Print Inspection: RL010066

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 report injuries of unknown cause to the local Department office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, for 1 of 1 sampled resident (# 2) who had injuries of unknown cause. Findings include but are not limited to: Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. Review of the resident's clinical record, including progress notes from 12/11/25 through 03/11/26, identified the following: * The 03/03/26 service plan indicated Resident 2 experienced expressive aphasia (impaired ability to speak) that severely limited his/her ability to communicate verbally with staff. The service plan noted the resident was “not always able to communicate [his/her] needs” nor had the ability to “understand a conversation.” * 12/19/25 – In a charting note, a Temporary Service Plan (TSP) noted, “Resident has a skin tear to [his/her] left elbow”; * 12/22/25 - In a charting note, a TSP noted, “Resident seems to have developed a skin tear in [his/her] upper right wrist with no bleeding but is very red”; and * 03/01/26 – In a charting note, a TSP noted, “Make sure to monitor [his/her] bruise and skin tear on [his/her] right toes for any changes or improvements.” These skin tears and bruise represented injuries of unknown cause which were required to be reported to the local Department office unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse. During an interview on 03/13/25 at 1:20 pm, Staff 1 (ED) confirmed the above injuries were not investigated. The facility failed to immediately investigate injuries of unknown cause and report the injuries to the local Department office if an immediate investigation was not completed. The need to ensure all injuries of unknown cause were immediately investigated to rule out suspected abuse and were reported to the local Department office if abuse could not be ruled out, was discussed with Staff 1 on 03/13/26 at 3:55 pm. He acknowledged the findings. Survey requested the facility report the above incidents to the local Department office. Confirmation that the incidents were reported was received on 03/16/26 at 3:08 pm.

1- Resident #2, has been reviewed and the requested self-reports have been completed. 2- All care staff, med-techs and supervisors have been re-educated that any injury of unknown cause must be reported immediately to the med-tech, RCC, RN or Administrator before the end of the shift and documented on the community incident report (August health). During daily stand-up and shift-to-shift communication, staff are reminded that injuries of unknown cause, require prompt reporting and investigation. Management reviews all incident reports daily to ensure that injuries of unknown cause are identified, investigated timely, and abuse or neglect is ruled out. If abuse and neglect cannot be ruled out, the report will be submitted to APS per OAR requirements. 3- This system will be reviewed weekly with the management team to ensure that it is in compliance. Any findings will be brought to the Quality Assurance Committee for additional review and corrections. 4- The Administrator will be responsible for compliance.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were available to staff, reflective of residents’ care needs, provided clear instruction to staff regarding the delivery of services, and were implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and history of falls. Resident 1’s service plan, dated 03/11/26, and temporary service plans (TSPs), dated 12/11/25 through 03/11/26, were reviewed, observations were made, and interviews with staff and the resident were conducted. a. On 03/11/26 during the acuity interview, staff reported current service plans were kept in a service plan binder located in the “pass through hallway”; however, Resident 1’s service plan was not observed in the service plan binder. At 3:58 pm, staff provided a service plan dated 12/11/25 and reported it was in the locked MT room. On 03/11/26 at 5:00 pm, the residents’ current service plan, dated 03/11/26, was provided; however, it was not available to staff. The facility failed to ensure current service plans were available to staff. b. The service plan was not reflective of the resident’s care needs and lacked clear instruction to staff in the following areas: * Interventions for behaviors that included yelling and agitation when other residents entered his/her room or were near the door to his/her room; and * Preference to keep the door to his/her room open. Throughout the survey, staff were observed to close the door to Resident 1’s room. On 03/12/26 at 10:45 am, Resident 1 was in his/her room when an unsampled resident was observed entering the room. Resident 1 became visibly agitated and yelled at the unsampled resident to get out. Resident 1 reported the unsampled resident “…comes here all the time, appears nice but [s/he] is mean” and voiced the desire to keep his/her door open so s/he does not “…miss out on what’s going on in the world.” Interviews with Staff 4 (RCC), Staff 9 (CG), and Staff 10 (CG) during survey, between 03/11/26 and 03/13/26, confirmed Resident 1 did not like his/her door closed and became agitated by other residents’ going into his/her room or being near his/her door. The need to ensure service plans were available to staff, were reflective of residents’ care needs, and provided clear instruction to staff regarding the delivery of services was discussed with Staff 1 (ED) on 03/13/26 at 4:30 pm. He acknowledged findings. 2. Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. a. On 03/11/26 during the acuity interview, staff reported current service plans were kept in a service plan binder located in the “pass through hallway”; however, Resident 2’s service plan was not observed in the service plan binder. At 3:58 pm, staff provided a service plan dated 11/06/26 and reported it was in the locked MT room. On 03/11/26 at 4:30 pm, the residents’ current service plan, dated 03/03/26, was provided; however, it was not available to staff. The facility failed to ensure current service plans were available to staff. b. The 03/03/26 service plan was not reflective of the resident’s current care needs, lacked clear instruction, and was not implemented in the following areas: * Use of a Hoyer device, including which colored loops on the sling to use, where the resident should place their hands, and the reclined position of the wheelchair; * Skin integrity, including multiple areas of breakdown; * Aspiration precautions, including remaining upright for 30 minutes after eating; * Positioning when in wheelchair for protection of skin, including removal of sling and cushion behind legs; and * Use of fall mat when in bed. Observations during the survey showed the resident used a Hoyer device to transfer, and the caregiver provided instruction to another caregiver on which colored loops to use when connecting the sling to the Hoyer. Additional observations showed the back of the resident’s wheelchair was reclined during a transfer into the chair, and a cushion was placed behind his/her legs as protection. On 03/12/26 Resident 2 was assisted back to bed and did not remain upright for 30 minutes after finishing his/her lunch. During an interview on 03/12/26 at 10:40 am, Staff 10 (CG) indicated the fall mat was used for protection in case the resident fell out of bed. The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, provided clear instruction to staff regarding the delivery of services, and were implemented was reviewed with Staff 1 (ED) on 03/13/26 at 3:55 pm. He acknowledged the findings.

1- A 100% audit has been completed to ensure that all resident service plans are available for staff review and sign offs, and located in the "Pass through hallway". Resident # 1 has had their service plan reviewed and corrections made to address the residents care needs, to include interventions for behaviors, including yelling and agitiation and preferences for the residents door to be open. Resident #2's service plan has been reviewed, updated and is currently in the Service Plan Binder, and has been updated to reflect the residents needs. This is to include the use of the Hoyer device for transfers, and the use of the colored straps, the skin integrity, aspiration precautions and positioning when in the wheelchir for the protection of the skin, to include sling removal and the use of cushion behind the legs, and the use of the fall bed next to bed. 2- New admissions, returns from hospital, temporary service plans (TSPs) and changes of condition will be reviewed daily during stand up to ensure service plans are current, reflective of the residents needs, and contain clear staff instructions for care delivery. Random care observations will be conducted to ensure staff are implementing the service plan as written. Any gaps identified will result in immediate service plan updates and staff re-education. Clinical team will review findings routinely to ensure ongoing compliance and accuracy. 3- This system will be audited weekly by the management team to ensure compliance. Any findings will be brought to the Quality Assurance Committee for additional review and corrections. 4- The Clinical Director and the RCC will be responsible for compliance.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to communicate determined actions or interventions to staff, document weekly progress through resolution, and monitored each resident consistent with his or her evaluated needs and service plan for 2 of 2 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Resident 2 had a heel wound that became infected. Resident 1 experienced severe, ongoing weight loss. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. During the acuity interview on 03/11/26 at 2:25 pm, Resident 2 was identified as having a heel wound, needing a two-person assist with mobility and ADL care, and receiving hospice services. A review of Resident 2’s clinical record, from 12/11/25 through 03/11/26, revealed the following: * The resident’s 03/03/26 service plan indicated the resident “recently experienced a series of skin integrity/breakdown issues” that was followed by hospice and the facility RN, and s/he needed to be out of bed for no more than an hour/day per hospice recommendation to promote healing of skin breakdown areas. * A hospice note dated 12/17/25 instructed staff to “use foam booties to protect feet and ankles from skin breakdown” and a 12/18/25 TSP communicated the information to staff. * A hospice note dated 12/24/25 indicated, “DTI [deep tissue injury] medial R [right] heel.” A physician communication dated 12/24/25 provided wound care instructions for the heel wound, noting the facility was to change the dressing if there was “soilage or dislodgement,” to notify hospice with signs of infection, and the hospice nurse would change the dressing two times per week. The physician instructions for PRN dressing changes were noted on the MAR and did not provide additional information on the status of the wound. There was no documented evidence the resident had been placed on alert and monitored for the right heel wound. * A 12/26/25 Temporary Service Plan (TSP) instructed staff to float the resident’s heels and keep pressure off his/her feet. * A hospice note dated 12/30/25 indicated DTI to right heel “appear to have resolved.” However, three days later, on 01/02/26, hospice noted “dressings on R heel … changed. Both wounds slowly improving.” On the same day, Staff 2 (Facility RN) completed a weekly significant change of condition note regarding resident’s additional skin conditions and a pressure wound in another location but made no mention of the right heel wound or its status. * Eleven days after the status of the heel wound was last documented, on 01/19/26, a hospice noted indicated, “No dressing on R heel again wound [sic] larger with darker center . . . Please keep heel dressing in place.” A note from Staff 2, dated 01/20/26, documented the resident had a “dry and intact dressing to [his/her] right heel . . . will continue to monitor with weekly skin assessment.” This was the first documented evidence the right heel wound had been addressed by Staff 2. * A hospice note dated 01/23/26 indicated, “Continue to monitor heel.” However, no additional information was provided regarding the status of the wound. * On 01/29/26, ten days after the wound was documented as worsening, Staff 2 completed a weekly skin assessment but there was no information about the current status of the right heel, including the size of the wound. * Eleven days later the wound was noted as worsening and on 01/30/26, a hospice note indicated the right heel wound measured 1 cm (centimeter) by 1 cm. * On 02/13/26, 02/19/26, and 02/26/26, Staff 2 documented a weekly skin assessment addressing a different wound but there was no information regarding the right heel wound or its current status. Hospice visits were made between 02/02/26 and 03/01/26; however, there was no documented evidence on the status of the wound. * On 03/01/26, 27 days from the last documented evidence on the status of the right heel wound, the resident was put on alert charting by the MT for his/her right heel due to “discharge of puss [sic] and blood noted, no odor.” The charting notes indicated, “Hospice, RCC, and CRN [facility RN] were notified.” On 03/03/26 the wound had “leaks and the bandage was full of puss [sic],” and the MT cleaned the wound. There was no documented evidence the resident’s wound had been evaluated by the facility RN or the hospice nurse. * Day shift charting notes on 03/04/26 indicated the right heel wound had “developed odor” with ongoing pus and blood and “appeared to be getting deeper and burrowed in the surrounding skin.” After reading the note documented earlier that day, an overnight MT noted hospice was contacted. * On 03/05/26, Staff 2 documented a weekly skin assessment and noted Resident 2 had an “open wound” to the right heel, which had an odor and small amount of pus-like drainage. She noted the wound measured 3 cm by 2.5 cm and had “a ring of dark peri wound skin [surrounding the wound].” She indicated the hospice nurse assessed it and “looks like [the resident] needs an antibiotic for the wound.” Resident 2 was noted to have a right heel wound which worsened, became infected, and required a seven-day course of antibiotics, completed on 03/12/26. The facility failed to monitor the progress of the wound, at least weekly, and the wound became infected. Observations of the resident during the survey identified a dressing on his/her right heel, heel booties were worn in bed and when up in the wheelchair, and staff were repositioning the resident in bed using pillows. A caregiver was observed changing the resident’s right heel dressing on 03/12/26 after it became partially dislodged. On 03/12/26 at 10:52 am, Resident 2’s right leg was observed hanging off of his/her bed, without the right heel protector bootie, and his/her heel was resting against the side of the bed. During an interview at 2:43 pm on 03/12/26, Staff 2 acknowledged she was responsible for completing the weekly skin assessments. During an interview at 3:55 pm on 03/13/26, Staff 1 (ED) acknowledged the right heel wound was not monitored weekly in the RN’s weekly skin assessments and confirmed the resident was on antibiotics for the infected wound. The need to ensure the facility monitored short-term changes of condition, with progress noted at least weekly, was discussed with Staff 1 on 03/13/26 at 3:55 pm. He acknowledged the findings. 2. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and a history of falls. During the acuity interview on 03/11/26 at 2:25 pm, Resident 1 was identified as having had significant weight loss, a fall with fractures, a hospitalization, and a recent decline. A review of Resident 1’s clinical record, between 12/11/25 and 03/11/26, revealed the following: Resident 1’s recorded weights were as follows: * 12/13/25 - 105.5 pounds; * 01/10/26 - 99.0 pounds; * 02/10/26 - 92.4 pounds; and * 03/10/26 - 88.0 pounds. Between 12/13/25 and 01/10/26 the resident experienced a weight loss of 6.5 pounds, or 6.16% of his/her total body weight, in 30 days. On 01/13/26 an RN assessment was completed with a documented intervention to encourage the resident to eat his/her meals. However, there was no documented evidence the determined interventions were communicated to staff on each shift or implemented. An RN follow-up assessment was completed on 01/29/26 for significant weight loss, which indicated the resident had lost 4.6 pounds since 01/21/26. The documented interventions noted were previously identified on the 01/13/26 assessment, and there was no documented evidence they were communicated to staff, that the resident was monitored consistent with his/her evaluated needs, or that the interventions were implemented. A 02/03/26 RN follow-up assessment for the significant weight loss indicated the resident had lost another pound in one week. In addition to the previously documented interventions, additional interventions were to encourage the resident to go to the dining room for meals and offer frequent snacks. However, there was no documented evidence previous interventions or the new documented interventions were communicated to staff or implemented. On 02/07/26 the facility received a physician’s order to arrange a dietician consult; however, there was no documented evidence the facility communicated the intervention to staff. On 03/13/26 at 4:30 pm, Staff 1 (ED) confirmed the dietician consultation was not implemented. Between 01/10/26 and 02/10/26, the resident experienced another weight loss of 6.6 pounds, or 6.60% of his/her total body weight, in 30 days. An RN assessment was completed on 02/13/26 for the continued weight loss and noted the resident did not appear to be gaining weight. In addition to the previously documented interventions from the 02/03/26 RN Assessment, the RN added meal monitoring to the MAR. There was no documented evidence the prior interventions identified were communicated to staff or were monitored consistent with the resident’s evaluated needs. Between 12/13/26 and 03/10/26, the resident experienced a total weight loss of 17.5 pounds, or 16.5% of his/her total body weight, in 90 days. Resident 1 experienced a severe weight loss on 01/10/26. There was no documented evidence the facility consistently communicated the determined interventions regarding the weight loss to staff and monitored the resident according to his/her evaluated needs. The resident continued to lose weight. During the survey the following was observed: * For breakfast on 03/12/26, Resident 1 was observed eating scrambled eggs, sausage, biscuits, fruit cocktail, and apple juice, and s/he consumed about 50% of the meal. S/he complained of feeling sick and nauseous and went back to bed. The MT provided Resident 1 with medication for gas. * For lunch on 03/12/26, Resident 1 was observed eating meatloaf, potatoes, green beans, a cookie, water, and juice, and s/he consumed about 50% of the meal. On 03/13/26 at 2:30 pm, Staff 4 (RCC) confirmed there was no documented evidence that temporary service plans were created for weight loss interventions after each RN assessment. During an interview on 03/13/26 at 4:30 pm, Staff 1 acknowledged the interventions were not consistently communicated to staff, implemented and monitored. The need to ensure the facility communicated determined actions or interventions for changes of condition to staff on each shift and monitored each resident consistent with his or her evaluated needs and service plan was reviewed with Staff 1 on 03/13/26 at 4:30pm. He acknowledged the findings.

1-Resident # 1 has been reassessed by another RN and her weight variances and interventions have been reviewed for effectiveness and will be followed weekly to establish her new baseline. Care staff instructions have been reviewed with the care staff for implementation. Resident # 2 identified in the survey- these wounds have resolved. 2- All residents have been reviewed by the clinical team to determine if there are any short or long term changes of condition. The RN and RCC will meet weekly to review the clinical dashboard and the resident's conditions to determine if any triggers have been identified, this is to include monthly weight variance reports and skin conditions (weekly assessments to be completed & to include treatment regime effectiveness). 3- This system will be evaluated weekly to ensure compliance by the RN. Any areas identified will be reviewed in the Quailty Assurance Committee for system changes as needed. 4- The RN will be responsible for compliance.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 1 sampled residents (# 2) who experienced a significant change of condition for a pressure ulcer. Findings include, but are not limited to: Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. Resident 2’s clinical record was reviewed from 12/11/25 through 03/11/26 and revealed the following: An RN hospice note, dated 12/24/25, indicated Resident 2 had a “stage 2 medial R [right] great toe” pressure wound. During an interview on 03/13/26 at 2:15 pm, Staff 1 (ED) acknowledged there was no RN assessment completed which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 on 03/13/26 at 3:55 pm. He acknowledged the findings.

1- Resident # 1 identified in the survey has been re-assessed for changes to his condition. A new significant change of condition has been initiated by a new RN and will be followed weekly until stabilized at baseline. 2- When a resident experiences a significant change of condition (short or long term conditions), the RN will complete and document a comprehensive nursing assessment that includes the resident’s current status, assessment findings, changes from baseline, contributing factors, and interventions initiated. The RN assessment will also include follow-up actions such as service plan updates, physician and family notification as appropriate, monitoring frequency, and evaluation of intervention effectiveness. The RN will continue to reassess the resident until stabilization or a new baseline is established. All residents have been reviewed by the clinical team, RN and RCC to review the clinical dashboard and residents conditions to determine if any triggers have been identified, this is to include monthly weight variance reports and skin condition. 3- This system will be evaluated weekly to ensure compliance by the RN. Any areas identified will be reviewed in the Quailty Assurance Committee for system changes as needed. 4- The RN will be responsible for compliance.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions recommended by outside providers and the service plan was adjusted, if necessary, for 2 of 2 sampled residents (#s 1 and 2) who received hospice and home health services. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and a history of falls. The resident's clinical record, from 12/11/25 through 03/11/26, was reviewed, and staff were interviewed. The following was identified: Resident 1 began receiving home health services after a fall resulting in rib fractures. The following transcriptions of the outside provider recommendations were identified in the residents’ progress notes: * 01/11/26: One staff assist for all mobility and to walk three times daily with a walker and staff assist; * 01/20/26: One staff assist for all mobility secondary to safety; * 01/28/26: Continue with assistance of one staff for mobility and noted when the resident ambulated short distances his/her blood oxygen levels dropped and indicated the resident may benefit from a medication review; and * 02/24/26: Continue assistance of one staff for all mobility and noted the resident had progressive weakness. Documentation revealed staff reviewed the above recommendations; however, there was no documented evidence direct care staff were informed of the recommendations or that the service plan was adjusted. In an interview on 03/13/26 at 4:30 pm, Staff 1 (ED) confirmed the interventions recommended by the outside provider were not communicated to staff, and the service plan was not updated. The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after outside provider services were provided was discussed with Staff 1 on 03/13/26 at 4:30 pm. He acknowledged the findings. 2. Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. Resident 2’s clinical record from 12/11/25 through 03/11/26 was reviewed, including outside provider notes. There was no documented evidence staff were informed of new instructions and the service plan was updated, as necessary, for the following recommendations: * 12/19/25: A hospice RN documented “Instructions for the care team: Please encourage fluid. Offer every 2 hours while awake if possible”; * 12/27/25: A hospice nurse instructed staff to “ensure patient is able to swallow food properly”; and * 02/02/26: A hospice nurse identified “stage 1 circular wound to right ankle . . . reposition to keep pressure off right ankle.” During an interview with Staff 4 (RCC) on 03/13/26 at 11:50 am, she confirmed there was no documented evidence the hospice instructions were communicated to staff. The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after outside provider services were provided was discussed with Staff 1 (ED). He acknowledged the findings.

1- The residents identified in the survey (resident #1 & #2) have had their medical records reviewed by the clinical team to ensure that all of the communications received from their outside prviders has been collated to ensure that there is a comprehensive service plan that reflects coodination of care. 2- A community wide audit has been completed to have a master list of outside providers for the residents. This list will be updated as services change. All Outsider Provider Forms will be collected with each provider visit and reviewed daily in the clinical meetings. Any changes, recommendations or other directions will be transferred to a TSP for communication to staff. This process will be reviewed weekly by the RN and RCC for compliance. 3- This process will be evaluated weekly for compliance. 4- The RN & RCC will be responsible for the compliance.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 2) who received ADL care and meal delivery in the room. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and was noted to receive meal service in his/her room. Observations were made, from 03/11/26 through 03/13/26, to determine adherence to universal precautions for infection control. a. During ADL observations on 03/12/26 at 12:54 pm, the following was noted: * Staff 12 (Housekeeper/CG) exited Resident 2’s room with disposable gloves on her hands and did not doff the gloves prior to entering Resident 1’s room; * Staff 12 assisted Resident 1 with his/her bedding, turned off the call light, exited Resident 1’s room, and re-entered Resident 2’s room without doffing the gloves or completing hand hygiene; and * Staff 12 exited Resident 2’s room, doffed the gloves in the hallway, put the potentially contaminated gloves in her pocket, and entered another resident’s room. b. During meal service observations on 03/12/26 and 03/13/26, Staff 12 delivered Resident 1’s meal to his/her room uncovered, which created the potential for contamination. The facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. The need to ensure universal precautions for infection control were exercised, during meal delivery and before and after ADL care, was discussed with Staff 1 (Executive Director) on 03/13/26 at 4:30 pm. He acknowledged the findings. 2. Resident 2 was admitted to the MCC in 03/2022 with diagnoses including Alzheimer’s disease. Observations were made, from 03/11/26 through 03/13/26, to determine adherence to universal precautions for infection control. The following was identified: a. On 03/12/25 at 10:52 am, the surveyor observed two staff provide incontinence care for Resident 2 in bed and personal hygiene once the resident was sitting in the wheelchair. Both staff donned gloves, without first performing hand hygiene. One caregiver determined the resident’s brief was dry and applied barrier cream to the buttocks, then removed the glove used to apply the barrier cream. Without performing hand hygiene, she donned a clean glove. The same caregiver proceeded to remove the resident’s dislodged heel wound dressing, used wound cleansing spray, dabbed the wound with gauze, and put on a fresh dressing. With the same soiled gloves, the caregiver assisted the resident with donning his/her shirt, cleaned the underarm skin with a washcloth, and touched the Hoyer and sling, wheelchair, cushion for behind the legs, and the toothbrush head. The caregiver removed her gloves and washed her hands. There was no evidence the second caregiver changed her gloves between dirty and clean tasks. b. On 03/12/26 at 12:48 pm, the surveyor observed two staff perform incontinence care after transferring the resident back to bed. Staff 2 (Facility RN) was also present to obtain wound care measurements of the coccyx and heel wound. Two staff were observed donning gloves without first performing hand hygiene. Once the resident was in bed on his/her side, both staff began to remove the soiled brief. One staff left the room to answer Resident 2’s call light, Staff 2 remained to assist Resident 1 and provided peri care with disposable wipes. Staff 2 handed the caregiver the soiled wipes, which she placed on the nightstand, and then the soiled brief, which the caregiver placed on the floor, not in a trash receptacle. The second caregiver returned to the room. There was no observation of either caregiver performing hand hygiene after re-entering the resident room and/or prior to touching the resident’s clean brief, pillows, draw sheet, heel protectors, sling, bed controller, sheet, blanket, and fall mat. The facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) on 03/13/26 at 3:55 pm and he acknowledged the findings.

1- Resident # 1 & # 2 have been reassesssed by the RN and have not had negative effects based on the lack of infection control practices by care staff. 2- Re-training has been provided to all care staff regarding the need to follow handwashing, proper glove donning and doffing, and touching of contaminated surfaces, to include proper disposal of contaminated products, and proper delivery of meal services. 3- Random one on one observations will be conducted to the care staff to ensure compliance. This system will be evaluated weekly to ensure compliance by the RN & RCC. Any areas identified will be reviewed in the Quailty Assurance Committee for system changes as needed. 4- The RN & RCC will be responsible for compliance.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (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 interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications the facility was responsible to administer for 2 of 2 sampled residents (#s 1 and 2) who were administered medications. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and a history of falls. The resident’s physician orders, dated 02/20/26, and the 02/01/26 through 03/11/26 MAR were reviewed, and the following was identified: a. Senna 8.6 mg tablet, give one tablet twice daily, was not administered on 16 occasions between 02/01/26 and 03/11/26 because the medication was not available. During an interview on 03/13/26 at 4:30 pm with Staff 1 (ED), he confirmed the medication was a “house stock” for the facility and the medications were not ordered timely. b. On 02/07/26, Resident 1 had the following new orders: * Take nutrition supplement Ensure twice a day between meals for weight loss. The MAR revealed the nutritional supplement was scheduled at 8:00 am and 5:00 pm, during facility mealtimes, not between meals as ordered. On 03/13/26 at 9:53 am, Staff 6 (MT) confirmed the Ensure was given with breakfast. * Arrange for a dietician consultation for weight loss. On 03/13/26 at 4:30 pm, Staff 1 (ED) confirmed the dietician consultation was not arranged. The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 on 03/13/26 at 4:30 pm. He acknowledged the findings. 2. Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. The resident's 02/01/26 to 03/11/26 MARs and physician orders, dated 02/19/26, were reviewed, and the following was identified: a. The following medications were ordered by the physician: * Bisacodyl 10 mg suppository QD PRN (for constipation); * Glycopyrrolate 1 mg tablet every four hours PRN (for secretions); * Lorazepam 0.5 mg tablet every two hours PRN (for anxiety/shortness of breath); and * Morphine 0.25 mL every four hours PRN (for pain). There was no indication the above orders were transcribed to the resident’s 02/19/26 through 03/11/26 MAR. b. Resident 2’s 02/19/26 – 03/11/26 MAR showed Milk of Magnesia give 30mL once a day as needed for constipation. There was no documented evidence the facility had a signed physician or other legally recognized practitioner order to administer the medication. In an interview on 03/12/26 at 11:35 am, Staff 4 (RCC) acknowledged the above orders were missing from Resident 2’s MAR and there was no order for Milk of Magnesia. The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (ED) on 03/13/26 at 3:55pm. He acknowledged the findings.

1- The residents (#1 & #2) identified in the survey have had their PCP orders reviewed to ensure accuracy of the orders. Additionally, the nutritional supplement timeframes have been adjusted to reflect more appropriate administration timeframes. RN has completed an assessment for weight loss and has determined that the current interventions have been effective for the resident and will reach out if a dietician consultation needs to be completed. Resident #2 has had the PCP orders reviewed for accurate transcriptions to the MAR. 2- All Resident physician orders have been reviewed for accuracy. And updated orders have been sent out to PCP for review and clarification as needed. The RCC and RN will review the MAR and clinical dashboard daily to identify any medications not administered, unavailable medication or transcription discrepancies. If a medication is found to be out of stock, the medication will be reordered immediately, the pharmacy will be contacted the same day, and the physician will be notified as appropriate for any missed or delayed doses. Routine audits of the med cart, MAR & PCP orders will be conducted to ensure medications are available and the physician orders are accurately transcribed and followed as written. Any discrepancies will be corrected immediately and reviewed through the Quality Assurance program. 3- All physician orders will be reviewed, printed and sent out to the PCP's on a routine 90 day schedule. On return of these signed orders, the orders will be reconcilied for accuracy. This system will be reviewed every 90 days and as needed with changes to the residents orders. 4- The RCC and RN will be responsible for compliance.

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must 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 hosed 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 systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident, failed to increase staffing to maintain resident care and services with the use of universal workers and failed to ensure fire safety evacuation standards were met. Findings include, but are not limited to: On 03/11/26 the “ABST [acuity-based staffing tool] Facility Entrance Questionnaire” was provided to the facility and was returned on 03/12/26. The following was noted: * The memory care was home to 23 residents; * The facility had two shifts: Day shift was 6:00 am to 6:00 pm, and the overnight shift was 6:00 pm to 6:00 am; * Five residents required support with dining services; * Three residents required two-person transfers; and * Four residents required assistance with behavioral support. a. On 03/12/26 at 9:34 am, Staff 1 (ED) reported the facility had one housekeeper who also provided direct-care and regularly worked as a caregiver. Staff 1 stated the caregiving job responsibilities included assisting residents with housekeeping, laundry, and dining services in addition to providing direct resident services. The caregiving responsibilities provided by Staff 1, define the role of a universal worker, which was reviewed with Staff 1. Staff 1 confirmed the caregivers met the definition of a universal worker and staffing was not increased to maintain resident care and services with the use of universal workers. b. On 03/13/26 at 10:32 am, Staff 1 reported there wasn’t a current system to ensure time for resident’s unscheduled needs were accounted for on the ABST. c. On 03/12/26 at 12:42 pm, Staff 1 reported fire drills had not been conducted on the overnight shift in the past six months and confirmed he needed to review the overnight staffing plan. The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident, staffing was increased to maintain resident care and services with the use of universal workers, and ensure fire safety evacuation standards were met, was reviewed with Staff 1 on 03/13/26 at 3:19 pm. He acknowledged the findings.

1- The ABST tool has been reviewed and updated to reflect the current resident acuity, including care needs, dining assistance, behavior management, and evaluation requirements. Staffing adjustments have been made to staff up for the use of universal workers, account for unscheduled resident needs, and ensure sufficient overnigt staffing to safely evacuate dependent residents in the event of an emergency. 2- The ABST tool will be updated prior to admission, upon admission, with any change in resident condition, and at least quarterly to reflect both scheduled and unscheduled needs of residents. Daily stand up meetings will include review of residents acuity, unscheduled needs and staffing adjustments. Staffiing levels will be modified based on ABST findings to ensure compliance with fire safety evacuation standards, including overnight staffing requirements. 3- The ABST tool will be reviewed daily in the Stand Up / Clinical meetings to ensure that all care needs have been captured and that the tool itself is accurate. Staffing will be adjusted timely per the tool. This system will be monitored and audited for accuracy minimally 3 times weekly. 4- The ED will ultimately be responsible for compliance.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must 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 hosed 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 systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was reviewed and updated when a resident experienced a significant change of condition, for 1 of 2 sampled residents (#2) and failed to use the results of the ABST to develop and routinely update the facility’s posted staffing plan. Findings include, but are not limited to: The facility’s ABST data and documentation provided with the Department’s “ABST Entrance Questionnaire” was reviewed, and the following was identified: a. Resident 2 experienced a significant change of condition on 12/15/25, and the resident’s individual ABST evaluation noted it was last reviewed and updated on 11/15/25, indicating the resident’s ABST evaluation was not reviewed and updated associated with the significant change of condition. b. On 03/13/26 at 9:34 am, Staff 1 (ED) reported the last update to the posted staffing plan was approximately one year ago and confirmed it was not reflective of the current staffing level. The need to ensure residents’ ABST evaluations were reviewed and updated associated with significant changes of condition and the results of the ABST were used to develop and routinely update the facility’s posted staffing plan was reviewed with Staff 1 on 03/13/26 at 3:19 pm. He acknowledged the findings.

1- The ABST tool has been reviewed to reflect the accurate number of staff needed based on residents care needs, dining assistance and behavior management. To include residents identified on the survey (#1 & #2) Adjustments have been made to reflect these needs as well as the abilty for staff to safely evacuate the dependent resident in the event of an emergency. And this updated and the staffing plan is posted. 2- When the RN identifies a significant change of condition, the ABST will be updated immediately to reflect the residents revised care needs. The community's posted staffing plan will be updated from the revised ABST data the same day to ensure it accurately reflects current resident acuity and staffing requirements. The posted staffing plan will be updated daily and with any changes to resident condiiton or census to ensure ongoing compliance. 3- The ABST tool will be reviewed daily in the Stand Up / Clinical meetings to ensure that all care needs have been captured and that the tool itself is accurate. Staffing will be adjusted timely per the tool. This system will be monitored and audited for accuracy minimally 3 times weekly. Postings will be updated daily and with changes. 4- The ED will ultimately be responsible for compliance.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure unannounced fire drills were conducted on different shifts. Findings include, but are not limited to: On 03/12/26, fire drill and fire and life safety records for the previous six months were requested and reviewed with Staff 1 (ED). The following was identified: a. There was no documented evidence the facility conducted fire drills on the overnight shift. b. Staff 1 scheduled all fire drills at the same time every month. The need to conduct unannounced fire drills on all shifts was reviewed with Staff 1, on 03/13/26 at 3:19 pm. He acknowledged the findings, and no additional documentation was provided.

1. The Maintenance Manager will have required unannounced fire and life safety drills monthly from day and night shift. 2. The Maintenance Manager will conduct unannounced fire drills rotating from day to night monthly. 3. The system will be evaluated once a month during monthly management meetings. 4. The Executive Director will be responsible for compliance.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0200 (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, the facility failed to keep all interior materials and surfaces clean and in good repair and to keep the interior free from unpleasant odors. Findings include but are not limited to: From 03/11/26 through 03/13/26, the interior of the facility was toured and the following was identified: a. The following areas were noted to be unclean and/or in need of repair: * Walls, baseboards, and wall corners had scratches, paint chips, and/or gouges in multiple areas throughout the facility; * The following doors and/or door frames were scratched, chipped, and/or gouged: Resident room #s 1, 2, 3, 6, 10, and 14, “Shower Room 2,” and the Medication Room; * The flooring was chipped, scratched, and peeling in the dining room, television/living room, and in the corridor intersection near room 13 and the television/living room, and there was an approximate one by one inch hole outside the “Fire Riser Room”; * Three dining chair seat cushions had scuffed and peeling seats, making them uncleanable; * The television/living room had what appeared to be an air conditioning unit mounted at the top of a wall which was noted to have dark spot and appeared unclean; and * The flooring throughout the facility had multiple areas with dark spots, dirt/dust, food wrappers, and food debris and were sticky. b. Throughout the survey, a pervasive, unpleasant odor was noted throughout the facility. On 03/13/26 at 11:36 am, a walk-through was completed with Staff 1 (ED) and at 12:04 pm, Staff 1 stated he agreed with the areas identified above. The need to ensure all interior materials and surfaces were clean and in good repair and the interior was kept free from unpleasant odors was reviewed with Staff 1 on 03/13/26 at 3:19 pm. He acknowledged the findings.

1. Maintenance Manager will repair identified areas including walls, wall corners and baseboard and flooring in the DR, tv/living room, corridor by 13 and Fire riser room. The dining chairs that are uncleanable will be replaced or repaired 2. Maintenance will conduct a monthly walkthrough with the Executive Director to ensure the community remains in good condition, and a dedicated housekeeper will be hired. 3. Monthly by Maintenance and Executive Director during cheduled environmental rounds to ensure community remains in good condiiton and compliant with regulations. 4. The Executive Director will be responsible for compliance.

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

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation, including the Department-approved LGBTQIA2S+ course, was completed prior to beginning job responsibilities for 2 of 4 newly hired staff (#s 7 and 11) whose training records were reviewed. Findings include, but are not limited to: Refer to Z155.

1- The staff that have been identified in the survey have been given clear instructions and guideance that the training modules are completed. 2- All employee files have been auditied to ensure that all required training is completed per rules. All new hires will be audited for completion of the required trainings and current staff will be promted with required on going required trainings. This is include all pre-servcie orientation, Department approved LGBTQIA2S+ course. 3-All employee files will be audited on hire, upon completion of all of the required training for compliance, or they will not be allowed access to the residents unitl completed. Routine auditing will be completed monthly for compliance. The Business Office Manager and the ED are responsible for over all compliance.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C295, C360, C363, C420, and C513

Refer to C231, C295, C360, C363, C420, and C513

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 7, 8, 11, and 12) completed all pre-service orientation training prior to beginning their job responsibilities and completed all required pre-service dementia trainings prior to independently providing personal care or other services to residents. Findings include, but are not limited to: Staff training records were reviewed on 03/12/26 at 10:52 am, with Staff 3 (Business Office Manager), and the following was identified: a. There was no documented evidence Staff 7 (MT), hired 07/10/25, Staff 8 (MT), hired 08/29/25, Staff 11 (CG), hired 10/22/25, and Staff 12 (Housekeeper/CG), hired 10/02/25, completed required pre-service orientation training prior to beginning job duties in one or more of the following areas: * Abuse reporting requirements; * Fire and safety and emergency procedures; * Infectious disease prevention; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 7, Staff 8, Staff 11, and Staff 12 completed one or more of the following pre-service dementia training topics prior to independently providing personal care or other services to residents: * 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; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities. The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was reviewed with Staff 1 (ED) on 03/13/26 at 3:19 pm. He acknowledged the findings, and no additional documentation was provided.

1- All employee files have been audited for compliance for the required training in this Z155 area of regulations. (OAR 411-054-0070(3). All training, has been completed. 2- All employee files will be reviewed on hire, 30 day, on going required training of 16 hours of in-servicing annually, 6 hours of annual Dementia training, to include the Pre-service dementia training, and other trainings as outlined in the rule. Staff competencies will be completed annually to ensure that trainings are documented by the community. 3- The Business Office Manager will be auditing all employee files to ensure compliance on a weekly basis for compliance. 4- The business Office Manager and ED will be responsible for compliance.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C280, C290, and C303.

*** Refer to C260, C270, C280, C290, and C303.

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: