Print Inspection: RL007163

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#2) with a reportable incident. Findings include, but are not limited to: Resident 2 moved into the facility in 05/2025 with diagnoses including dementia, chronic myeloid leukemia, generalized muscle weakness, and osteoarthritis. Resident 2’s clinical record was reviewed during the survey. The following was identified: Staff documented in an Observation Note dated 08/25/25, that bruising was discovered on the resident’s left side torso. Staff 4 (RN) documented on 08/25/25 that staff discovered the bruising on 08/20/25 - five days earlier. Staff 4’s investigation determined the bruising was likely caused by the way staff were lifting the resident during transfers and the service plan was updated for staff to utilize a different method for transferring the resident. Staff documented in an Event Report, dated 08/25/25, that when staff asked the resident what had happened, the resident stated, “The big big [sic] dark girl hurt me when getting me up in the morning and I don’t want her helping me anymore.” Resident 2’s statement that someone hurt him/her constituted an incident of suspected abuse which required the facility to immediately notify the local Department office and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect the resident and prevent the reoccurrence of abuse. In an interview on 10/07/25, Staff 1 (MCC Administrator) stated she did not report the incident because she believed the investigation determined the cause of the injury and therefore, ruled out abuse. She acknowledged the investigation was not completed until five days after the bruising was discovered. The facility failed to immediately notify the local office and promptly investigate the incident. The need to immediately notify the local Department office of all reported incidents of suspected abuse and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence, was reviewed with Staff 1 on 10/07/25. She acknowledged the deficiencies. The facility was instructed to report the incident to the local Department office. Confirmation the incident was reported was received on 10/11/25.

1. Investigation in question was reported to APS. 2. All community staff will be trained on the importance of completing incident reports immediately. All incidents will be investigated within 24 hours and during the investigation any issues of concern will be reported to APS within 24 hours. 3. Community progress notes and incident reports will be reviewed each morning with the health services team at the daily clinical meeting. 4. RN, RCC, Memory Care Administrator

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 5) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in 07/2025 with diagnoses including dementia and diabetes mellitus. The resident’s move-in evaluation was reviewed and lacked the following required elements: * Customary routines including eating and bathing; * Leisure activities; * Cultural preferences and traditions; * Physical health status including: List of current diagnoses, list of medications and PRN use, and visits to health practitioners, emergency room, hospital, or nursing facilities in the past year; * Mental health issues including: Presence of depression, thought disorders or behavioral or mood problems, history of treatment, and effective non-drug interventions; * Cognition including: Orientation and decision making abilities; * Personality including how the person copes with change or challenging situations; * Activities of daily living including: personal hygiene and eating; * Non-pharmaceutical pain interventions; * List of treatments including: Type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated tasks; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Elopement risk or history; and * Environmental factors that impact the resident's behavior including, but not limited to: Noise, lighting, room temperature. The need to ensure all required elements were addressed in move-in evaluations was discussed with Staff 1 (MCC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 1:12 pm. They acknowledged the findings.

1. Resident's care plan was updated to include all pertinent information. 2. RN or appointed designee will review new admissions prior to admission to the facility and assure that a new evaluation has been completed prior to admit. 3. Evaluation will be verified as completed prior to each new admission 4. Memory Care Administrator and RN or appointed designee

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences and provided clear direction regarding the delivery of services for 2 of 4 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 08/2020 with diagnoses including Alzheimer’s disease. The resident’s service plan, dated 08/26/25, was reviewed. Resident 3 was observed, and Staff 12 (CG) was interviewed. The resident was observed to need a mechanical soft diet texture and was provided with honey-thickened liquids. Staff 12 confirmed that Resident 3 required staff to provide full assistance in ADLs and that the resident’s verbal communication was not always accurate. The service plan was not reflective of the resident’s current needs and/or did not provide clear direction to staff in the following areas: * Conflicting information relating to the resident's diet texture and thickened liquids; * Use of heating device for soothing; * Resistance to oral care; * Ability to communicate his/her wants effectively; * Ability to complete ADL tasks independently; and * Staff to ensure water was in his/her bedroom, in a purple water bottle. The need to ensure service plans were reflective of the resident’s current needs and provided clear direction to staff was discussed with Staff 1 (MCC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 3:42 pm. They acknowledged the findings. 2. Resident 4 moved into the facility in 07/2025 with diagnoses including dementia, Alzheimer’s disease, and diabetes mellitus. The resident’s service plan, dated 10/01/25, was reviewed. Resident 4 was observed, and Staff 10 (MT) was interviewed on 10/08/25 at 11:06 am. The resident was observed to use a wheelchair with ambulation. Staff 10 confirmed Resident 4 was not receiving any medications to treat his/her diabetes and staff did not need to monitor the resident’s blood sugar. The service plan was not reflective of the resident’s current needs and/or did not provide clear direction to staff in the following areas: * The use of mobility devices; * What staff should monitor the resident's siderail for and who should they report to if the siderail becomes loose or is in disrepair; * Assistance needed with oral care; * Meal times; * Conflicting information regarding the medications and treatments staff were responsible for relating to diabetes; * Independence with maintaining "medical supplies/equipment"; and * Person-centered signs or symptoms for staff to monitor for relating to urinary tract infection. The need to ensure service plans were reflective of the resident’s current needs and provide clear direction to staff was discussed with Staff 1 (MCC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 1:12 pm. They acknowledged the findings.

