Print Inspection: RL012377

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system with adequate professional oversight. Findings include, but are not limited to: Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: C 302: Systems: Tracking Controlled Substances; C 303: Systems: Medication and Treatment Orders; C 330: Systems: Psychotropic Medication. The need to ensure adequate professional oversight of the medication and treatment system was discussed at 2:32 pm on 06/10/26 with Staff 1 (Administrator), Staff 2, Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

•MCC ED or Designee reviewed Resident survey selection and addressed concerns identified. •Pharacy Audit of MC medication systems being scheduled and completed addressing concerns identified. •MCC Director or Designee will conduct random audits via observation and or documentation review on medication systems weekly x 3 weeks then monthly x 2 months •MCC Director is responsible.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a system for tracking controlled substances for 1 of 1 sampled resident (#2) whose record was reviewed for controlled substances. Findings include, but are not limited to: Resident 2 was admitted to the MCC in 02/2026 with diagnoses including dementia. The resident’s current signed orders and 05/01/26 to 06/09/26 MAR and controlled substance disposition log were reviewed, and the following was identified: The resident had orders for morphine sulfate, 15 mg tab, administer one tablet by mouth every hour PRN for pain. The controlled substance disposition log showed staff administered the medication four times. On two occasions, the MAR lacked a corresponding entry. On 06/10/26 at 2:32 pm, the discrepancies were reviewed, and the need to ensure a system for tracking controlled substances was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

•MCC ED or Designee reviewed Resident #2 controlled substance records were reviewed addressing concerns identified. •MCC Director or Designee audited current Memory Care Residents controlled substance records, addressing concerns identified. •MCC Director or Designee re-educated Med Techs on the controlled substance system for tracking including documentation requirements. •MCC Director or Designee will conduct random audits via observation and or documentation review on controlled substance tracking system weekly x 3 weeks then monthly x 2 months •MCC Director is responsible.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 1 sampled resident (#1) whose medication and treatment orders were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the MCC in 04/2026 with diagnoses including Alzheimer's disease and anxiety. The resident’s signed prescriber orders and 04/17/26 to 06/09/26 MARs were reviewed, and the following was identified: The resident had an order for buspirone 5 mg tab, administer one tablet by mouth every day PRN 15 to 20 minutes “before husband leaves home to reduce anxiety.” The MAR showed staff administered the medication on multiple occasions, including up to three times per day, during a period when Resident 1’s spouse was banned from the MCC pending a police investigation. In an interview at 10:22 am on 06/10/26, Staff 8 (Lead MT) confirmed the resident’s spouse had not been in the facility during the dates the medication was administered. The need to ensure orders were administered as prescribed was discussed at 2:32 pm on 06/10/26 with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

•MCC ED or Designee reviewed Resident #1 PRN medication administration addressing concerns identified. •MCC ED reviewed current Memory Care Resident’s PRN medication administration as compared to order for the last 30 days addressing concerns identified. •MCC ED or Designee re-educated Med Tech on requirement to administer orders as prescribed •MCC ED or Designee will conduct random audits on PRN medication administration weekly x3 weeks then monthly x 2 months. •MCC ED is responsible.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure documentation that non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medication for 1 of 1 sampled resident (#1) whose record was reviewed for PRN psychotropic medication. Findings include, but are not limited to: Resident 1 was admitted to the MCC in 04/2026 with diagnoses including Alzheimer's disease and anxiety. The resident’s signed prescriber orders and 04/17/26 to 06/09/26 MARs and progress notes were reviewed, and the following was identified: The resident had orders for: * Buspirone 5 mg tab, administer one tablet by mouth every day PRN 15-20 minutes “before husband leaves home to reduce anxiety,” that was discontinued on 05/22/26; * Haloperidol, 1 mg tab, administer one tablet by mouth every hour PRN for agitation, that was started on 05/26/26; and * Lorazepam, 0.5 mg tab, administer one tablet by mouth every three hours PRN for anxiety, that was started on 05/28/26. There was no documented evidence that staff attempted non-pharmacological interventions with ineffective results prior to administering any of the above PRN psychotropic medications. Additionally, the MAR lacked resident-specific parameters for how Resident 1 demonstrated agitation and anxiety. The need to ensure written, resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications was discussed at 2:32 pm on 06/10/26 with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

•MCC ED or Designee reviewed Resident #1 PRN Psychotropic medications for non-pharmacological interventions and resident-specific parameters, addressing concerns identified. •MCC ED reviewed current Memory Care Resident’s PRN psychotropic medications for non-pharmacological interventions and resident specific parameters, addressing concerns identified. •MCC ED or Designee re-educated Med Tech on requirement that non-pharmacological interventions are tried with ineffective results prior to administering PRN psychotropic medications as well as resident-specific parameters. •MCC ED or Designee will conduct random audits on PRN psychotropic medications for compliance weekly x3 weeks then monthly x 2 months. •MCC Director is responsible.

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 updated and reviewed prior to a resident moving in for 1 of 1 sampled resident (#1) whose ABST was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the MCC in 04/2026 with diagnoses including Alzheimer's disease. The resident’s ABST evaluation was reviewed and showed it was not created until nine days after the resident moved in. In an interview at 8:15 am on 06/10/26, Staff 1 (Administrator) and Staff 5 (Resident Services Director) both confirmed Staff 1 was responsible for completing the ABST, was new to the role, and was still learning how to complete it. The need to ensure the ABST was reviewed and updated prior to resident move-in was discussed at 2:32 pm on 06/10/26 with Staff 1, Staff 2 (ED), Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

•MCC ED or Designee reviewed Resident #1 as compared to ABST addressing concerns identified. •MCC ED or Designee reviewed current MC Residents as compared to ABST, addressing concerns identified. •MCC ED was re-educated on the requirement that ABST is updated and reviewed prior to resident moving in. •MCC or Designee will conduct audits on new MC move-ins for ABST evaluation timeliness weekly x 3 weeks then monthly x 2 months. •MCC Director is responsible.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired direct care staff (#10) demonstrated competency in first aid within 30 days of hire and 2 of 2 newly hired direct care staff (#s 9 and 10) demonstrated competency in abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (ED) at 12:20 pm on 06/10/26. The following was identified: Staff 9 (CG) was hired on 03/31/26, and Staff 10 (CG) was hired on 05/05/26. There was no documented evidence Staff 9 and Staff 10 completed abdominal thrust training within 30 days of hire, and there was no documented evidence Staff 10 completed first aid training within 30 days of hire. The need to ensure newly hired direct care staff demonstrated competency in first aid and abdominal thrust training within 30 days of hire was discussed at 2:32 pm on 06/10/26 with Staff 1 (Administrator), Staff 2, Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

•Staff #10 and #9 completed training required within 30 days of hire •MCC ED or Designee reviewed current MC staff’s training record for 30 days of hire compliance, addressing concerns identified. •MCC ED was re-educated on the direct care staff required training within 30 days of hire •MCC ED or Designee will conduct audits on newly hired direct care staff on training compliance weekly x 3 weeks then monthly x 2 months. •MCC Director is responsible.

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, it was determined the facility failed to ensure fire drills were conducted per the Oregon Fire Code (OFC) and fire and life safety was provided on alternate months from fire drills. Findings include, but are not limited to: The building housed an assisted living and MCC with separate licenses. Six months of fire drill and fire and life safety records were requested at survey entrance on 06/09/26. Records were reviewed in an interview with Staff 2 (ED) at 9:02 am on 06/10/26. The following was identified: * There was no documented evidence fire drills were being conducted in the MCC; and * There was no documented evidence fire and life safety training for staff was being conducted on alternate months. The need to ensure fire drills were conducted per OFC and fire and life safety training was provided to staff on alternate months from fire drills was discussed at 2:32 pm on 06/10/26 with Staff 1 (Administrator), Staff 2, Staff 3 (RN), Staff 4 (Health Services Director), and Staff 5 (Resident Services Director). They acknowledged the findings.

• Fire Drill will be completed in MCC on June 30, 2026. •MCC ED or Designee re-educated the Maintenance Director on the requirement to complete Fire Drills and fire & lift safety training conducted on alternate months. •MCC ED or Designee will conduct audits on Fire Drills/Fire & Life Safety training for compliance weekly x 3 weeks then monthly x 2 months. •MCC Director is responsible.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exterior pathways were smooth and maintained in good repair. Findings include, but are not limited to: The exterior MCC courtyard was observed at 2:26 pm on 06/09/26. There were multiple cracks and uneven surfaces in several areas of the concrete walkway, near the courtyard furniture, creating a potential fall hazard for residents accessing the courtyard. In an interview at 1:00 pm on 06/10/26, Staff 15 (Maintenance Director) stated, “We know we need to do something about that.” The pathways were shown to and the need to ensure exterior pathways were smooth and maintained in good repair was discussed with Staff 1 (Administrator) at 1:00 pm on 06/10/26. She acknowledged the findings.

•Exterior Courtyard concrete walkways were addressed •MCC ED or Designee walked the exterior areas for good repair, addressing concerns identified. •MCC ED re-educated the Maintenance Director on the requirement to keep exterior areas in good repair •MCC ED or Designee will conduct random audits of MC exterior areas weekly x 3 weeks then monthly x 2 months. •MCC ED is responsible.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior of the building was maintained clean and in good repair. Findings include, but are not limited to: The MCC was toured at 2:20 pm on 06/09/26. The following was identified: * The fabric chairs in the common television room had multiple dark stains on the seats and arms; * The linoleum in the dining room had long scratches and two areas covered with peeling tape; * The door to the exterior courtyard had chipped paint in multiple areas; and * Walls throughout the MCC had patches of primer and lacked paint. The interior was toured with and the above areas were shown to Staff 1 (Administrator) and Staff 15 (Maintenance Director) at 1:00 pm on 06/10/26. They acknowledged the findings.

•The Chairs in the common television room have been cleaned or replaced, the linoleum in the dining room has been replaced, the door to the exterior courtyard had been painted, the walls throughout MCC have been painted. •The MCC ED conducted a walkthrough of the MCC noting any additional areas not clean or in good repair, addressing items identified. •The MCC ED re-educated the Maintenance Director of the requirement to keep the interior of the building clean and in good repair. •The MCC ED will conduct random audits on the interior of MCC for compliance weekly x 3 weeks then monthly x 2 months. •The MCC ED is responsible.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure each individual had privacy in his or her own unit for multiple sampled and unsampled residents who shared bathrooms. Findings include, but are not limited to: In the acuity interview at 1:43 pm on 06/09/26, the resident roster was reviewed and showed eight of the current 13 residents were housed in a shared unit. Observations made on 06/09/26 at 2:26 pm showed the following: All units in the MCC were constructed to house two residents with a shared bathroom in the unit. Units 134 and 139 were observed and lacked a locking mechanism on the shared bathroom door to ensure residents’ privacy in the unit. In an interview at 2:26 pm on 06/09/26, Staff 1 (Administrator) confirmed none of the units’ shared bathrooms had locking mechanisms. The need to ensure an individual’s right to privacy in his or her own unit was discussed at 2:32 pm on 06/10/26 with Staff 1, Staff 2 (ED), Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

•Locks will be installed in MC Shared Restrooms to create individual privacy for MC residents. •The MCC ED is responsible.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure keys were provided to individuals to access their units for 1 of 2 sampled residents (#1) and multiple unsampled residents. Findings included, but are not limited to: At 1:20 pm on 06/10/26, Staff 1 (Administrator) was asked to describe the system to provide keys to residents for their units. Staff 1 confirmed there was no system to ensure MCC residents were provided keys to their units. She further confirmed Resident 1 had not been provided a key at admit. Staff 8 (Lead MT) stated during the same interview the prior system was to provide residents with a key at admit and place it on a hook near the entrance door. She stated currently only two unsampled residents had keys to their units. Observations of Rooms 139 and 140 showed no keys hanging near the entrance door. The need to ensure individuals were provided keys to access their units was discussed at 2:32 pm on 06/10/26 with Staff 1, Staff 2 (ED), Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

•Apartment keys to be provided to resident or resident responsible party to provide access to their unit. •The MCC ED is responsible.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C363, C372, C420, C510, and C513.

See attached POC for citations C363, C372, C420, C510, C513.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 9 and 10) completed preservice orientation training, including dementia care training, prior to beginning job responsibilities and demonstrated competency in assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (ED) at 12:20 pm on 06/10/26. The following was identified: Staff 9 (CG) was hired on 03/31/26, and Staff 10 (CG) was hired on 05/05/26. 1. There was no documented evidence Staff 9 and Staff 10 completed the following training prior to providing personal care: * Environmental factors that are important to a resident’s well-being; and * Family support and the role the family may have in the care of the resident. 2. There was no documented evidence Staff 9 and Staff 10 completed the following prior to providing care and services independently: * Use of supportive devices with restraining qualities in MCC. 3. There was no documented evidence Staff 9 and Staff 10 demonstrated competency in the following areas within 30 days of hire: * Providing assistance with ADLs; * Identification, documentation, and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure direct care staff completed all preservice orientation training requirements and demonstrated competency in assigned job duties within 30 days of hire was discussed at 2:32 pm on 06/10/26 with Staff 1 (Administrator), Staff 2, Staff 3 (RN), Staff 4 (Health Services Director), Staff 5 (Resident Services Director), Staff 6 (Regional Director of Operations), and Staff 7 (Vice President of Clinical). They acknowledged the findings.

• MC Staff 9 and 10 completed all pre-service required training. • MC audit of staff required training will be completed, following audit staff with missing training will complete trainining required. • Employee tracker for required onboarding and ongoing training will be implemented and maintained. • MCC ED Responsible

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on 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 C300, C302, C303, and C330.

See attached POC for citations C363, C372, C420, C510, C513.