OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#2) who had a diagnosis of Alzheimer’s dementia and a known behavioral history of leaving the community unsupervised. This placed the resident at risk and constituted an immediate threat to the resident’s physical health, safety and welfare. Findings include, but are not limited to: Resident 2 moved into the facility in 01/2026 with diagnoses including Alzheimer’s dementia. During the acuity interview on 09/21/26 at approximately 12:08 pm, Resident 2 was identified to have left the facility unobserved and would require cueing back to the facility if staff saw him/her outside unsupervised. The resident's service plan available to staff, dated 07/21/26, evaluation dated 07/20/26, incident reports, and caregiving notes were reviewed, observations of the resident were made, and interviews with staff were conducted. The evaluation noted, “[Resident 2] is not to leave the community unsupervised due to having dementia. [Resident 2] is only to leave the facility with [family].” However, the service plan noted, “[Resident 2] doesn’t exhibit any exit seeking behaviors and isn’t an elopement risk at this time.” An incident report dated 08/07/26 at 7:35 pm noted Resident 2 walked to a local community member’s home north of the facility and the resident appeared “…very antsy and [seemed] eager to roam.” The investigation noted the resident was walked back to the facility by the community member and a staff member assisted when s/he observed the resident at the community member’s home. There was no documented evidence the facility re-evaluated Resident 2’s risk for elopement, or the service plan had been updated with interventions specific to elopement. On 09/23/26 at 1:20 pm, Staff 1 (ED) stated, “Staff are to watch pagers closely for any north door alerts to ensure [the resident] is not trying to go back there [out the exit door]. Signs have also been implemented.” Additionally, Staff 1 confirmed there was no documented evidence Resident 2 had been re-evaluated or the service plan had been updated. In an interview with Staff 10 (Care Partner) on 09/23/26 at 3:17 pm, he stated he would be concerned about Resident 2’s ability to find his/her way back to the facility if s/he exited the community. Additionally, he saw Resident 2 exit the community on one other occasion (aside from the 08/07/26 incident) and had to escort him/her back inside. In an interview with Staff 8 (Care Partner) on 09/23/26 at 3:25 pm, she stated Resident 2 would get confused/disoriented and would not be able to find his/her way back to the facility if they exited independently. Additionally, she had to escort Resident 2 back inside the community when the resident exited unsupervised. On 09/22/26 at 1:15 pm, Resident 2 was observed ambulating in the hallway, approached the front door, looked outside for approximately 15-20 seconds, started to open the front door, and then turned around and walked back to her room. There was no documented evidence of what precautions or interventions the facility took to ensure the safety of Resident 2. The facility's failure to evaluate Resident 2’s behavior, determine interventions, and take actions to ensure the health, safety, and welfare of Resident 2 constituted an immediate threat to his/her physical health, safety, and welfare. An immediate plan of correction was requested from Staff 1 and Staff 3 (Assistant Director) on 09/23/26 at approximately 2:40 pm. The facility provided a plan of correction that was accepted on 09/23/26 at 4:32 pm. The immediate risk was addressed; however, the facility must evaluate the overall systemic failures associated with this specific violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 and Staff 3 on 09/24/26 at 12:50 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation; o This is specific to the resident. Resident has been evaluated for the behavior and has a new updated service plan and evaluation for interventions to prevent exiting the facility across the street and keeping resident safe. Locking exit doors following dinner and staff being alert of opening doors from pagers. Continuing frequent checks of 45 minutes on resident as outlined in service plan, and keeping exit signage on North exit door next to resident room. Staff are also to lower blinds in her living room in the evenings to prevent her from looking directly at the house she believes is her sons. Resident door alarm has also been placed on resident specific apartment door to inform staff any time the door opens from her apartment and respond directly each time this alarm goes off. If the resident chooses to exit the facility following re direction, staff are to walk with her until she returns and call her family to be present with her as needed. Director and Assistant Director may also respond to assist. 2. How will the system be corrected so these violations will not happen again; o What system or process will change to ensure similar situations will not happen again. The facility shall assess residents for elopement risk, implement individualized interventions, educate staff, and maintain procedures for immediate response if a resident leaves the facility without authorization or supervision. All employees shall receive training upon hire and annually regarding elopement prevention, wandering behaviors, dementia-related behaviors, resident supervision, emergency response procedure. Staff are to always alert management if any resident has exit seeking behaviors following elopement training and changes of condition training all take upon hire. Staff are to document concerns or behaviors and inform RN and ED immediately to ensure if any interventions or plans need to be put in place at that time for safety. 3. How often will the area needing correction be evaluated; and o Who will be monitoring the corrections to the rule violation with regards to the resident and the system to ensure the plan or new system is working. Executive Director and Assistant Director will re-evaluate interventions for effectiveness in first 30 days or prior as needed, then every 90 days to ensure methods are effective and change plans as needed/ if necessary. 4. Who will be responsible to see that the corrections are completed? o Name of individual or individuals to oversee corrections are completed. Hanna Bass- Executive Director April Holm- Assistant Director

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included the reason for use and dosage, resident-specific parameters, and instructions for medications, for 1 of 2 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 06/2022 with diagnoses including dementia. The resident’s clinical record was reviewed, including the 09/01/26 through 09/21/26 MARs and physician orders. The following was identified: a. The following orders lacked a reason for use: * Mirtazapine 7.5 mg; * Trazodone 50 mg (at bedtime); * Fentanyl 12 mcg/hr patch; * Haloperidol lactate 2 mg; and * Magic mouthwash. b. The order for Morphine sulfate concentrate (for pain) was to administer “2.5 – 5mg” [sic] and lacked clear direction to unlicensed staff for dosage to administer. c. The following orders were not transcribed accurately to the MAR: * There was an order for Acetaminophen 325 mg (for pain) to be administered three times daily, however the MAR indicated the medication was “as needed”; * There was an order for Miralax 17-gram pack (for constipation) to be administered daily, however the MAR indicated the medication was as needed, and lacked instructions to “…hold if the resident presented with diarrhea...”; and * There was an order for trazodone 100 mg to be administered once daily, however the MAR revealed the facility was administering 50 mg at 9:00 am and 7:00 pm. d. The following orders lacked resident specific parameters and instructions for as needed bowel medications for constipation: * Bisacodyl 10 mg suppository; * Dulcolax 10 mg suppository; * MiraLAX 17-gram pack; * Milk of magnesia 30 ml; * Polyethylene glycol powder; and * Fleet enema. e. The following orders lacked resident specific parameters and instruction for as needed pain medication: * Morphine sulfate take 2.5 mg – 5 mg; * Acetaminophen 650 mg suppository; and * Tylenol 325 mg. On 09/22/26 at 11:35 am, the MAR was reviewed with Staff 4 (Lead) and he confirmed facility staff administered “as needed” medications for constipation and pain differently for Resident 1. The need to ensure resident MARs were accurate and included the reason for use, dosage, resident-specific parameters, and instructions for medications was reviewed with Staff 1(ED) and Staff 3 (Assistant Director) on 09/24/26 at 12:05 pm. They acknowledged the findings.

During survey administation worked with hospice RN and PCPs to provide claification orders and clear directions on MAR. Following survery staff will ensure clear orders, routes, when to use etc will be looked over by RN. Facility RN has also went through facility MAR for each resdient to ensure all requirements on orders are met. Upon move in and new orderd director and RN will review to ensure all requirements for medications are met. This will be reviewed upon each order and director and RN will oversee to ensure completion.

OAR 411-054-0037 (4-7) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete, update, review, and document 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 and corresponding with resident service plan updates, updating 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 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. (a) The posted staffing plan must incorporate: (A) The total ABST care time in minutes per shift, per day. If a proprietary ABST does not have this functionality, at a minimum the ABST total time must be shown in daily minutes as referenced in paragraph (2) of this rule. (B) The unscheduled care needs of residents. (C) The staffing requirements outlined in OAR 411-054- 0070(1). (D) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (E) The 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. (F) The facility’s distinct and 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. Each distinct and segregated area must have a posted staffing plan. (G) The staffing needs required under the Specific Needs Contracts, if applicable. (b) The facility must maintain staffing documentation to show consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (c) The facility must maintain historical posted staffing plans. The posted staffing plan must contain the date(s) it was effective. Records must be kept for a minimum of three years. (6) CONSISTENTLY MEETING NEEDS. The facility must consistently meet the scheduled and unscheduled needs of all residents, 24 hours a day, seven days a week. (7) 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 a 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 numbers as indicated in the exception or the ABST. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated before a resident moved in for 2 of 2 sampled residents (#s 2 and 3) whose initial ABST evaluations were reviewed, and failed to use the results of the ABST to develop and update the facility’s posted staffing plan that outlined staffing numbers required to meet the scheduled and unscheduled needs of all residents for each shift. Findings include, but are not limited to: On 09/24/26 at 10:05 am, the facility’s ABST data was reviewed with Staff 1 (ED) and Staff 3 (Assistant Director), and the following was revealed: a. Resident 2 moved into the facility in 01/2026, and the ABST evaluation was created seven days following the move-in and not before the resident moved in. Resident 3 moved into the facility in 08/2026, and the ABST evaluation was created three days following the move-in and not before the resident moved in. b. On 09/21/26 at 11:34 am, the facility’s posted staffing plan, dated “June 2025,” was observed and outlined the following “[typical] staffing patterns for full-time personnel…”: * Days (6:00 am – 2:00 pm): Two universal workers, one medication aide, one caregiver, and two other workers; * “Days C.G.” (6:00 am – 2:00 pm): Two universal workers, one medication aide, one caregiver, and two other workers; * Swing (2:00 pm – 10:00 pm): One medication aide and one caregiver; * “Swing C.G.” (4:00 pm – 9:00 pm): One medication aide and one caregiver; and * Overnight (10:00 pm – 6:00 am): Two medication aides. On 09/24/26 at 8:34 am, Staff 1 reported the posted staffing plan was not reflective of the facility’s current staffing plan and confirmed the following current staffing plan: * Days (6:00 am – 2:00 pm): One “lead” medication aide, one medication aide, and two caregivers; * Swing (2:00 pm – 10:00 pm): One medication aide and one caregiver; * Swing Short Shift (2:00 pm – 4:30 pm): One caregiver; and * Overnight (10:00 pm – 6:00 am): Two medication aides. The results of the ABST were not used to develop and update the facility’s posted staffing plan that outlined staffing numbers for each shift. The need to ensure the ABST was updated before a resident moved in and to use the results of the ABST to develop and update the facility’s posted staffing plan that outlined the staffing numbers required to meet the scheduled and unscheduled needs of all residents, for each shift, was reviewed with Staff 1 and Staff 3 on 09/24/26 at 12:05 pm. They acknowledged the findings.

Facility staffing plan is current, updated and posted. Administation is aware of the ABST rules being updates and will ensure it is done prior to move in alongside with changes and or when service plans are being updated. Assistant director will ensure ABST is completed following evaluation prior to move in to ensure staffing is up to date. This will be evaluated every move in and quarterly by director and assitant director.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF 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) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF 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 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF 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 keep all poisons, chemicals and other toxic materials under locked storage. Findings include, but are not limited to: On 09/21/26 at approximately 2:00 pm and 3:20 pm a can of 24-hour sanitizing spray, opened bags and a bucket containing ice melt were observed in common areas of the facility and were not stored in a locked location for resident safety. In interviews on 09/21/26 with Staff 1 (ED) at 2:35 pm and Staff 7 (Activities) at 3:20 pm both acknowledged the items observed should not be left in common areas, accessible to residents. On 09/24/26 at 8:40 am, an aerosol can of disinfectant spray and at 8:44 am a cleanser/disinfectant spray bottle were observed in common areas of the facility and were not stored in a locked location for resident safety. In an interview on 09/24/26 at 8:41 am Staff 1 and Staff 3 (Assistant Director) acknowledged the items observed should not be left in common areas, accessible to residents. The need to ensure the facility took measures to keep all poisons, chemicals and other toxic materials under locked storage was discussed with Staff 1 and Staff 3 on 09/24/26 at 12:50 pm. They acknowledged the findings.

Sanitizing spray, laundry chemicals and ice melt are currently all stored properly and not out in open areas to residents. Staff have been counseled at a staff meeting, and all have been assigned Relias training regarding chemicals and storing. Training provided to housekeeping and staff regarding chemicals and will ensure all items are stored properly. Housekeeping will check daily for items that do not belong out alonside director when in facility.