Print Inspection: RL008116

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 3 moved into the facility in 09/2025 with diagnoses including hypertension and bipolar disorder. The new move-in evaluation failed to address the following required elements: * Pronouns; * Gender identity; * Physical health status including vital signs if indicated by diagnoses, health problems or medications; * Mental Health issues including presence of depression, thought disorders or behavioral or mood problems, history of treatment and effective non-drug interventions; * Cognition, including memory, orientation, confusion and decision-making ability; * Pain including non-pharmaceutical interventions and how a person expressed pain or discomfort; * List of treatments; * Indicators of nursing needs including potential for delegated nursing tasks; * Complex medication regimen; and * Elopement risk or history. The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 12/03/25 at 10:10 am. Staff acknowledged the findings.

*New move-in evaluation failed to address required elements 1. Resident move-in/evaluation process is updated to ensure all required questions and elements are addressed on the initial move-in prior to the resident moving in 2. The system will be corrected to ensure the violation doesn't happen again with reviews of the initial move-in/evalution to verify all questions are answered in full 3. The system will be evaluated monthly 4. ED, RCC, & RN will be responsible to ensure corrections are monitored

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: HEADER & EX #1 Malia Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 12/2020 with diagnoses including chronic obstructive pulmonary disease and depression. Resident 4’s current signed physician orders and 11/2025 MAR were reviewed. The following was identified: The resident had orders for hydroxyzine HCl 25 mg, one tablet every six hours as needed for anxiety or shortness of breath. The orders, dated 07/07/25, instructed staff to attempt non-drug interventions prior to administering the medication. The resident was administered the medication 57 times in November. In an interview on 12/02/25 at 10:32 am, Staff 4 (MT) stated MTs were only directed to document on the MAR whether Resident 4 requested the medication for shortness of breath or anxiety. Staff had documented the reason for administration of the hydroxyzine 56 times as “anxiety.” On 12/02/25 at 11:20 am, Staff 2 (RCC) confirmed staff were not following physician’s orders to attempt non- pharmaceutical interventions prior to administering hydroxyzine to Resident 4. The need to ensure all physician’s orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 on 12/03/25 at 10:20 am. They acknowledged the findings. E EX #2 Eun-suk 2. Resident 1 was admitted to the facility in 12/2019 with diagnoses including type 2 diabetes and hypothyroidism. Resident 1's MARs, dated 11/01/25 through 11/30/25, and physician orders dated 09/05/25 were reviewed and the following was identified: Resident 1 was prescribed levothyroxine 175 mcg by mouth every morning before breakfast. The MAR showed the medication was scheduled for administration at 7:00 am along with all other morning medications. On 12/02/25 at approximately 11:20 am, Staff 2 (RCC) reviewed the actual administration time which indicated the medication was administered between 7:15 am and 7:45 am. Staff 2 reported the resident usually had soup and yogurt between 7:00 am and 7:30 am. It was evident the levothyroxine was not administered before breakfast as prescribed. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 on 12/03/25 at 10:10 am. Staff acknowledged the findings.

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 2 of 2 sampled residents (#s 1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 12/2020 with diagnoses including chronic obstructive pulmonary disease and depression. Resident 4’s current signed physician orders and 11/2025 MAR were reviewed. The following was identified: The resident had orders for hydroxyzine HCl 25 mg, one tablet every six hours as needed for anxiety or shortness of breath. The orders, dated 07/07/25, instructed staff to attempt non-drug interventions prior to administering the medication. The resident was administered the medication 57 times in November. In an interview on 12/02/25 at 10:32 am, Staff 4 (MT) stated MTs were only directed to document on the MAR whether Resident 4 requested the medication for shortness of breath or anxiety. Staff had documented the reason for administration of the hydroxyzine 56 times as “anxiety.” On 12/02/25 at 11:20 am, Staff 2 (RCC) confirmed staff were not following physician’s orders to attempt non- pharmaceutical interventions prior to administering hydroxyzine to Resident 4. The need to ensure all physician’s orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 on 12/03/25 at 10:20 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2019 with diagnoses including type 2 diabetes and hypothyroidism. Resident 1's MARs, dated 11/01/25 through 11/30/25, and physician orders dated 09/05/25 were reviewed and the following was identified: Resident 1 was prescribed levothyroxine 175 mcg by mouth every morning before breakfast. The MAR showed the medication was scheduled for administration at 7:00 am along with all other morning medications. On 12/02/25 at approximately 11:20 am, Staff 2 (RCC) reviewed the actual administration time which indicated the medication was administered between 7:15 am and 7:45 am. Staff 2 reported the resident usually had soup and yogurt between 7:00 am and 7:30 am. It was evident the levothyroxine was not administered before breakfast as prescribed. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 on 12/03/25 at 10:10 am. Staff acknowledged the findings.

There was no documented evidence staff attempted nondrug interventions prior to administering medication 1. Received & updated residents doctor's orders who are able to self-direct a PRN anti-psychotropics to ensure parameters are in place to clarify non-pharm interventions 2. The system will be corrected to ensure the violation doesn't happen again with triple check of doctor orders to verify parameters and non-pharm interventions are in place 3. The system will be evaluated monthly 4. The ED, RCC, & RN will be responsible to ensure corrections are monitored *MAR showed the medication was scheduled for 7:00am along with other morning medication 1. Updated residents MAR to administer the levothyroxine at 6:00am prior to breakfast 2. The system will be corrected with a review/audit of medication times listed on the MARs 3. The system will be evaluated monthly 4. The ED, RCC, & RN will be responsible to ensure corrections are monitored

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0300 (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, the facility failed to ensure all exterior pathways were made of smooth material and maintained in good repair, grounds were kept orderly and free of litter and refuse, and garbage was stored in covered refuse containers. Findings include, but are not limited to: During the re-licensure survey, dated 12/01/25 through 12/03/25, the facility’s exterior grounds were toured, and the following observations were made: Multiple drop-offs between pathways and landscaping were identified and measured between two and six inches. These drop-offs posed a potential risk for falls; Uneven seams in the concrete pathways were noted near the fenced smoking area, near the exit door to the left of the main entrance, and near the front street turnaround. These uneven seams posed a potential risk for falls; Refuse, including a small refrigerator, upholstered armchair, wooden bench, and multiple tables were stored on the facility’s back patio; and The facility’s garbage dumpster lacked a covering, and the enclosure area had litter on the floor. The need to ensure exterior pathways were made of smooth material and maintained in good repair, grounds were kept orderly and free of litter and refuse, and garbage was stored in covered refuse containers was discussed with Staff 1 (Administrator) and Staff 3 (Environment Services) on 12/03/25 at 10:02 am. They acknowledged the findings.

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, the facility failed to ensure all exterior pathways were made of smooth material and maintained in good repair, grounds were kept orderly and free of litter and refuse, and garbage was stored in covered refuse containers. Findings include, but are not limited to: During the re-licensure survey, dated 12/01/25 through 12/03/25, the facility’s exterior grounds were toured, and the following observations were made: * Multiple drop-offs between pathways and landscaping were identified and measured between two and six inches. These drop-offs posed a potential risk for falls; * Uneven seams in the concrete pathways were noted near the fenced smoking area, near the exit door to the left of the main entrance, and near the front street turnaround. These uneven seams posed a potential risk for falls; * Refuse, including a small refrigerator, upholstered armchair, wooden bench, and multiple tables were stored on the facility’s back patio; and * The facility’s garbage dumpster lacked a covering, and the enclosure area had litter on the floor. The need to ensure exterior pathways were made of smooth material and maintained in good repair, grounds were kept orderly and free of litter and refuse, and garbage was stored in covered refuse containers was discussed with Staff 1 (Administrator) and Staff 3 (Environment Services) on 12/03/25 at 10:02 am. They acknowledged the findings.

*Multiple drop-offs between pathways and landscaping were identified and measured between two and six inches. These drop-offs posed a potential risk for falls 1. To correct this violation of drop-offs that pose a potential fall risk, we are proposing to install a split rail fence to allievate fall risk along the walkway/s 2. The system will be corrected with the installation of a split rail fence 3. The system will be evaluated monthly 4. ED & ESD will be responsible to ensure installation of split rail fence to reduce fall risk *Uneven seams in the concrete pathways were noted near the fenced smoking area, near the exit door to the left of the main entrance, and near the front street turnaround. These uneven seams posed a potential risk for falls 1. To correct this violation concrete will be grinded down in areas with uneven seams 2. The system will be corrected by grinding the concrete down evening out concrete in various areas 3. The system will be evaluated monthly 4. ED & ESD will be responsible to ensure concrete areas are even throughout the walkways *Refuse, including a small refrigerator, upholstered armchair, wooden bench, and multiple tables were stored on the facility’s back patio 1. A dump run has been done and all debris has been taken to the dump 2. The system will be corrected by doing more frequent dump runs as needed 3. The system / property will be evaluated monthly to ensure that there is no refuse/debris stored on the patio/property 4. ED & ESD will be responsible to ensure that refuse is not stored & dump runs are made in a timely manner *The facility’s garbage dumpster lacked a covering, and the enclosure area had litter on the floor 1. We have received a new dumpster with lids to ensure proper enclosure for the area & area is swept 2. The system will be corrected by evaluating to make sure the dumpster lid stays intact and regular cleaning/sweeping the the enclosure area 3. The system / area will be monitored monthly to ensure lids stays intact on dumpster & area is clean 4. ED & ESD will be responsible for monitoring area

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, the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: During the re-licensure survey, dated 12/01/25 through 12/03/25, the interior of the facility was toured, and the following observations were made: * Multiple window screens were threadbare, had holes and/or were not seated securely in the window tract; * Elevator carpeting was damaged and frayed at the seam. Interior elevator wall paneling was chipped and gouged; * Hallway benches were found with stained slipcovers and chips and scratches to the legs; and * Front reception desk wooden paneling had chips and scratches. The need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Environment Services) on 12/03/25 at 10:02 am. They acknowledged the findings.

*Multiple window screens were theadbare, had holes and/or were not seated securely in the window tract 1. We have started replacing screens on the lower level windows and will continue to replace worn screens 2. The system will be corrected based on visual observation and walkthroughs of the window screens 3. The system will be evaluated monthly 4. The ED & ESD will be responsible to ensure screens are in good condition and securely in the window tract *Elevator carpeting was damaged and frayed at the seam. Interior elevator wall paneling was chipped & gauged * Elevator Floor 1. To correct this violation the elevator carpet tile to be replaced and/or laminate installed 2. The system will be corrected by repairing or replacing the frayed seam in the elevator 3. The elevator floor will be evaluated monthly 4. The ED & ESD will be responsible to ensure flooring in elevator is in good condition *Elevator Paneling - Interior Wall 1. To correct the violation of the elevator paneling on the interior wall, wood filler will be used to fill scratches. 2. The system will be corrected with wood filler to fill the scrathes along the wall 3. The elevator wall will be evaluated monthly to ensure no scrathes and the walls are in good condition 4. ED & ESD will be responsible to ensure elevator wall remains in good condition *Hallway benches were found w/ stained slipcovers and chips and scratches to the legs 1. To correct the hallway benches, the benches and/or covers will be repaired or replaced and/or covers washed weekly and as needed; wood filler/pens will be used to repair scratches on bench legs 2. The system will be corrected by repairing or replacing benches w/ vinyl seating and/or replacement of bench covers that will be washed weekly or as needed to prevent stains; wood filler/pens will be used to repair scratches on bench legs 3. The condition of the benches will be evaluated weekly to ensure covers are clean and benches are in good condition 4. ED & ESD will be responsible to ensure benches/covers remain in good condition *Front reception desk wooden paneling had chips & scratches 1. To correct the reception desk area the surface will be cleaned and scrathes repaired with a wood/pen filler 2. The system will be corrected by cleaning & using wood filler pens to repair scrathed surface 3. The condition of the reception area will be monitored monthly 4. ED & ESD will be responsible to ensure the reception area remains in good condition

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:

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including pronouns and gender identity, for 1 of 1 sampled resident (#3) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

1. The resident move-in/evaluation process has been updated to ensure all required questions and elements are addressed on the initial move-in prior to the resident moving in to indicate residents name, pronoun, and gender idenity 2. The system will be corrected to ensure the violation doesn't happen again with reviews of the initial move-in/evalution to double check that all questions are answered in full prior to move-in 3. The system will be evaluated monthly 4. ED, RCC, & RN will be responsible to ensure corrections are monitored

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: