not reflective of the resident’s current care needs and did not provide clear instruction to staff in the following areas: * The level of assistance for toileting; * Bathing or showering; * Dressing and undressing status; * Grooming and personal hygiene; * Laundry; and * Eating preferences and eating habits. Multiple staff interviews indicated inconsistent information regarding the resident’s level of assistance required in various care areas, including toileting, showering, dressing, personal hygiene, and laundry. Some staff reported the resident required full physical assistance, set-up, or guidance while other staff indicated the resident was completely independent in those areas. On 09/21/26 between 1:35 pm and 2:00 pm, the resident was observed walking throughout the facility while carrying his/her lunch plate, eating with his/her hands and frequently approaching and talking with other residents and staff. The resident did not remain in any one location or position for more than a few minutes. The service plan indicated the resident required assistance in all of these areas. The service plan also indicated the resident was to eat meals in the dining room. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Service Director), Staff 3 (Regional Director of Operations), and Staff 6 (Resident Care Coordinator) on 09/23/26 at 1:42 pm. The staff acknowledged the findings.

• The Regional Nurse or designee reviewed Resident #3 and Resident #4 Service plan, addressing concerns identified. • In accordance with the Conditions, The HSD or Designee conducted a Service Plan Audit for current residents ensuring the service plan meets the current needs of each residents and provides clear instruction to staff regarding the delivery of services, addressing concerns identified. • The HSD or Designee reset Service Plan Process for staff sign-off and acknowledgement of service plan changes and SPAs. HSD or Designee will ensure all caregivers have read and signed each Resident’s service plan. • The Regional Nurse or Designee re-educated the HSD and RCCs on the requirement that Service plans are reflective of residents’ current care needs and provide clear instruction to staff regarding the delivery of services. • The HSD or Designee re-educated Med Techs and PCAs on the importance of service plans being reflective of residents' current care needs and provide clear instructions and steps they can take if something on the service plan is not reflective or clear. Training included process for staff sign-off and acknowledgement of service plan changes and SPAs. • HSD or Designee will conduct random audits on service plan via observation, record review, and/or staff/resident/family interview weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD is responsible.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts, with weekly progress noted until resolution, for 2 of 5 sampled residents (#s 3 and 4) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the MCC in 05/2026 with diagnoses including Alzheimer’s disease, major depressive disorder, and generalized anxiety disorder. The resident’s 06/23/26 to 09/22/26 clinical record was reviewed, and the following was identified: There was no documented evidence resident-specific actions or interventions had been determined, documented, and communicated to staff on all shifts and weekly progress noted until resolution for the following changes of condition: * 09/01/26 – Experienced a 7.27 % weight loss between 06/01/26 and 09/01/26; * 09/06/26 – The dosage of Seroquel (to treat major depressive disorder) reduction from twice a day to daily; * 09/13/26 – Discontinued Seroquel; * 09/19/26 – Started a new medication, brexpiprazole (to treat mental health condition); and * 09/19/26 – Re-started Seroquel twice daily. On 09/23/26 between 1:42 pm and 2:15 pm, Staff 2 (Regional Nurse/Health Service Director/LPN) and Staff 3 (Regional Director of Operations) reported they identified several system breakdowns, including the clinical oversight where the facility did not consistently implement the established system and procedure. The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift for all short-term changes of condition and that changes were monitored, with weekly progress noted through resolution, was reviewed with Staff 1 (Interim ED), Staff 2, Staff 3, and Staff 6 (Resident Care Coordinator) on 09/23/26 at 1:42 pm. The staff acknowledged the findings. 2. Resident 4 was admitted to the MCC in in 05/2022 with diagnoses including Alzheimer’s disease, abnormal weight loss, and dysphagia (difficulty swallowing). The resident’s 06/21/26 to 09/21/26 clinical record was reviewed, and the following was identified: There was no documented evidence resident-specific actions or interventions had been determined, documented, and communicated to staff on all shifts and weekly progress noted until resolution for the following changes of condition: * 08/17/26- New antibiotic to treat a urinary tract infection; and * 09/04/26- 7.98% weight loss in four months, between 05/04/26 and 09/04/26. On 09/23/26 at 2:30 pm, Staff 2 (Regional Nurse/Service Director) confirmed Resident 4 was not being monitored for weight loss outside of monthly weight tracking, and the extent of his/her weight loss had not been identified because it had not triggered a significant change of condition due to inconsistencies with monthly weight documentation. The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift for all short-term changes of condition and that changes were monitored, with weekly progress noted through resolution, was reviewed with Staff 1 (Interim ED), Staff 2, Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 4:11 pm. They acknowledged the findings.

• The Regional Nurse or designee conducted a comprehensive review of the records for Residents #3 and #4, addressing concerns identified • HSD or Designee reviewed current residents for change of condition monitoring, addressing concerns identified. • The HSD or Designee reset Service Plan Process for staff sign-off and acknowledgement of service plan changes and SPAs. • In Accordance with the Conditions, Registered Nurse providing onsite clinical support with resident record review, change of condition monitoring processes, and implementation of corrective actions. • Regional Staff re-educated ED, RCC, HSD on Change of Condition and the requirement to monitor residents for change of condition and the SMART meeting process. SMART is the daily (M-F) health services meeting that covers orders, nurse delegation, alert monitoring, incident reports, change of condition, wounds, weights, etc. The 72-hour communication is reviewed on Mondays to cover the weekend and the rest of the week the 24-hour communication is reviewed. • The HSD or Designee re-educated Med Techs and PCAs on process for staff sign-off and acknowledgement of service plan changes and SPAs. • HSD or Designee will conduct random audits on resident records for change of condition monitoring compliance weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible

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 interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system was in place. This placed the residents’ health and safety at risk. Findings include, but are not limited to: During the relicensure survey, conducted 09/21/26 through 09/24/26, professional oversight of the facility's medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C301- Systems: Medication Administration; * C303- Systems: Treatment Orders; * C310- Systems: Medication Administration; * C315- Systems: Treatment Administration; and * C330- Psychotropic Medication. The deficiencies in the medication and treatment systems constituted an immediate threat to the health and safety of the residents. On 09/24/26 at 11:11 am, an immediate plan of correction was requested from Staff 1 (Interim ED). The plan of correction was received and accepted by the survey team on 09/24/26 at 2:42 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The need to ensure the facility had a safe medication and treatment administration system was reviewed with Staff 1, Staff 2 (Regional Nurse/ Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 11:11 am. They acknowledged the findings. Refer to C301, C303, C310, C315, and C330.

• Immediate POC was given to State on 9/24/2026, • Pharmacy conducted Audit on 9/29/2026, The Regional Nurse and State Approved Consultant, per the conditions, have reviewed the findings, ensured identified concerns have been addressed, and utilized the findings to support corrective actions and improvements to medication management systems. • Regional Nurse has reviewed and ensure findings have been addressed. Findings • Regional Nurse or Designee re-educated HSD, RCCs on SMART meeting process. • Regional Nurse or Designee re-educated HSD, RCCs, and Med Techs on 3 folder system. • HSD or Designee will do audits on safe medication and treatment for compliance via observation, chart review and/or interview weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD is responsible.

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medications administered by the facility were documented by the same person who administered the medications for 1 of 2 sampled residents (#9). Findings include, but are not limited to: Resident 9 was admitted to the MCC in 06/2026 with diagnoses including Alzheimer's disease and type 2 diabetes mellitus. S/he was subsequently admitted to hospice services on 09/08/26 with admitting diagnoses of mixed Alzheimer’s and vascular dementia. MARs from 09/01/26 through 09/24/26 were reviewed, interviews with facility staff were conducted, and the following were identified: * The resident had an order for diabetic ulcer on right great toe to “apply betadine to ulcer, allow to dry. Wrap lightly in kerlix [a cotton gauze for wound care] and secure with tape. Complete daily.” * From 09/09/26 through 09/24/26, each MAR was initialed by an MT as administered. In an interview on 09/23/26 at 1:24 pm, Staff 19 (MT) stated, “Betadine is applied by caregivers, and betadine is [kept] in the [resident’s] room.” On 09/23/26 at approximately 2:45 pm, Staff 19 and Staff 14 (MT) approached the surveyor to provide additional information regarding treatment for Resident 9’s diabetic ulcer. Staff 14 stated, “Only caregivers who know what they are doing can do treatments. Not all caregivers. Betadine is in the resident’s room.” The need to ensure the same person who administered the medication to the resident documented the administration of the medication on the MAR was discussed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 3:26 pm. They acknowledged the findings.

• Regional Nurse or Designee reviewed Resident #9’s medications and treatments, addressing concerns identified. • HSD or Designee reviewed other residents receiving facility-administered medications through room observation for medication and treatments and staff interviews to identify any additional medication administration documentation concerns, addressing concerns identified. • Medication Administration Training through OCP was completed with documentation submitted to corrective action for current Med Techs, RCC and ED. • HSD or Designee Re-educated Med Techs on the requirement that the same person who administers the medication to the resident documents the administration on the MAR. • HSD or Designee re-educated PCAs on medications and treatments kept in room, and who performs treatment. • HSD or Designee will do audits through observations and/or staff interviews for compliance weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD is responsible

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner medication and treatment orders were carried out as prescribed for 7 of 8 sampled residents (#s 1, 2, 3, 4, 6, 7, and 8) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the MCC in 02/2026 with diagnoses including type 2 diabetes mellitus, complete loss of teeth, and Alzheimer’s disease. Resident 6's legally authorized prescriber orders and MARs from 09/01/26 through 09/21/26 were reviewed. Interviews with facility staff were conducted. a. The physician orders, dated 08/10/26, contained the following aspiration precautions: * Supervision in the dining room; * Sitting upright 90 degrees for all eating/drinking; * Wait 30 minutes after meals before laying down; * Cup with lid; * If participant begins to cough, choke, sneeze, have wet voice or runny nose/eyes while eating, cue to STOP eating; resume only after cleared; and * Meds floated in puree. There was no documented evidence the orders were transcribed to the resident’s MAR. On 09/22/26 at 9:05 am, Resident 6 was observed lying in bed eating cream of wheat without supervision. The head of the resident’s hospital bed was at an angle of about 45 degrees, and a cup of coffee two-thirds full without a lid was placed on the bedside table. Resident 6 was heard coughing at 9:10 and 9:24 am; however, no facility staff came to check on the resident. At 9:29 am, Staff 14 (MT) administered one whole medium-sized pill that the resident took with coffee. On 09/24/26 at 1:27 pm, Resident 6 was observed lying in bed eating cream of wheat without supervision. The head of the hospital bed was at an angle of about 40 degrees. During an interview on 09/24/26 at 1:27 pm, Staff 13 (Personal Care Attendant) stated, “[Resident 6] eats by [his/her]self. We just have to get food from the kitchen.” Staff 14 (MT) added, “S/he is not a feeder, we bring food provided by the kitchen.” The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 3:26 pm. They acknowledged the findings. 2. Resident 1 was admitted to the MCC on 07/31/26 with diagnoses including dementia. Resident 1's hospice orders, dated 08/21/26, and MARs were reviewed from 08/01/26 through 09/21/26, and the following was identified: *Haloperidol 5MG 1 tablet by mouth every 2 hours as needed for anxiety, agitation, or paranoia not relieved by the scheduled dose; and *Lorazepam 1MG 1 tablet by mouth/sublingual every 3 hours as needed for severe restlessness or agitation not relieved by other interventions. Use last only if Haloperidol is ineffective after 30 min or more. According to the August MAR, the PRN lorazepam was given first, before the PRN haloperidol, on three occasions and according to the September MAR, PRN lorazepam was given first, before the PRN haloperidol, on two occasions. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Service Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 3:00 pm. They acknowledge the findings. 3. Resident 2 was admitted to the MCC in 04/2025 with diagnoses including diabetes. The 09/01/26 to 09/21/26 MAR and current physician's orders, dated 08/06/26, were reviewed, and the following was identified: * Resident 2 had physician’s orders for Lantus SoloStar subcutaneous solution (Insulin Glargine), inject 8 units in the morning. * On 06/28/26, a MT documented in progress notes, “I am not delegated to give [resident] insulin, I attempted to contact multiple on call nurses and was told not to administer, no one could delegate me because it’s the weekend, I was told to call nurse [tomorrow] for delegation.” In an interview on 09/22/26 at 1:00 pm, Staff 16 (MT) reviewed Resident 2’s eMAR and confirmed the medication was not administered as prescribed on 06/28/26. The need to ensure residents’ orders were carried out as prescribed was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/ Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 4:11 pm. They acknowledged the findings. 4. Resident 4 was admitted to the MCC in 05/2022 with diagnoses including Alzheimer’s disease, abnormal weight loss, and dysphagia (difficulty swallowing). The 09/01/26 to 09/21/26 MAR and physician orders dated 07/02/26 were reviewed, and the following was identified: a. Resident 4 had orders for mechanical soft diet textures. According to the National Dysphagia Diet (NDD), a mechanical soft diet consists of foods that are modified by chopping, grinding, blending, or pureeing so they require less chewing effort. Food should be cut into pieces no larger than 1.25 by 1.25 cm. On 09/21/26 at 1:00 pm, the resident was served pieces of a grilled cheese sandwich without added moisture, and a half banana that was not cut into 1.25 cm pieces as prescribed. b. Resident 4 had orders for lisinopril 2.5 mg, give daily, may hold if systolic blood pressure is less than 100 mm/Hg. There was no documented evidence staff took Resident 4’s blood pressure prior to administering the medication. On 09/22/26 at 1:00 pm, Staff 16 (MT) confirmed staff had not been checking Resident 4’s blood pressure prior to administering the lisinopril. The need to ensure residents’ physician orders were carried out as prescribed was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse, Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 4:11 pm. They acknowledged the findings. 5. Resident 8 was admitted to the MCC in 06/2023 with diagnoses including Alzheimer’s dementia and dysphagia (difficulty swallowing). The 09/01/26 to 09/21/26 MAR and physician’s orders dated 05/05/26 were reviewed, and the following was identified: Resident 8 had orders for “mechanical soft (IDDSI level SB6/ soft and bite-sized)” diet and aspiration precautions. According to the International Dysphagia Diet Standardization Initiative (IDDSI), Level 6 food should be soft, tender, and moist throughout, with pieces no larger than 1.5 cm by 1.5 cm. Food should be easily mashed with a fork. On 09/21/26 at 1:00 pm, Resident 8 was served pieces of a grilled cheese sandwich, a bowl of lentil soup, and steamed diced carrots. The sandwich pieces were larger than 1.5 cm and were not moistened or fork mashable as prescribed. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/ Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 4:11 pm. They acknowledged the findings. 6. Resident 3 was admitted to the MCC in 05/2026 with diagnoses including Alzheimer’s disease, major depressive disorder, and generalized anxiety disorder. The clinical record, dated 06/23/26 through 09/22/26, was reviewed, and the following was noted: A physician order, dated 08/26/26, indicated to implement the following plan once the facility “[obtained] the brexpiprazole” (to treat mental health condition): * Week 1 – Start brexpiprazole 0.5 mg in the evening and reduce quetiapine (to treat major depressive disorder) to 12.5 mg at AM and noon; * Week 2 – Increase brexpiprazole 0.5 mg in the AM and 0.5 in the evening and reduce quetiapine to 12.5 mg at noon only; and * Week 3 – Increase brexpiprazole to 2 mg in the evening only and “stop scheduled quetiapine”. On 09/04/26, staff noted brexpiprazole was not covered by the insurance. The 09/01/26 – 09/21/26 MAR showed quetiapine dosage was decreased and then discontinued. However, the brexpiprazole was never administered to the resident as ordered during the period. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Interim ED), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 2:45 pm. The staff acknowledged the findings. ?7. Resident 7 was admitted to the MCC in 03/2025 with diagnoses including moderate vascular dementia with anxiety and dysphagia (difficulty swallowing). A physician order, dated 05/05/26, indicated the resident required mechanical soft diet. According to the National Dysphagia Diet (NDD), mechanical soft diet consists of foods that are modified by chopping, grinding, blending, or pureeing so they require less chewing effort. Food should be cut into pieces no larger than 1.25 by 1.25 cm. During the lunch observation on 09/21/26, between 12:43 pm and 1:05 pm, Staff 14 (MT) served a chopped grilled cheese sandwich to the resident. No gravy, sauce, or other topping was provided to add moisture to the sandwich. The chopped sandwich pieces were larger than 1.5 cm and were not moistened or fork mashable as prescribed. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Service Director), Staff 3 (Regional Director of Operations), and Staff 6 (Resident Care Coordinator) on 09/23/26 at 1:42 pm. The staff acknowledged the findings.

• The Regional Nurse or designee conducted a review of Orders for Residents #2, #3, #4, #6, #7, and #8, addressing concerns identified, including ensuring appropriate physician communication and follow-up. Resident #1 no longer resides in Community. • HSD or Designee sent 90-day orders out to Physician for review and signature, ensuring appropriate follow up. • HSD or Designee completed delegation audit; reviewing current staff delegations against residents requiring delegated nursing tasks, addressing concerns identified. • HSD or Designee identified current residents on blood pressure medications and reviewed parameters and order set up in MAR to capture, addressing concerns identified. • HSD or Designee identified and reviewed residents on PRN Psychotropic Medications for indications of use, addressing concerns identified • HSD or Designee reviewed meds not available report for 7 day look back, addressing concern identified. • The HSD or Designee identified and reviewed current residents requiring modified diets and/or thickened liquids, addressing concerns identified. • As per Conditions, Registered Nurse providing onsite assistance with review of physician orders, treatment processes, and related corrective actions. • As per Conditions, State Approved Consultant retained on 9/27/2026 and assisting onsite with review of systems. • As per Conditions, Registered Dietician retained and assisting onsite with review of modified diets, meal service processes, and implementation of corrective actions. • The Meal Service Process for modified diets was reviewed by leadership team, State Approved Consultant and Registered Dietician, a revised Meal Service Plan was developed. Diet orders were reviewed across EHR system and Menu system to ensure aligned to NDD Food Textures. • Regional Nurse or Designee re-educated ED, HSD, RCC on SMART Meeting process, training includes medications not available review. • Regional Nurse or Designee re-educated ED, HSD, RCC, and Med Techs on the 3-folder system, PRN Psychotropic Medications require indications of use, and blood pressure medication orders with parameters require documentation and steps to take if indications of use are unclear or if unable to chart on parameters. • Regional Nurse or Designee re-educated HSD and RCCs on requirement to ensure there is adequate delegated staff coverage to meet resident needs. • ED or Designee re-educated DSM, Dietary Staff, HSD, RCC, Med Techs, PCAs, and Activities on Modified Diets and Meal Service Plan. Modified Diet training on National Dysphagia Diet (NDD) Food Textures Included; Levels, Definitions, Preparation and Appearance. • HSD or Designee will audit via chart review parameter and indications of use weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD or designee will review current staff delegations against residents requiring delegated nursing tasks to ensure adequate delegated staff coverage to meet residents' needs weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED or Designee will review modified diet compliance via observation weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • Regional Nurse or Designee will Audit to ensure SMART meeting and three folder systems are followed weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD is responsible

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents' MARs included resident-specific parameters and instructions for PRN medications for 2 of 5 sampled residents (#s 3 and 9) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 9 was admitted to the MCC in 06/2026 with diagnoses including Alzheimer's disease and type 2 diabetes mellitus. S/he was subsequently admitted to hospice services on 09/08/26 with admitting diagnosis of mixed Alzheimer’s and vascular dementia. Resident 9's MAR from 09/01/26 through 09/21/26 and physician orders were reviewed and revealed the following: a. The following PRN medications lacked instructions for sequential order of use: * Olanzapine 5mg (for agitation); and * Haloperidol 0.5 mg (for agitation). b. The following PRN medications lacked resident-specific parameters for use: * Olanzapine 5mg (for agitation); * Haloperidol 0.5 mg (for agitation); and * Lorazepam 0.5mg (for anxiety). The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 3:26 pm. They acknowledged the findings. 2. Resident 3 was admitted to the MCC in 05/2026 with diagnoses including Alzheimer’s disease, right ankle osteoarthritis, and pain in leg. The resident’s clinical record, dated 06/23/26 through 09/22/26, and 09/01/26 through 09/21/26 MAR were reviewed and revealed the following: *The 09/03/26 service plan indicated the resident “CANNOT determine [his/her] own need for PRN medication and cannot clearly communicate symptoms indicating a need for PRN medication.” * Multiple PRN pain medications, including Tylenol 650 mg three times daily as needed and Tylenol 650 mg every 4 hours as needed, did not include clear parameters to instruct unlicensed staff regarding when the medications should be administered and which medication should be given first. The PRN pain medications were not administered to the resident during the review period. The need for resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Service Director), Staff 3 (Regional Director of Operations), and Staff 6 (Resident Care Coordinator) on 09/23/26 at 1:42 pm. The staff acknowledged the findings.

• Regional Nurse of Designee reviewed PRN orders for Resident #3 and Resident #9, addressing concerns identified. • HSD or Designee reviewed current resident PRN medications for resident specific parameters and instructions for use, addressing concerns identified. • Medication Administration Training through OCP was completed with documentation submitted to corrective action for current Med Techs, RCC and ED. • Regional Nurse or designee re-educated the HSD, RCC, and Med Techs on the requirement to ensure PRN medication orders include resident-specific parameters, clear instructions for use, and sequential indications for administration when applicable. Training also covered what to do if parameters are missing or instructions are unclear. • Regional Nurse or Designee re-educated the HSD, RCC on SMART Meeting process. • Regional Nurse or Designee Re-educated the HSD, RCC, and Med-Techs on the 3 Folder System. • HSD or Designee will audit PRN medication parameters and instructions for use compliance via documentation review weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD is responsible.

OAR 411-054-0055 (3) Systems: Treatment Administration (3) TREATMENT ADMINISTRATION. (a) An accurate treatment record for each resident must be kept of all treatments ordered by a legally recognized practitioner and administered by the facility to that resident. (b) The treatment record must include: (A) Current month, day and year. (B) Type of treatment (e.g., dressing change, ointment application), treatment instructions and if applicable, significant side effects or when to call the prescriber or nurse. (C) Date and time administered. (D) Resident allergies and sensitivities, applicable to treatments. (E) Instructions for p.r.n. treatments, including resident specific parameters. (F) Initials of person administering the treatments. (G) Any deviation from instructions or refusal of treatment must be documented. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure any deviation from instructions were documented for 1 of 2 sampled residents (#9) who had a treatment order administered by the facility. Findings include, but are not limited to: Resident 9 was admitted to the MCC in 06/2026 with diagnoses including Alzheimer's disease and type 2 diabetes mellitus. S/he was subsequently admitted to hospice services on 09/08/26 with admitting diagnoses of mixed Alzheimer’s and vascular dementia. MARs from 09/01/26 through 09/24/26 were reviewed, observations and interviews with facility staff were conducted, and the following were identified: * The resident had an order for diabetic ulcer on right great toe to “apply betadine to ulcer, allow to dry. Wrap lightly in Kerlix [cotton gauze used for wound care] and secure with tape. Complete daily.” * From 09/09/26 through 09/24/26, the treatment in the MAR was initialed by an MT as administered. In an interview on 09/23/26 at 2:03 pm, Witness 2 (Family member) stated s/he did not recall seeing Kerlix on the resident’s right foot. Around 2:30 pm, Witness 2 removed a sock from the resident’s right foot, and no Kerlix was present on the great toe. In an interview on 09/23/26 at 2:38 pm, Staff 10 (Personal Care Attendant) stated “[I] haven’t seen it [great toe] wrapped in at least a week… Last time the wound was wrapped by the third-party provider but [I’m] not sure.” The need to ensure any deviation from instructions was documented for residents who had a treatment order administered by the facility was discussed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 3:26 pm. They acknowledged the findings.

• Regional Nurse or Designee reviewed Resident #9 treatment orders and documentation, addressing concerns identified. • HSD or Designee reviewed current residents receiving facility-administered treatments through room observation for medication and treatments, staff interviews and/or record review to identify deviations from treatment orders, addressing concerns identified. • HSD or Designee re-educated Med Techs on the requirement to follow prescribed treatment instructions and ensure any deviations are appropriately documented, communicated to appropriate parties and followed up on. • HSD or Designee re-educated PCAs on medications and treatments kept in room, and who performs treatment. • HSD or Designee will audit through observations, staff interviews and/or documentation review to ensure compliance with treatment orders and documentation of any deviations weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD is responsible.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and that non-pharmacological interventions were tried with ineffective results documented prior to administering PRN psychotropics for 1 of 2 sampled residents (# 3) who was administered PRN psychotropic medications. Findings include, but are not limited to: Resident 3 was admitted to the MCC in 05/2026 with diagnoses including Alzheimer’s disease, major depressive disorder, and generalized anxiety disorder. During the survey, on 09/21/26 between 1:35 pm and 2:00 pm, multiple times the resident was observed approaching staff and insisting they eat his/her food. At other times, the resident approached other residents and interfered with activities in which approximately 10 residents were participating. Review of the resident’s 09/01/26 through 09/21/26 MAR and current physician orders identified the following: * Quetiapine 25 mg daily as needed and was increased to twice daily as needed on 09/18/26 for agitation or sleep. The resident was administered the PRN quetiapine 11 times between 09/01/26 and 09/21/26. There was no documented evidence staff attempted non-pharmacological interventions with ineffective results prior to administering the medication. On 09/22/26 at 1:51 pm, the surveyor and Staff 14 (MT) reviewed the progress notes and electronic documentation and confirmed there was no documented evidence staff attempted non-pharmaceutical interventions prior to administering the PRN psychotropic medication to Resident 3. The need to ensure PRN psychotropic medications were administered only after documented non-pharmacological interventions were tried with ineffective results was discussed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Service Director), Staff 3 (Regional Director of Operations), and Staff 6 (Resident Care Coordinator) on 09/23/26 at 1:42 pm. The staff acknowledged the findings.

• Regional Nurse or Designee reviewed residents #3 PRN Psychotropic Medications for non-pharmacological interventions, addressing concerns identified. • HSD or Designee reviewed current residents receiving PRN Psychotropic Medications for non-pharmacological interventions, addressing concerns identified. • Regional Nurse or Designee Re-educated HSD, RCC, MTs on the requirement that non-pharmacological interventions are tried with ineffective results prior to administering PRN psychotropic medications. • HSD or Designee will conduct random audits on PRN psychotropic medications for compliance weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD is responsible.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing Temporary rule language in effect until 02/05/2027 (1) STAFFING REQUIREMENTS. Facilities must consistently have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support. (a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services. (b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule. (c) The following facility employees are ancillary to the caregiver requirements in this section: (A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation. (B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services). (C) Administrators. (d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection. (e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department. (f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents. (g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs. (h) In facilities where residents are housed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times. (i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic. (A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience. (B) Facilities must be able to demonstrate how their staffing system works. (j) All staff will have a written position description that specifies their specific duties and responsibilities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and failed to meet the fire safety evacuation standards as required by the fire authority. Findings include, but are not limited to: At the time of survey, from 09/21/26 to 09/24/26, the MCC was home to 40 residents housed in two distinct and segregated floors: 20 residents on the second floor and 20 residents on the third floor. The current facility staffing plan and Acuity-Based Staffing Tool (ABST) were reviewed, and interviews with facility staff were conducted. The following was revealed: 1. The facility’s posted staffing plan indicated there were two direct care staff scheduled on the third floor and one direct care staff scheduled on the second floor for each overnight shift, with one MT scheduled to float between the two floors. On 09/23/26 at 9:55 am, Staff 6 (RCC) stated overnight staff were not permitted to leave the building during their unpaid breaks. The survey investigation indicated nine residents required the assistance of two care staff with mechanical lifts for transfers on the third floor, and two residents required two care staff for transfers with mechanical lifts on the second floor. According to the facility’s second floor staffing plan, when the MT took their unpaid lunch break, the facility was without available staff to meet the residents’ unscheduled medication needs. Further, when a second floor staff member took their unpaid 30-minute break, this left only one staff available to assist residents who required two staff to assist with transfers using a mechanical lift and/or ADL cares. The facility failed to meet the scheduled and unscheduled needs of each resident during staff breaks on the overnight shift. 2. Review of staffing records, including the facility’s posted staffing plan, staff schedule, and timecards, dated 09/01/26 through 09/14/26, showed the facility failed to staff according to its posted staffing plan on 9 of 42 shifts reviewed, or 21.4% of the time. In an interview with Staff 6 on 09/23/26 at 9:55 am, she stated open shifts were filled internally and if they could not be filled, she would cover the shift. The facility also relied on agency staff when necessary. During the survey on 09/22/26, it was noted one caregiving staff and one MT were working on the second floor during the day shift. However, the posted staffing plan indicated the facility should have two caregiving staff and one MT assigned on the second floor during the day shift. On 09/22/26 at 9:37 pm, Staff 14 (MT) confirmed one caregiving staff and one MT were working on the second floor on that day, resulting in short staffing. Staff 14 further reported it happened up to approximately three times per week. The need to ensure the facility maintained staffing levels in accordance with its posted staffing plan was discussed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) during the exit interview on 09/24/26 at approximately 5:30 pm. They acknowledged the findings. 3. At the time of the survey, the MCC was home to 40 residents. The facility consisted of three floors with exit stairwells on either end of the building. Interviews with direct care staff between 09/21/26 and 09/24/26 indicated not all staff were aware of the procedure for evacuating residents who used wheelchairs to ambulate or could not negotiate the stairs if there was a need to move them to a different floor or outside the building. On 09/22/26 at 11:45 am, Staff 18 (Personal Care Attendant) stated she did not know how to use the evacuation chair and had not participated in a fire drill in which she was required to move residents. On 09/23/26 at 11:00 am, Staff 10 (Personal Care Attendant) stated he had never been trained on how to use the evacuation chair to transport residents down the stairs. On 09/22/26 at 9:30 am, Staff 7 (Maintenance Director) stated he had not conducted a fire drill with only the number of staff members scheduled for the overnight shift and was not sure if four staff could safely evacuate the residents to the point of safety across the street from the facility. The need to ensure the facility had qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and meet the fire safety evacuation standards was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/ Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 4:11 pm. They acknowledged the findings.

• ED or Designee reviewed current staffing plan, resident care needs, and staff assignment to ensure adequate qualified staff are scheduled to meet residents scheduled and unscheduled needs, including residents requiring two-person assistance. • ED or Designee reviewed overnight staffing and break practices to ensure adequate staff coverage is maintained throughout each shift. A process is being developed to address paid breaks for overnight staff who are required to remain onsite and available to respond to resident needs, ensuring appropriate staffing coverage is maintained at all times. • Maintenance Director conducted Fire Drill on NOC • ED or Designee will review staffing in daily stand-up meetings (M-F) to ensure adequate staffing per conditions and to meet resident scheduled and unscheduled needs. • ED or Designee created a Reference Document for Staff outlining what to do if there is a staffing shortage. Document includes; who to call if community will be short, steps to take to internally to cover shift, resources and available to cover shift externally. • Maintenance Director or Designee reviewed emergency evacuation procedures, including the building’s layout, fire doors, fire safety features, and available evacuation equipment to determine appropriate evacuation strategies based on resident mobility and assistance needs with scheduled staffing. • Regional Director of Operations or Designee re-educated ED and RCC on maintaining required staffing levels, ensuring appropriate coverage during breaks, and promptly addressing staffing shortages • ED or Designee educated staff on Reference Document for what to do if there is a staffing shortage. • Maintenance Director of Designee re-educated staff on emergency evacuation procedures, including utilizing the building’s layout, fire doors, and fire safety features to help contain smoke and fire, support horizontal relocation or phased evacuation when appropriate, and safely evacuate residents using available equipment and established procedures. • Maintenance Director or Designee re-educated direct care staff on Evacuation chairs and assisting residents who cannot independently navigate stairs. Staff will participate in practical demonstrations of evacuation procedures and equipment. • ED or Designee will review staffing schedules and actual staffing coverage weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • The Maintenance Director or Designee will validate staff knowledge of emergency evacuation procedures and equipment through observation and/or staff interviews weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is Responsible.

OAR 411-054-0070 (5, 9-10) Training Within 30 Days of Hire ? Direct Care Staff Temporary rule language in effect until 02/05/2027 (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible for verifying 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. (b) Exempt from this training requirement are contractors who contract directly with the resident or the resident’s representative, and contractors who do not generally provide services or supports directly to residents, including, but not limited to, contractors for landscaping, pest control, deliveries and building repairs. (c) By December 31, 2024, facilities shall ensure that all contracts entered into with entities described in paragraph (a) of this section shall include language requiring contractors provide Department-approved LGBTQIA2S+ training to their employees within 12 months of entering into the contract with the facility and every two years thereafter. (d) For existing contracts in effect January 1, 2025, facilities shall require the contractor provide Department-approved LGBTQIA2s+ training to employees by December 31, 2025, and every two years thereafter. (e) For new contracts created after January 1, 2025, facilities shall require contractors provide the Department-approved LGBTQIA2S+ training to employees within 12 months of entering into the contract with the facility, and every two years thereafter. (f) Facilities must inform contractors that the cost of all LGBTQIA2S+ trainings for contracted employees shall be paid by the contractor. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired direct care staff (#s 18, 19, 21, and 22) completed first aid and abdominal thrust training within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 4 (Business Office Director) on 09/22/26, 09/23/26 and showed the following: * There was no documented evidence Staff 18 (Personal Care Attendant), hired 06/30/26, Staff 19 (MT), hired 08/03/26, Staff 21 (MT), hired 07/19/26, and Staff 21 (Personal Care Attendant), hired 07/16/26, had completed first aid and abdominal thrust training within 30 days of hire. The need to ensure staff completed first aid and abdominal thrust training within 30 days of hire was reviewed with Staff 3 on 09/23/26 and with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Service Director), Staff 3 (Regional Director of Operations), and Staff 6 (Resident Care Coordinator) on 09/23/26 at 1:42 pm. The staff acknowledged the findings.

• Staff 18, 19, 21, & 22 completed first aid and abdominal thrust training. • ED or Designee audited current staff for first aid and abdominal thrust training compliance, addressing concerns identified. • Staff training audit completed for current staff per condition, with a plan to ensure staff have completed required trainings and competencies appropriate to their role by date of compliance. • Regional Director of Operations or Designee re-educated ED and OM on requirement that staff must complete first aid and abdominal thrust training w/in 30 days of hire. • ED or designee will audit via documentation review new hires for abdominal thrust & first aid training completion compliance weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible.

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 ensure each resident was re-instructed 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: Review of facility records on 09/23/26 revealed the following: * There was no documented evidence annual re-instruction on fire and life safety was provided to residents. In an interview on 09/23/26 at 9:00 am, Staff 7 (Maintenance Director) stated he was not aware of annual instruction on fire and life safety training for the residents. In an interview on 09/24/26 at 10:40 am, Staff 6 (RCC) stated the facility was not providing or documenting annual re-instruction on fire and life safety for the residents. The need to provide and document annual re-instruction of fire and life safety training for residents, in accordance with the Oregon Fire Code, was discussed with Staff 1 (Interim ED/Director of Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Service Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at 3:00 pm. They acknowledge the findings.

• Maintenance Director or Designee provided annual re-instruction on fire and life safety training for the residents. • ED or Designee re-educated the Maintenance Director on the required to provide annual re-instruction to the residents on 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. • Maintenance Director or Designee will review annual resident fire and life safety training for compliance weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide each resident with privacy in his or her own unit for multiple sampled and unsampled residents who resided in shared units. Findings include, but are not limited to: During the acuity interview on 09/21/26, the survey team was provided with a resident roster which indicated 16 double-occupancy rooms had two residents sharing one unit. The tour of the double-occupancy rooms revealed the bathroom doors did not have a lock to allow privacy. The need to ensure residents’ right to be afforded privacy was reviewed with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Services Director), Staff 3 (Regional Director of Operations), and Staff 24 (Senior ED) on 09/24/26 at around 5:30 pm. They acknowledged the findings.

• Maintenance Director or Designee installed a lock to allow privacy on the bathroom door for the double-occupancy rooms, lock can be opened by staff from outside in an emergency • ED or Designee re-educated Maintenance Director on the requirement to ensure each resident is provided with privacy, for shared units a lock on the bathroom door that allows for privacy is required. • Maintenance Director or Designee will audit double occupancy room bathroom doors for compliance weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible.

OAR 411-057-0140(1&6) Administration Responsibilities Temporary rule language in effect until 12/27/2026 (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, safety and comfort. This includes the supervision, training, and overall conduct of the staff. (6) The licensee must ensure that each administrator assigned responsibility for an endorsed memory care community: (a) Has completed and maintains compliance with the administrator qualification, licensure, and continuing education requirements applicable to the facility’s license type, including but not limited to: (A) OAR 411-054-0065 for assisted living facilities and residential care facilities; or (B) OAR chapter 853, division 30 for nursing facilities; and (b) Completes and documents Department-approved training specific to memory care operations, dementia-related risk factors, and the physical design, environment, and safety requirements of this division. (c) Nothing in this subsection alters, replaces or expands administrator licensure, authorization, or examination requirements established under other applicable statutes or administrative rules. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Residents were placed at risk related to deficiencies in dietary and medication systems. Findings include, but are not limited to: During the relicensure survey, conducted 09/21/26 through 09/24/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. 1. Situations were identified which constituted an immediate threat to the health and safety of the residents in the following areas: * OAR 411-054-0025 (4) Reasonable Precautions; and * OAR 411-054-0055 (1)(a) Systems: Medications and Treatments. The facility developed and implemented immediate plans of correction during the survey to address the threat to residents' safety, and the immediate risks were addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violations. 2. Refer to deficiencies in the report.

• C160 Immediate POC was given to State on 9/21/2026, also refer to POC for C160 • C300 Immediate POC was given to State on 9/24/2026, also refer to POC for C300, C301, C303, C310, C330 • In response to the license conditions, restriction of admission signs were posted on 9/25/2026. • State Approved Consultant retained on 9/27/2026 to assist community leadership with review of identified concerns, implementation of corrective actions and strengthening operational systems. Reports are being submitted to Corrective Action Coordinator by consultant per condition. • Strengthened Community leadership and staffing through the hiring of several key positions, in addition to direct care staff, including Interim ED 10/5, Permanent HSD 10/5, Community RN 9/29, DSM 10/19, and RCC 10/19 • Senior ED has been assigned to assist ED with day-to-day questions and processes. • Regional Team, including the Regional Director of Operations, Regional Nurse, and Resident Experience Manager, has been onsite providing support and oversight to the community team, reinforcing operational systems, staff training, and regulatory compliance. • Regional Team member or Senior ED will be onsite at least 1 day per week for 60 days for additional training support and ensuring Community systems are stabilizing. • Regional Team Member or Senior ED will audit via observation, staff/resident interview, and/or documentation review to validate improvement weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: 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, C200, C372, and C422.

• Regional Team Member or Designee reviewed the SOD with ED re-educating on findings, including applicable licensing requirements and corrective actions necessary to achieve and maintain compliance. • Refer to Plans of Correction for C160, C200, C372, and C422 • State Approved Consultant retained on 9/27/2026 to assist community leadership with review of corrective actions, operational processes, and regulatory compliance. Reports are being submitted to Corrective Action Coordinator by consultant per condition. • Senior ED has been assigned to provide ongoing guidance and support to the ED regarding regulatory requirements, community processes, and implementation of corrective actions. • Regional Team, including the Regional Director of Operations, Regional Nurse, and Resident Experience Manager, has provided onsite support to assist community leadership with implementation of corrective actions and reinforcement of regulatory expectations. • Regional Team Member or Senior ED will be onsite at least 1 day per week for 60 days to review progress on corrective actions, provide additional guidance, and validate implementation of community systems. • Regional Team Member or Senior ED will audit via observation, staff/resident interview, and/or documentation review to validate improvement weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 18, 19, 21, and 23) completed all required orientation and pre-service training and 4 of 4 sampled newly hired staff (#s 18, 19, 21, and 22) completed pre-service dementia training and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: The facility’s training records were reviewed on 09/22/26 and 09/23/26 with Staff 4 (Business Office Director) and showed the following: a. Staff 18 (Personal Care Attendant) was hired 06/30/26, Staff 19 (MT) was hired 08/03/26, Staff 21 (MT) was hired 07/18/26, and Staff 23 (Housekeeper) was hired 08/19/26. There was no documented evidence the staff had completed the orientation and pre-service training in one or more of the following required topics prior to performing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fires safety and emergency procedures; * Infectious Disease Prevention; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. Additional training records reviewed for Staff 18, 19, 21 and 2 noted the following. There was no documented evidence the staff had completed the pre-service dementia training on one or more of the following required topics: * Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging person with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety f residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. Additionally, there was no documented evidence Staff 18, 19 and 21 had completed the following pre-service dementia training on one or more of the following required topics prior to performing any job duties: * 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 * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 18, 19, 21 and Staff 22 (Personal Care Attendant), hired on 07/16/26, had demonstrated competency in one or more of the following required topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. Additionally, there was no documented evidence Staff 21 (MT) had completed a medication and treatment administration competency demonstration, demonstrating the ability to safely administer medications and treatments without supervision within 30 days of hire. During the record review, Staff 4 reported Staff 21 was no longer working as a MT and had stopped performing medication technician duties approximately two weeks ago. The facility’s need to ensure all training was completed and staff demonstrated competency within the required timeframes was discussed with Staff 3 on 09/23/26 and with Staff 1 (Interim ED), Staff 2 (Regional Nurse/Health Service Director), Staff 3 (Regional Director of Operations), and Staff 6 (Resident Care Coordinator) on 09/23/26 at 1:42 pm. The staff acknowledged the findings.

• Staff Member #18, #19, #21, #23 completed required orientation, pre-service training, and demonstrated competency in assigned job duties • ED or Designee conducted audit of current staff for training compliance for orientation, pre-service, dementia and demonstrated competency, addressing concerns identified. • Staff training audit completed for current staff per condition, with a plan to ensure staff have completed required trainings and competencies appropriate to their role by date of compliance. • Regional Team Member or Designee re-educated ED, OM, HSD, RCC on requirement that staff complete Orientation, Pre-service, Dementia training and demonstrated competency. • ED or Designee will do random audits on staff training records for compliance weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • ED is responsible

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: 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 C260, C270, C300, C301, C303, C310, C315, C330, and C360.

• • Regional Nurse or designee reviewed the Statement of Deficiencies (SOD) with the HSD and Community RN re-educating on findings, including identified health care deficiencies, applicable licensing requirements, and corrective actions necessary to achieve and maintain compliance. • As per Conditions, State Approved consultant, Registered Dietician and Registered Nurse providing onsite support, clinical and dietary review, corrective action review, and system corrections. • Refer to Plans of Correction for C260, C270, C300, C301, C303, C310, C315, C330, and C360 • Regional Nurse or designee has provided onsite support and oversight to the Health Services team, reinforcing clinical systems, resident care processes, staff training, and regulatory compliance. • Regional Nurse or designee will provide ongoing guidance and support to the HSD and Community RN to ensure implementation of corrective actions and stabilization of health care systems. • Regional Nurse or Designee will audit via observation, staff/resident interview, and/or documentation review to validate clinical systems improvement weekly for 4 weeks, biweekly for 4 weeks, and monthly for 2 additional months to ensure ongoing compliance. • HSD is responsible.