Print Inspection: RL005142

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: The kitchen was toured on 06/24/35 and the following was observed: * Multiple shelves and cupboards had exposed wood where the finish was worn off, leaving an uncleanable surface; and * Laminate countertop had gouges and chips on top and edges, leaving an uncleanable surface. These findings were discussed with Staff 3 (Food Service Director) and Staff 4 (Maintenance Director) on 06/24/25 and with Staff 1 (ED) on 06/25/25. They acknowledged the findings.

1)The kitchen counters will be replaced with stainless steel tables. The shelving units will be removed and replaced with stainless or wirerack shelving. 2) By replacing the wood with stainless steal/wirerack there will be no exposed wood, at risk of chipping or wearing off. 3) Food Service Director, Cook, Maintenance Director will evaluate area monthly to ensure daily, weekly, and monthly cleanings continue. 4) Food Service Director, Maintenance Director, Executive Director

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine resident-specific actions or interventions for residents following a short-term change of condition, provide written communication of the actions or interventions to staff on each shift, monitor the effectiveness of interventions consistent with the evaluated needs of the resident, and/or monitor and document weekly progress until the condition resolved for 2 of 3 sampled residents (#s 1 and 3) who experienced short term changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 05/2025 with diagnoses including Alzheimer’s disease and failure to thrive. The resident was identified during the entrance interview as a high fall risk. The resident’s progress notes dated 05/09/25 through 06/23/25, service plan dated 6/4/25, and alert charting notes from 05/10/25 through 06/04/25 were reviewed. The following was identified: a. Between 05/09/25 and 06/18/25 the resident experienced eight falls. There was no documented evidence the facility provided written communication of the resident’s fall interventions for caregivers on each shift. In an interview on 06/25/25, Staff 1 (ED) confirmed caregivers had not been provided with written communication of the resident’s interventions. b. The following changes of condition were not monitored weekly through resolution: * 05/15/25 – red mark on right rib; * 05/21/25 – medication dosage decrease; * 06/04/25 – urinary tract infection; * 06/06/25 – multiple medications discontinued; * 06/19/25 – fall at 9:05 am; and * 06/19/25 – fall at 7:00 pm. The need to ensure the facility provided written communication of interventions for short-term changes of condition to staff on all shifts and monitored the resident at least weekly according to his or her evaluated needs through resolution was discussed with Staff 1 and Staff 2 (Healthcare Services Director) on 06/25/25. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 07/2025 with diagnoses including Parkinson’s disease, aortic stenosis, and dementia. In an acuity interview on 06/23/25, the resident was identified as a fall risk. Review of progress notes dated 03/23/25 through 06/23/25 and incident reports revealed Resident 1 experienced 14 falls. The resident’s service plan included the following fall interventions: * Frequent checks for items on floor; * Assure resident has appropriate and well-fitted footwear; * Offer the bathroom, water, etc., frequently; and * “The resident should have a one-person escort and standby assist for all transfers/ambulation; however [he/she] declines the assistance and prefers to do things on [his/her] own despite the fall risk.” On all three days of the survey, Resident 1 was observed ambulating with a walker around the perimeter hallway of the building without a staff escort. On 06/25/25 at 11:15 am, documentation was provided by Staff 2 (Health Services Director) showing evidence of a “Community at Risk Meeting” where additional fall interventions were outlined. However, in an interview on 06/25/25 at 12:40 pm, Staff 1 (ED) and Staff 2 acknowledged these interventions were not made available to staff. Also, there was no documented evidence the existing interventions were evaluated for effectiveness following the series of repeated falls. On 06/25/25, the need to determine resident-specific actions or interventions needed following a short-term change of condition, provide written communication of these interventions to staff on each shift, and monitor the effectiveness of the interventions was discussed with Staff 1 and Staff 2. They acknowledged the findings.

1) The identified service plans have been reviewed and updated to reflect current interventions. Staff signatures have been obtained acknowledging the changes. 2) Health Services Director and Executive Director will monitor to ensure that STM/ISP's are implemented timely for any change of condition, ensuring staff signatures are obtained. Our significant change of condition policy has been reviewed with our regional team to ensure accuracy and completion of the processes are being followed. For significant change of condition, a comprehensive review of service plan will be conducted by the health services director within 48 hours of the change, followed by weekly notes which will be guided by RN, until baseline status or resolution is established. 3) Daily at stand up, weekly evaluation by nurse for significant changes, quarterly with service plan updates. 4) Health Services Director and Executive Director

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

OAR 411-054-0055 (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 PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 2 of 2 sampled residents (#s 2 and 3) who were prescribed a PRN medication to address behaviors. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility 03/2025 with a diagnosis of dementia. Resident 2 was prescribed lorazepam 0.5 mg (psychotropic medication) as needed for anxiety. The facility administered the Lorazepam to the resident two times in 06/2025. There was no documented evidence of written, resident-specific parameters for staff describing how Resident 2 demonstrated anxiety. There were no non-pharmaceutical interventions on the MAR for staff to attempt prior to administering the medication. The need to ensure there were resident-specific descriptions of how the resident demonstrated anxiety and non-drug interventions for staff to attempt prior to administering the medications was reviewed with Staff 1 (ED) and Staff 2 (Healthcare Services Director) on 06/25/25. They acknowledged the findings. 2. Resident 3 moved into the facility in 05/2025 with diagnoses including Alzheimer’s disease and failure to thrive. The resident had an order for lorazepam 0.5 mg every four hours as needed for anxiety, nausea, and/or vomiting. a. There was no documented evidence of written, resident-specific parameters for staff describing how Resident 3 expressed anxiety. b. There were no non-pharmacological interventions on the MAR for staff to attempt prior to administering the PRN psychotropic. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and non-drug interventions for staff to attempt prior to the administration of PRN psychotropic medications was reviewed with Staff 1 (ED) and Staff 2 (Healthcare Services Director) on 06/25/25. They acknowledged the findings.