1. Care plans updated to reflect current care needs. Resident prefences added to care plan. 2. All care plans will be reviewed for accuracy and all required updates will be made to the care plans to assure all information reflects resident current care needs and preferences. Quarterly care plans will continue to be held with updates made in real time to assure completion and accuracy. 3. Care plans will be reviewed at move in, 30 days and quarterly after that. Changes will be reviewed daily. 4. Memory Care Administrator, RCC and RN or appointed designee

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, for 2 of 3 sampled residents (#s 2 and 3) with outside service providers. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2025 with diagnoses including dementia, chronic myeloid leukemia, generalized muscle weakness, and osteoarthritis. Resident 2’s clinical record was reviewed during the survey. The following was identified: * On 06/27/25, a home health RN documented, “Please monitor resident for depression” and “encourage activities, encourage to go outside.” * On 07/03/25, a home health physical therapist (PT) documented, “Encourage self [wheelchair] propulsion using [left upper extremity] and [bilateral lower extremities] for mobility in [wheelchair]. * On 07/21/25, a home health PT documented in the discharge note to encourage the resident to self-propel and to encourage the resident to participate in facility activities as noted previously. There was no documented evidence the facility adjusted the resident’s service plan to include the home health instructions. In an interview on 10/07/25, Staff 4 (RN) acknowledged the home health instructions were not added to Resident 2’s service plan and implemented. The need to ensure the facility coordinated on-site health services with outside service providers was reviewed with Staff 1 (MC Administrator) and Staff 2 (Campus Administrator) on 10/08/25. They acknowledged the findings. 2. Resident 3 moved into the facility in 08/2020 with diagnoses including Alzheimer’s disease. During the acuity interview on 10/06/25, the resident was identified as needing a mechanical soft diet. Resident 3’s clinical record which included outside provider notes, dated 07/08/25 through 09/16/25, were reviewed. The resident was observed eating breakfast and lunch meals on 10/07/25 and 10/08/25. Staff were interviewed. Outside provider notes identified the following: * 09/03/25: Resident 3 “requires a lot of direction to stay engaged in eating”, “this may be why she is [losing] weight rapidly. Please help feed [him/her]”; and * 09/16/25: A hospice RN documented the resident’s lunch as “large chunks of chicken, raw onion and tomato, and sliced black olives.” In addition, “Please ensure mechanical soft diet” “soft textured foods.” Resident 3’s service plan, dated 10/01/25, had conflicting information relating to the resident's diet texture and it specified food preferences that were not mechanical soft. Staff were directed to provide assistance with eating “as needed.” Staff were not observed to provide any assistance to the resident with eating during the survey. On 10/07/25 at 11:40 am, Resident 3 was observed to have cut up chicken, cubed in approximately ¾ inch bites, with grilled onions and peppers mixed in. The resident had an eating utensil in one hand and was just looking at the meal. Survey requested Staff 9 (RCC) to get the resident a mechanical soft lunch. At 11:47 am, Staff 9 returned to the unit with mechanical soft chicken, onions, and peppers. On 10/08/25 at 3:42 pm, Staff 1 (MCC Administrator) confirmed the outside provider notes had not been communicated to staff. The need to ensure the facility informed staff of new interventions, and that the service plan was adjusted when necessary when outside providers leave written information, was discussed with Staff 1 and Staff 2 (Campus Administrator) on 10/08/25 at 3:42 pm. They acknowledged the findings.

1.Outside provider notes were reviewed and all suggestions and orders were updated into the residents care. 2. Provider notes will be reviewed daily first by the Med Tech and then additionally reviewed for completion by either the RN, RCC and Memory Care Administrator to assure that all recommendations and information is addressed on the care plan in a timely manner. 3. Outside provider notes will be reviewed daily to assure completion 4. RN, RCC, and Memory Care Administrator

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

OAR 411-054-0055 (1)(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 medication and treatment orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 07/2025 with diagnoses including cognitive impairment and hypertension. The resident’s facility records, including MARs dated 09/01/25 through 10/06/25, and physician’s orders dated 10/01/25 were reviewed and the following was identified: Resident 1 had the following physician-ordered medications with parameters for when to administer and/or hold the medications and directions to notify provider when medications were held: a. Amlodipine 5 mg twice daily for hypertension. Hold for top blood pressure number less than 110 and/or heart rate less than 60 and notify primary care provider. * Amlodipine was held on 17 occasions. 11 occasions lacked documentation of provider notification; and * On 09/09/25, resident’s heart rate was 54, amlodipine was not held as ordered. b. Losartan 50 mg every day for hypertension. Hold for top blood pressure number less than 110 and bottom blood pressure number under 50. Notify Hospice if held. * Losartan was held on 2 occasions. There was no documented evidence hospice was notified. c. Omeprazole 20 mg every day on an empty stomach, 30 minutes before first food for heart burn. * Omeprazole was scheduled for 8:00 am. Observation made on 10/7/25 at 08:30 am. Resident 1 was having breakfast in his/her room. * At 9:30 am, Staff 10 (MT) administered morning medications for Resident 1. Upon interview she acknowledged that medications that were being administered included omeprazole. On 10/08/25 at 10:45 am, Staff 3 (Wellness Director/RN) acknowledged there was no documented evidence the provider was notified as ordered. The need to ensure the facility followed the physician’s orders was discussed with Staff 1 (MCC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 2:30 pm. They acknowledged the findings. No further information was provided. 2. Resident 3 moved into the facility in 08/2020 with diagnoses including Alzheimer’s disease. During the acuity interview on 10/06/25, the resident was identified as needing a mechanical soft diet. Resident 3’s clinical record, which included provider’s orders dated 08/27/25 and 09/10/25, were reviewed. The resident was observed eating breakfast and lunch meals from 10/07/25 to 10/08/25, and staff were interviewed. A prescriber’s order, electronically signed on 08/27/25, specified, “Diet: mechanical soft with honey thickened liquids.” On 10/07/25 at 11:40 am, Resident 3 was observed to have cut up chicken, cubed in approximately ¾ inch bites, with grilled onions and peppers mixed in. Survey requested Staff 9 (RCC) to get the resident a mechanical soft lunch. At 11:47 am, Staff 9 returned to the unit with two bowls of mechanical soft chicken, onions, and peppers. One bowl was given to Resident 3 and the other bowl was given to an unsampled resident. During an interview relating to the resident’s incorrect diet texture on 10/07/25 at 11:58 am, Staff 1 (MC Administrator) stated, “This has been an issue with the kitchen.” On 10/07/25 at 12:28 pm, Staff 5 (Dining Services Director) stated the process of ensuring residents received the proper diet texture was through verbal communication between her, her staff, and the MCC staff. She stated it was not a good system. The need to ensure the facility followed prescriber’s orders relating to diet texture was discussed with Staff 1 and Staff 2 (Campus Administrator) on 10/08/25 at 3:42 pm. They acknowledged the findings.

1. RCC or Designee will impliment MAR audits and assure that all blood pressures outside of the designated parameters set by the primary care provider have been reported to the physician 2. Training will be provided to all staff that adminster medicaiton about the importance of following a physcians order and to completing all portions of the order as directed. 3. RCC will audit the MARs once a week 4. RCC, RN and Memory Care Administrator

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were given only after documented non-pharmacological interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 1) who had an order for PRN psychotropic medication. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2025 with diagnoses including cognitive impairment and hypertension. Resident 1’s 09/01/25 through 10/06/25 MARs and observation notes were reviewed and showed the following: Resident 1 had an order for Ativan 0.5 mg every four hours as needed for anxiety or agitation, demonstrated by yelling, crying and pacing in his/her room or building. Prior to giving engage in calm conversation, offer snack, and position for comfort. The PRN Ativan was administered on six occasions in September and on three occasions, there was no documentation of non-drug interventions being attempted with ineffective results prior to administering the medication. On 10/08/25 at 10:45 am, Staff 3 (Wellness Director/RN) acknowledged the lack of documentation of non-drug interventions being attempted prior to administering the Ativan and stated she would provide re-education to staff. The need to ensure non-pharmacological interventions and their ineffectiveness were documented prior to administering the as-needed psychotropic medication was discussed with Staff 1 (MCC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 2:30 pm. They acknowledged the findings. No further information was provided.

1. Interventions for the use of all PRN psychotropic medications was added to the MAR for all residents. 2. Will review in Daily Clinical meetings any new PRN orders and ensure that non-pharmacological interventions have been added. 3. PRN medication non-pharmacological interventions will be reviewed every 90 days with the 90 day orders to ensure appropriate interventions are in place for prn medications. 4. RN, RCC, Med Techs, and Memory Care Administrator will be responsible to see that the corrections are completed/monitored.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time for the care elements that staff were providing to residents as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 3 and 4) whose ABSTs were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the MCC in 08/2020 with diagnoses including Alzheimer’s disease. The resident was identified during the acuity interview on 10/06/25 as needing full assistance with ADL care, including one- to two-person assist with transfers and incontinence care, and was on hospice services. The current service plan, dated 08/26/25, and the resident’s corresponding ABST individual evaluation were reviewed, interviews with staff were conducted, and observations were made during the survey. The following was identified: During an interview on 10/08/25 at 11:28 am, Staff 12 (CG) reported Resident 3 needed two staff members to assist with transfers and incontinent care at times. She went on to say the resident had days when s/he was weak and was not able to stand or help in the restroom. Staff 12 also reported checking on Resident 3 every time she “walks by the room” due to the resident being a high fall risk. She also reported that staff did the resident’s laundry and light housekeeping as the housekeeping staff only came “once a week.” The service plan directed staff to “perform safety checks on [the resident] four times per hour while [s/he] was in [his/her] recliner” and to reposition the resident every two hours. Resident 3 was not observed to spend any time in his/her recliner during the survey. The resident’s service plan was reflective of care staff doing his/her laundry and housekeeping. The resident's care time was not reflective in the following areas: * Safety Checks; * Repositioning in bed or chair; * Transferring in or out of bed or a chair; and * Housekeeping and laundry services performed by care staff. The need to ensure the facility ABST accurately captured the care time that staff were providing was discussed with Staff 1 (MC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 3:42 pm. They acknowledged the findings. 2. Resident 4 moved into the facility in 07/2025 with diagnoses including dementia and Alzheimer’s disease. The current service plan, dated 10/01/25, and the resident’s corresponding ABST individual minutes were reviewed, interviews with staff were conducted, and observations were made during the survey. The following was identified: During an interview on 10/08/25 at 11:08 am, Staff 13 (MT/CG) reported Resident 4 needed full assistance with oral care, needed help with leisure activities such as turning on the television, and was a high fall risk so required at least six safety checks per shift, and needed repositioning with s/he was in his/her recliner as the resident had “slipped out of it before.” Staff 13 confirmed Resident 4 needed some cueing and reminders due to his/her memory loss. The service plan directed staff to “perform safety checks [eight times] per shift”, was independent with oral care, and did “not display any cognitive impairment”. Resident 4’s service plan was reflective of care staff doing his/her laundry and housekeeping. The resident's care time was not reflective in the following areas: * Safety checks; * Assisting with leisure activities; * Cueing or redirecting due to cognitive impairment or dementia; * Repositioning in bed or chair; and * Housekeeping and laundry services performed by care staff. The need to ensure the facility ABST accurately captured the care time that staff were providing was discussed with Staff 1 (MC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 1:12 pm. They acknowledged the findings. 3. Resident 1 moved into the facility in 07/2025 with diagnoses including cognitive impairment and hypertension. ABST data was reviewed during the survey and revealed inaccuracies in care times for Resident 1 through observation and interview, including, but not limited to: * Assisting with leisure activities; * Providing non-drug interventions for behaviors; * Providing treatments related to skin care; * Assistance with dressing and undressing; and * Assistance with grooming. In an interview on 10/08/25 Staff 1 (MCC Administrator) acknowledged the findings for Resident 1 and stated will update ABST. The need for the ABST to accurately capture care time that staff were providing to residents was discussed Staff 1 and Staff 2 (Campus Administrator) on 10/08/25 at 2:30 pm. They acknowledged the findings.

1. ABSTs updated to reflect residents' current care needs. 2. MC Administrator or designee will update the ABST in real time during care plan meetings and when needed for changes in resident care needs. 3. Updates will be made quarterly and as needed 4. MC Administrator, Campus Administrator and/or appointed designee

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

OAR 411-054-0090 (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 residents were 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. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following deficiencies were identified: There was no documentation that fire and life safety training was provided to residents within 24 hours of move in and/or that they were re-instructed at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually, was discussed with Staff 1 (MC Administrator) and Staff 2 on 10/08/25 at 2:30 pm. They acknowledged the findings. No further information was provided.

1. All current residents will review Emergency/Disaster Orientation to include: general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the facility. Worksheet to be reviewed with resident and signed by resident and staff member reviewing procedure with them. New residents moving in to complete worksheet within 24 hours of move in. 2. Binder created with worksheet review for emergency/disaster orientation/review and will be reviewed with residents at care conference, and any changes will be updated on the worksheet. 3. Worksheets will be reviewed quarterly with residents. 4. Campus Administrator, Maintenance Director

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair. Findings include, but are not limited to: 1. The facility was toured on 10/07/25 and the following was identified: * There were multiple dark spills and stains on the carpet throughout the unit. The need to ensure the interior of the facility was kept clean was reviewed with Staff 1 (MCC Administrator) on 10/08/25. She acknowledged the carpet stains. 2. Resident 1 moved into the facility in 07/2025 with diagnoses including cognitive impairment and hypertension. Observations made during the survey on 10/06/25 through 10/08/25 revealed the following: * Resident 1 preferred to eat meals in his/her room; * There was food crumbs and drink spill on the floor, side table and windowsill; and * Flies and fruit flies in the room, on the table, windowsill and landing on the food while the resident was having meals. On 10/8/25, Staff 2 (Campus Administrator) acknowledged she was aware of the above conditions and stated she would have Resident 1’s room cleaned more frequently.

1. Community will implement additional staff to assist with room cleanliness and carpet maintenance. 2. Community will implement additional staff to assist with room cleanliness and carpet maintenance. Memory Care Administrator, Maintenance Director and Campus Administrator will assure these tasks are being completed on a routine basis. 3. All common areas will be checked daily for cleanliness as well as residents rooms that have a history of eating in their apartments. 4. Maintance Director, Campus Administrator and Memory Care Administrator

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

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial evaluation included the resident’s pronouns and gender identity for 1 of 1 sampled resident (#4) whose initial evaluation was reviewed. Findings include, but are not limited to: Refer to C 252.

1. Care plan report completed for all residents that include the residents preferred pronouns and gender identities. 2. Computer program was updated by regional director to include the gender identity question. 3. The care plan report will be reviewed at the 30 day and the 90 day care conferences as well as any change of condition updates to the care plan. 4. Wellness Director, RCC, and Memory Care Administrator

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231, C 422, and C 513.

Please see plan of correction for the following mentioned tags C231, C422, C513.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 290, C 303, C 330 and C 362.

Please see plan of correction for the following mentioned tags C252, C260, C290, C303, C330, C362.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure each resident’s activity evaluation was updated and reflective of the resident’s current status and an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which some residents attended. Other residents did not attend the activities and, instead, stayed in their rooms or walked around the facility. Some residents were no longer able to ambulate independently. All the residents were diagnosed with some type of dementia. Resident 1, 2, 3 and 4’s clinical records were reviewed during the survey. The facility used a form called “Getting to Know You” to evaluate and document each resident’s activity information and documented an activity plan for each resident in the resident’s service plan. The following was identified: *Resident 4 moved from the assisted living (AL) part of the facility to the memory care unit. The facility did not update the resident’s activity evaluation, completed when the resident resided in the AL, to reflect the changes to the resident’s activity interests, physical abilities, limitations, and support needs. *Resident 1, 2, 3 and 4’s individualized activity plans lacked instructions for providing activities based on each resident’s activity evaluation. In an interview on 10/08/25, Staff 1 (MC Administrator) and Staff 7 (Life Enrichment Coordinator) acknowledged the lack of individualized activity plans for the residents in the memory care unit. Staff 7 stated she had not been provided information about the rule requirements when she started in her position for the MCC. The need to ensure each resident’s activity evaluation was complete, reflective and updated as needed, and that the information gathered was used to develop an individualized activity plan for each resident, was reviewed with Staff 1 and Staff 2 (Campus Administrator) on 10/08/25. They acknowledged the findings.

1. Residents care plans have been updated with preferences and activities of preference. 2. MC Administrator, RCC, Activity Director or appointed designee will ensure that preferences are updated quarterly during care plan meetings. 3. Resident activity preferences will be reviewed and updated quarterly during care plan meetings. 4. MC Admin, MC Activity Director, RCC

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: