Inspection·January 22, 2026

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent a confused resident (R1) from wandering into another resident's (R2) room. This failure resulted in both residents being found in bed together and R2 was inappropriately exposed. This failure affected one (R1) of three residents reviewed for quality of care in the sample of 3.The findings include:1. Review of facility's final incident report reads in part: on 01/16/2026, staff entered a resident room and observed a fully dressed female resident lying in bed with a male resident. The male resident was unclothed. The male resident's hands were observed resting on the bed, and the female resident's hands were positioned at her sides. No movement or sexual activity was observed at the time of discovery. Both residents appeared calm and exhibited no signs of distress. Staff immediately separated the residents.A post-incident body assessment of the female resident revealed clothing intact with incontinence brief in place. No injuries, bruising, or signs of trauma were noted. The male resident also exhibited no injuries. Both residents were interviewed and were unable to recall how or why they were in bed together or whether any interaction had occurred. The staff witness reported that no motion, refusals, verbalizations, or indications of negative or inappropriate behavior were observed. The male resident has no prior history of sexually inappropriate behavior and is typically quiet and remains in his room.The investigation was conducted in accordance with facility policy and federal regulations. Based on the findings, the allegation of sexual abuse is determined to be unsubstantiated. No further behaviors or concerns have been observed.R1's face sheet documented an admission date of 02/28/2023 with a past medical history not limited to: Alzheimer's Disease, need for assistance with personal care, mood [affective] disorder, psychosis, anxiety disorder and Dementia. R1's abuse/neglect assessment dated [DATE] documented R1 scored 6 that indicates she is at high risk for abuse/neglect (high: 6-7 intense: 8-12).R1's wandering/elopement assessment dated [DATE] documented resident is at high risk for wandering/elopement due to diagnosis of Dementia/Alzheimer's/confusion, independently mobile, paces/wanders, and history of elopement/wandering. R1's Minimum Data Set (MDS) Section C Brief Interview for Mental Status (BIMS) Evaluation (page 11 of 59) dated 01/09/2026 indicated R1 has severe cognitive impairment.R1's care plan last reviewed 01/16/2026 reads in part: has diagnosis of dementia and utilizes staff assistance with activities to ensure highest level of psycho-social functioning. Interventions included: allow her to socialize with others in common areas and encourage R1 to participate in group programs. R1's care plan also documented she is an elopement risk/wanderer related to impaired safety awareness, dementia, and Alzheimer's disease. Interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, has a baby and enjoys caring for it, provide structured activities such as toileting, walking inside, and reorientation strategies including signs, pictures and memory boxes.R1's progress note dated 01/16/2026 at 09: 12 PM (21:02) documented that R1 was in another male resident bed Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145476 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oregon Living and Rehabilitation Center 811 South 10th Street Oregon, IL 61061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)