1) A complete audit of all psychotropic medications will be completed ensuring that non pharmalogical interventions are added, if applicable. If non pharmalogical interventions are not required, will obtain orders stating such. 2) Regional team has reviewed the first, second, and third check processes and med techs will be re trained to ensure they understand this process and that the process is being followed. Med techs have been provided a copy of "PRN Paramaters Guidelines" provided by Elderwise, included in training. An audit will be completed quarterly to ensure that new 90-day orders from physicians remain in tact with non pharmalogical interventions or orders stating non pharmalogical interventions are not required. 3) At least weekly via third check by Health Services Director along with full audit Quarterly. 4) Health Services Director

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:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (#2) who had devices with potentially restraining qualities. Findings include, but are not limited to: Resident 2 was admitted to facility 03/2025 with diagnoses of dementia and cerebral infarction (stroke). Observation of Resident 2's room on 06/25/25 at 1:55 pm revealed two full-length side rails in the raised position on the bed. Review of the resident's clinical record revealed the following: * No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails. In an interview on 06/25/25, Staff 9 (CG) stated Resident 2 was not able to sit up or get out of bed without hands-on assistance from one staff member. The need to complete an assessment with the required components for the use of devices with potentially restraining qualities prior to use was discussed on 06/25/25 with Staff 1 (ED) and Staff 2 (Heathcare Services Director). They acknowledged the findings.

1) A complete audit will be completed to ensure all residents who have devices with potentially restraining qualities have a completed initial RN or PT assessment, and quarterly Health Service Director assessment in their chart. 2) An audit will be completed by Health Services Director with all service plan reviews. 3) Inital at move in and quarterly with service plan updates and with device changes. 4) Health Services Director

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

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 3 of 3 newly hired staff (#s 12, 13 and 15) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 06/25/25 at 9:00 am revealed the following: 1. There was no documented evidence Staff 12 (CG), hired 04/01/25, Staff 13 (CG), hired 02/27/25, and Staff 15 (MT/CG), hired 04/29/25, had demonstrated competency in all required areas and within 30 days of hire including: * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. 2. There was no documented evidence Staff 13 and Staff 15 had completed training in changes associated with normal aging within 30 days of hire. The need to document demonstrated competency of job duties training within 30 days of hire was discussed with Staff 1 (ED) on 06/25/25. She acknowledged the lack of documented evidence the required training had been provided.

1) A complete audit of staff files will be completed, ensuring all staff have completed initial, 30 day, and annual trainings are up to date. 2) Executive Director will set reminders as to when 30 day competencies are due. 3) With each new hire, monthly. 4) Health Services Director and Executive Director.

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:

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 ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to: The exterior grounds of the facility were toured on 06/24/25. The sidewalk in the courtyard contained drop-offs of 2 inches or greater, from the walking surface to the adjacent bark dust or gravel beds. Also noted were several cracks in the concrete resulting in uneven walking surfaces. These conditions created potential fall hazards for residents. On 06/24/25 at 10:15 am, the surveyor showed the outdoor drop-offs and concrete cracks to Staff 4 (Maintenance Director). He acknowledged the findings. On 06/25/25, the need to ensure all external pathways were maintained in good repair was discussed with Staff 1 (ED) and Staff 2 (Health Services Director). They acknowledged the findings.

1) The drop off from sidewalk to grass has been filled with bark ensuring there is no more than one inch drop off. The trees, creating uneven sidewalks will be removed and the sidewalk repaired, creating an even walking surface. 2) Maintenance Director will include these items as part of his daily environmental walk through. Safety Committee will include and review these items as part of monthly environmental walk through. 3) Daily and monthly 4) Maintenance Director, Safety Committee members

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:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must 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 environment was kept clean and in good repair. Findings include, but are not limited to: The internal environment of the facility was toured on 06/24/25 at 9:30 am. The following areas were in need of cleaning or repair: * Multiple scratches in the paint on pillars in dining room area and front lobby area; * Worn hole in the laminate surface of a round table in front common room; * Damage to wood baseboards in dining room; * Deep damage to laminated countertop in dining/coffee area, creating a non-cleanable surface; * Dark scratches and marks on door to the kitchen; * Dark stains on carpet in multiple areas of the building; * Deep gouges in wood door jamb of Room 136 and heavy black scrapes on door of Room 127; * Extensive damage to wood and paint of all four double doors to courtyard area. The building’s interior was toured with Staff 4 (Maintenance Director) on 06/24/25 at 10:20 am. The surveyor showed the above deficiencies to Staff 4, and he acknowledged the findings. On 06/25/25, the need to ensure the building’s interior was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 2 (Health Services Director). They acknowledged the findings.

1)The interior of the building will be painted where needed, baseboards repaired or replaced, and carpets shampooed by a professional carpet cleaner to remove the stains.The kitchenette counters in the common area will be repaired. The kitchen doors will be painted/repaired. The courtyard doors will be repaired and painted. 2) Maintenance director will include reviewing paint/chips/environmental issues on his daily walk throughs. The environment will be reviewed during safety committee meetings as well looking for items that need repaired. 3) Daily and monthly 4) Maintenance Director, Saftey Committee members

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by: