Print Inspection: RL010086

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 2 sampled residents (#1) who received health services from outside service providers. Findings include, but are not limited to: Resident 1 moved into the MCC in 08/2025 with diagnoses including Alzheimer’s disease and dementia with behavioral disturbance. During the acuity interview on 03/16/26, it was reported the resident was recently admitted to hospice services. Review of the resident’s observation notes and outside provider notes from 12/16/25 through 03/16/26, identified the following: * Multiple occasions where the resident yelled at staff and other residents; * Multiple occasions where the resident called law enforcement; * Multiple resident-to-resident verbal altercations; * Emergency room visits for unmanaged behavioral expressions; * Expressions of being unhappy, wanting out of the memory care, trying to get kicked out of the memory care, and expressions of self-harm; * On 12/21/25, the primary care physician responded to the resident’s increased behaviors to “Please add Behavioral health from [company name]”; * On 02/15/26 a hospice provider note read, “PT [patient] would benefit social [sic] work evaluation for behavior.”; and * On 02/18/26 a hospice provider note read, “Wants Therapy.” There was no documented evidence the facility assisted the resident with coordinating appointments with the above outside service providers to ensure the resident’s health needs were met. The need to ensure the facility coordinated on-site health services with outside service providers was discussed with Staff 2 (Administrator), Staff 3 (Regional Director of Operations), and Staff 5 (Regional RN) on 03/18/26 at 10:18 am. They acknowledged the findings.

1. Resident #1’s record was immediately reviewed by the licensed nurse and facility management to determine unmet coordination needs related to outside health services. The facility initiated coordination with applicable outside providers, including hospice and behavioral health resources, to address the resident’s identified behavioral health and supportive service needs. 2. The facility will revise its process for coordinating on-site and off-site health services to ensure recommendations from outside providers are reviewed, acted upon, and documented timely. A standardized tracking process will be implemented for all outside provider recommendations, referrals, appointments, and follow-up services. Facility policy will be reviewed with nursing and management staff to reinforce requirements that: 1. outside provider recommendations are communicated to facility management or the nurse, 2. written documentation from outside providers is maintained in the resident record, 3. service plans are reviewed and updated timely when new interventions or services are identified, and 4. protocols are followed to coordinate needed on-site or off-site services for residents who do not independently manage their own healthcare needs. 3.On-going internal audit will be conducted for the current Memory Care residents receiving services from outside providers, including hospice, home health, behavioral health, and other supplemental healthcare services, to ensure: • Provider recommendations are documented in the resident record, • Required follow-up appointments or referrals have been coordinated, • Communication from outside providers is present in the chart, and • Service plans have been updated as applicable. Any identified concerns will be addressed promptly through record updates, coordination with providers, and service plan revisions, as appropriate. 4. The nurse or designee will audit all new outside provider notes, recommendations, and related service plan changes weekly for 4 weeks, then monthly for 2 months, and ongoing via sampling to ensure: • outside provider services and recommendations are documented, • necessary referrals and appointments are coordinated, • relevant provider information is included in the resident record, and • service plans are adjusted timely when needed.

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 09/2025 with diagnoses including Alzheimer’s disease and malnutrition. Resident 2's current physician orders, dated 03/12/26, and MARs from 02/01/26 through 03/16/26 were reviewed, and interviews with facility staff and the outside provider were conducted. The resident was hospitalized from 03/01/26 through 03/12/26 for a urinary tract infection and dehydration. Upon discharge from the hospital, s/he was subsequently admitted to hospice on 03/12/26 due to “nearing end of life.” A hospice clinical note, dated 03/12/26, contained the following physician orders: * “Check on [Resident] every 1-2 hrs (hours)”; * “Every 2 hours alternate pillow support”; * “Keep heels elevated off of bed”; and * “[Resident] wil [sic] need to be fed. [S/he] can have a general diet if [s/he] would like, but may do best with soft foods (pudding/ice cream/mashed potatoes)”. During observations on 03/17/26 and 03/18/26, Resident 2 was noted to be lying in bed on his/her back at all times with eyes closed. Resident’s heels were not floated and were in direct contact with the sheets. No repositioning by staff was observed on 03/17/26 from 09:46 am until 1:29 pm, or at any other time during the observation, nor was pillow support alternated during this time. The resident was not offered or fed lunch on 03/17/26 or breakfast on 03/18/26. During an interview on 03/18/26 at 10:57 am, Staff 11 (MT) stated the staff offers food when the resident is awake. During an interview on 03/18/26 at 11:06 am, Staff 14 (CG) stated the resident has not been fed breakfast “because s/he is not lucid/awake yet.” Staff 14 demonstrated the assigned care tasks for Resident 2 in care coordination software but acknowledged the tasks had not been updated since the resident returned from the hospital. Staff 14 stated the resident became bed-bound after hospital discharge. The tasks were updated on 03/18/26 during the survey. On 03/18/26 at 11:37 am, Staff 14 was observed providing Resident 2 with a protein shake, of which the resident consumed about 90%. Resident 2 appeared to be awake and easily aroused when prompted by care staff. On 03/18/26 at 2:54 pm, Staff 12 (MT) stated Resident 2 “has not eaten much lately, had one hamburger in eleven days while in hospital. Hospital could not get [him/her] to eat. Usually, caregivers offer food or drinks.” The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 2 (Administrator) and Staff 3 (Regional Director of Operations) on 03/19/26 at 9:49 am. They acknowledged the findings. 2. Resident 1 moved into the MCC in 08/2025 with diagnoses including Alzheimer’s disease, dysphasia, and esophageal obstruction. Review of the resident’s signed physician orders, dated 01/11/26, and the 02/01/26 through 03/16/26 MARs identified the following: * The resident was prescribed omeprazole 20 mg delayed release tablet, give one tablet daily. The 02/01/26 through 03/16/26 MARs showed the resident was administered one 20 mg capsule every other day. The facility failed to carry out the omeprazole 20 mg order, as prescribed, for 25 doses between 02/01/26 and 03/16/26. The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (Administrator), Staff 3 (Regional Director of Operations), and Staff 5 (Regional RN) on 03/18/26 at 10:18 am. They acknowledged the findings.

1.Upon identification of the concern, the Administrator and licensed nurse collaborated to complete an immediate review of care and medication practices for Residents #1 and #2. For Resident #2, hospice orders were reviewed in full, and care staff were re-educated on required interventions, including repositioning, heel elevation, routine checks, and feeding support. The resident’s care plan and task list in the care coordination system were updated to reflect current physician and hospice orders. Staff began implementing interventions as prescribed, including repositioning schedules and nutritional support. For Resident #1, the medication administration record (MAR) and physician orders were reconciled. The discrepancy related to omeprazole administration was corrected, and staff were re-educated on ensuring medications are administered exactly as prescribed. Ongoing monitoring was initiated to ensure compliance. 2. The facility will strengthen processes to ensure all medication and treatment orders are accurately transcribed, updated, and carried out as prescribed. This includes: • Implementing a standardized process for reviewing and updating care tasks and MARs following hospital discharge, hospice admission, or any change in condition • Ensuring all written and signed physician or practitioner orders are promptly entered into the resident record and care systems • Reinforcing that only licensed practitioners may change orders, and staff must not alter administration practices without a documented order • Providing focused education to care staff and medication technicians on following orders as written, including hospice-specific care needs and feeding expectations 3. An audit will be conducted for Memory Care residents with active medication and treatment orders, including those receiving hospice or other outside services, to ensure: • Medication administration records match current physician or practitioner orders • Treatment and care tasks reflect current orders and resident condition • Orders related to repositioning, nutrition, and specialized care are being carried out as prescribed • Documentation supports that care and medications are administered according to orders Any identified discrepancies will be corrected promptly through order clarification, record updates, and staff re-education. 4.The nurse and program manager/Director will be responsible for overseeing the corrections, completing the audit, and ensuring medication and treatment orders are carried out as prescribed. The nurse or designee will complete: • Weekly audits of MARs, treatment records, and care tasks for 4 weeks • Monthly audits for 2 additional months, and as needed or indicated by review. Audits will ensure: • Orders are accurately transcribed and current • Medications are administered as prescribed • Treatment interventions are completed and documented appropriately.

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 411-054-0037 (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) data was updated no less than quarterly, at the same time the resident's service plan was updated, for 12 unsampled residents whose ABST evaluations were reviewed. Findings include, but are not limited to: The facility’s ABST was reviewed on 03/16/26 at 3:26 pm. The following was identified: ABST data for 12 of 26 residents was not updated at least quarterly, at the same time the resident's service plan was updated. The need to ensure residents’ ABST data was updated no less than quarterly, at the time of their quarterly service plan update, was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 03/17/26 at 9:30 am. They acknowledged the findings

1.-The ABST shall be completed prior to resident admission, updated promptly following any significant change in the resident’s condition, and reviewed no less than quarterly in alignment with scheduled service plan updates to ensure ongoing accuracy. 2.-The facility will implement the following system improvements: • Establish a centralized tracking system (electronic or manual) to monitor ABST due dates, including admission, significant change, and quarterly reviews • Develop a standardized workflow aligning ABST updates with service plan reviews • Provide staff re-education and training on ABST requirements and timelines • Assign designated responsibility (e.g., Administrator or Nurse) for oversight and compliance monitoring • Implement routine monthly audits to ensure ongoing adherence 3.- The Administrator or designee will conduct the following audits: • Monthly audits for three (3) months of: - ABST completion and update timeliness - Alignment between ABST data and posted staffing plan - Verification that staffing levels meet or exceed the posted plan 24 hours per day, seven (7) days per week - Audit findings will be documented and reviewed with the leadership team. Any identified concerns will result in immediate corrective action, including re-education or process adjustments. - After the initial monitoring period, compliance will be maintained through ongoing quarterly reviews aligned with service plan updates. 4.-The Administrator will maintain primary responsibility for ensuring completion of all corrective actions and sustained compliance. The Nurse will assist with day-to-day oversight, including monitoring ABST completion, conducting audits, and reporting findings to the Administrator for review and follow-up

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 411-057-0140(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 interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 363.

Please Refer back to C363

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

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

Please refer back to 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: