Print Inspection: RL012357

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure resident’s rights to receive services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#2) whose service plan was reviewed. Findings include, but are not limited to: Resident 2 moved into the assisted living in 03/2026 with diagnoses including unspecified dementia, diabetes, and was dependent on staff to transfer out of bed or chair and to assist with using a wheelchair. The resident’s clinical record was reviewed, interviews were conducted, and observations were made. The following was identified: The service plan, dated 04/26/26, indicated Resident 2 was unable to manage keys without assistance of another person; therefore, s/he was unable to independently lock and unlock the door for privacy. During an observation and interview on 06/08/26 at 11:50 am, Resident 2’s apartment door was open. The surveyor knocked and was given permission from the resident to enter. Resident 2 asked the surveyor to close the door during the meeting, stating “I prefer to have it closed.” While meeting with the resident from 11:50 am – 12:38 pm, the following was observed: At 12:18 pm, a MT knocked on the door and entered without permission. The MT left the door open and proceeded to give medication. Upon leaving, the MT left the door open. The surveyor called the MT back and requested she close the door, per resident request. At 12:26 pm, housekeeping staff opened the front door and entered without permission. The person didn’t announce who they were and began to take out the trash. Upon leaving, the housekeeping staff left the door open. Resident 2 reported “I prefer to go to the bathroom, but they say it’s easier for them if I just go right here and they will change me [in bed].” When asked if the care staff close the window blinds while providing care, the resident stated “I asked them about that, and they told me no one can see cause I’m up higher and there is a film so no one can see in. I don’t know why they just don’t close them.” On 06/09/26 at 1:38 pm, the resident’s door was observed open while the resident was in their apartment. On 06/09/26 at 3:04 pm the resident’s door was open. Staff 10 (CG) walked into Resident 2’s apartment without permission and stated, “it’s time to get up and I gotta do your catheter.” Resident 2 gave the surveyor permission to observe the provision of care. Staff 10 left the apartment door open and began providing catheter care. Surveyor asked the resident if they preferred the door open or closed. Per resident request, the surveyor closed the apartment door during care. The need to ensure residents' rights to receive services in a manner that protected privacy and dignity was discussed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings.

1. Action Taken to Correct the Violation: The facility immediately reviewed the resident’s privacy preferences and implemented a Temporary Service Plan for immediate and sustained correction. The resident’s service plan will be updated to reflect those preferences. All staff involved in direct care and environmental services were educated on resident rights, privacy expectations, knocking and announcing before entry, and maintaining privacy by closing doors and blinds during personal care. Staff were instructed to obtain resident permission before entering the apartment (knock and announce) and before continuing care when privacy concerns are identified. These corrective actions are designed to ensure ongoing compliance with OAR 411 051 0105 regarding resident rights to privacy and dignity. 2. How the System Will Be Corrected: The facility reviewed its resident rights and personal care procedures to ensure compliance to require staff to knock, announce themselves, wait for permission to enter, and close doors during all personal care unless the resident specifically chooses otherwise. Privacy expectations will be included in orientation, annual training, and ongoing coaching, and supervisors will complete routine compliance observations with immediate correction for noncompliance. 3. How Often the Area Will Be Evaluated: Compliance will be evaluated weekly for 90 days, then monthly ongoing, and more frequently if concerns are identified. Findings will be documented and reviewed through the facility’s quality assurance process. 4. Who Is Responsible: The Administrator is responsible for overall completion and monitoring. The Quality Assurance and Compliance Coordinator, Assisted Living Director, Director of Health Services, and Maintenance Director are responsible for staff compliance, coaching, and follow-up.

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 3 of 6 sampled residents (#s 2, 3 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the assisted living in 03/2026 with diagnoses including unspecified dementia, diabetes, a chronic skin condition, and had a catheter. Review of Resident 2’s physician orders and 05/01/26 to 06/08/26 MARs identified the following: The resident was prescribed the following medications or treatments that were not administered as prescribed because the medication or treatment was documented on the MAR as “not available”: * Triad Hydrophil wound paste on 05/26/26 and 05/29/26; * Solifenacin Succinate daily for overactive bladder from 05/01/26- 05/26/26; and * Tamsulosin daily for overactive bladder from 05/11/26 -05/13/26, 05/18/26, and 05/20/26. The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings. 2. Resident 3 moved into the assisted living in 03/2026 with diagnoses including memory loss. Review of Resident 3’s physician orders and 05/01/26 to 06/08/26 MARs identified the following: On 05/02/26 Resident 3 was prescribed famotidine 20mg tablet for heartburn, give one tablet twice per day. The medication was entered on the MAR as twice per day as needed rather than scheduled twice per day. There was no documented evidence the medication was administered twice per day from 05/02/26 - 06/08/26. The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings. 3. Resident 4 moved into the assisted living in 09/2021 with diagnoses including chronic obstructive pulmonary disease. Review of Resident 4's physician orders and MARs from 05/01/26 to 06/08/26 revealed the following: a. The resident had a physician’s order to administer Celecoxib100 mg every morning for pain. The MAR indicated the medication was not administered twelve times due to the medication not being available. b. The resident was not administered any of his/her morning medications on 05/02/26 due to “out of time frame.” c. The resident had an order to administer Mupirocin 2% ointment twice daily to an infected area on his/her left thumb. The medication was not administered on 05/07/26 due to the medication not being available. d. The resident had an order to administer Gabapentin 100 mg, three capsules in the morning and midday and two capsules every evening. The midday dose on 06/01/26 was not administered due to the medication being unavailable. The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), and Witness 2 (Consultant LPN) on 06/10/26 at 1:50 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? The facility will immediately review resident #2, #3, #4 physician orders, MARs, and treatment records to identify missed medications, incorrect transcription, and any doses documented as unavailable or out of time frame. The nurse and/or designee will notify the prescribing provider of the omissions, assess the residents for any adverse effects or change in condition, and ensure the orders are corrected and current medications are obtained accurately and without delay. 2. How will the system be corrected so this violation will not happen again? The facility will strengthen its medication and treatment administration system to ensure that all prescribed medications and treatments are accurately transcribed, available, and administered in accordance with physician orders, consistent with OAR 411 054 0055 requirements for safe medication and treatment systems. The facility will ensure the standardized three person verification process for all new, changed, and resumed medication and treatment orders: Under the guidance of the Director of Health Services (RN) the Medication Technician or designee will verify each order against the provider order and pharmacy label before the first scheduled dose, and will initial and date the MAR and an associated verification log. Medication Technicians will receive focused re education on accurate transcription of orders, correct entry of scheduled versus PRN medications, timely administration within ordered time frames, and the requirement to escalate when medications or treatments are unavailable or delay occurs. 3. How often will the area needing correction be evaluated? The area needing correction will be evaluated daily for 30 days, then weekly thereafter through the quality assurance process if compliance is maintained. Audits will include MAR accuracy, treatment record accuracy, missed-dose documentation, refill status, and evidence that provider and pharmacy follow-up occurred when medication or treatment issues were identified. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will be responsible for overall oversight of the correction plan and compliance with the medication and treatment administration system. The Director of Health Services or designee including Licensed Nurses, Medication Technicians, and Quality Assurance and Compliance Coordinator will be responsible for reviewing orders, verifying MAR accuracy, monitoring missed-dose follow-up, and documenting corrective action. Medication Technicians will be responsible for timely administration and immediate reporting of any unavailable medications or treatments to the DHS or designee.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. 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) accurately captured care time and care elements staff were providing to residents for 3 of 6 sampled residents (#s 2, 4, and 6) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living in 09/2021 with diagnoses including chronic obstructive pulmonary disease. Observations of the resident, interviews with staff, and review of the 04/09/26 service plan and Resident 4’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks, fall prevention; * Responding to call lights; * Repositioning; and * Toileting, bowel and bladder management. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), and Witness 2 (Consultant LPN) on 06/10/26 at 1:50 pm. They acknowledged the findings. 2. Resident 6 moved into the assisted living in 04/2026 with diagnoses including prostate cancer. Observations of the resident, interviews with staff, and review of the 04/04/26 service plan and Resident 6’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks, fall prevention; * Responding to call lights; and * Toileting, bowel and bladder management. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), and Witness 2 (Consultant LPN) on 06/10/26 at 1:50 pm. They acknowledged the findings. 3. Resident 2 moved into the assisted living in 03/2026 with diagnoses including diabetes, chronic skin condition, overactive bladder and unspecified dementia. Observations of the resident, interviews with staff, and review of the 04/26/26 service plan and Resident 2’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Responding to call lights; * Cognitive impairment or dementia; * Ambulation, escorting to and from meals and activities; * Repositioning in bed or chair; * Transfers; and * Additional care time for two-person care needs. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings. ?

1. What actions will be taken to correct the rule violation? The facility immediately reviewed the ABST assessments for Residents #2, #4, and #6 against each resident’s current service plan, daily care needs, and direct care observations to identify all missing or underreported care elements and care time. The facility will correct each resident’s ABST to ensure the following needs are accurately reflected: safety checks, fall prevention, call light response, repositioning, toileting, and bowel and bladder management, and any other care elements that were not fully captured. 2. How will the system be corrected so this violation will not happen again? The facility will revise its ABST completion process to require that ABST entries be based on observed care delivery, resident service plan requirements, and shift reports. Staff responsible for completing ABST reviews will be retrained on the specific ABST care elements, how to document actual care time provided, and the requirement to update the ABST when resident ADLs change, so the staffing plan reflects true resident acuity and support needs. The ABST management revisions are intended to bring practice into full compliance with OAR 411 054 0037, including accurately capturing care element time based on time for each resident. 3. How often will the area needing correction be evaluated? The area needing correction will be evaluated weekly for 90 days, then monthly for 3 months, with quarterly review thereafter in conjunction with the resident service plan review. Audits will include comparison of ABST entries to service plans, direct care documentation, resident observations, and staffing records to verify that care time and care elements are accurately captured. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will have overall responsibility for compliance and oversight. The Assisted Living Director and/or Director of Health Services, and/or Quality Assurance and Compliance Coordinator will complete and monitor ABST reviews and will verify that resident care needs are reflected accurately, and the staff member assigned to the facility’s staffing/QA process will track audit results and follow up on deficiencies.

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 were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 06/08/26 at 11:23 am, and the following was identified as needing repair: * Exterior concrete pathways located at the perimeter of the facility contained multiple drop-offs measuring greater than two inches from the concrete to the planting bed surface. These drop-offs created potential hazards for residents who frequently walked the pathways. * The exterior concrete steps, located at the southeast corner of the facility leading from the emergency exit door to the pathway, were not fitted with handrails and had drop-offs up to nine inches from the concrete to the planting bed surface on both sides of the steps. The facility’s exterior was toured on 06/10/26 at 10:24 am with Staff 1 (Senior Executive Director) and Staff 4 (Maintenance Director). They acknowledged these findings.

1. What actions will be taken to correct the rule violation? The facility will secure the identified exterior pathway hazards and steps by restricting resident access to the affected area until repairs are completed or a safe alternate route is established. The drop-offs adjacent to the concrete pathways will be corrected so the walking surface is level, stable, and free of hazardous height differences, and the exterior steps at the southeast corner will be fitted with compliant handrails on both sides and corrected so the step area is safe for resident use. 2. How will the system be corrected so this violation will not happen again? The facility will implement a routine environmental safety inspection process for exterior walkways, steps, landings, and emergency exits to identify and correct trip, fall, and egress hazards before residents are exposed. The maintenance process will include documented checks for concrete deterioration, grade changes, missing handrails, and other exterior conditions, with work orders generated immediately when hazards are found and completion verified before the area is returned to normal use. 3. How often will the area needing correction be evaluated? The exterior area will be evaluated weekly during the correction period, then monthly thereafter as part of the facility’s preventive maintenance and safety rounds. The evaluation will specifically include pathways, step condition, handrail integrity, and any change in grade or surface condition that could create a fall hazard or impede safe resident movement. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will have overall responsibility for completion of the correction plan. The Maintenance Director will be responsible for ongoing site inspections, repair oversight and environmental checks, and the Assisted Living Director or designee will monitor resident safety concerns and report any continued hazard to the Administrator and Maintenance Director immediately.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide each individual privacy in his or her own unit for 1 of 1 sampled resident (#2) whose service plan was reviewed. Findings include, but are not limited to: Refer to C200.

1. What actions will be taken to correct the rule violation? The facility will immediately review Resident #2’s service plan and care practices to ensure privacy preferences are clearly identified and followed during all personal care, medication administration, and staff entry into the resident’s unit. Staff involved in the resident’s care will be re-educated on knocking, announcing themselves, obtaining permission before entry when appropriate, closing the door during personal care, and maintaining visual and auditory privacy consistent with the resident’s preferences and dignity. Any staff practice that did not support privacy in the resident’s own unit will be corrected immediately. 2. How will the system be corrected so this violation will not happen again? The facility will update its resident care and staff training system to require privacy expectations to be addressed at admission, care plan review, and when resident preferences change. The system will require staff to follow a standardized privacy protocol for all residents, including knock-and-enter procedures, door closure during care, and use of privacy measures such as blinds or curtains when requested or clinically appropriate. Supervisors will reinforce these expectations during routine staff observation and coaching, so privacy is consistently supported across all shifts and departments. 3. How often will the area needing correction be evaluated? The privacy practices for Resident #2 and other residents will be evaluated daily during the correction period, then weekly for 90 days, and monthly thereafter through routine quality assurance monitoring. Observations will focus on staff entry practices, door and curtain/blind use, resident preference compliance, and whether privacy is maintained during hands-on care. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will have overall responsibility for completion and oversight of the correction plan. The Assisted Living Director, Quality Assurance and Compliance Coordinator, and/or designee will monitor privacy practices and ongoing Care and Medication Technician staff compliance. Maintenance Director and Housekeeping Supervisor will ensure non-care staff follow privacy expectations when entering resident units.

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the freedom and support to control his or her own schedule and activities for 1 of 1 sampled resident (#3). Findings include, but are not limited to: Resident 3 moved into the assisted living in 03/2026 with diagnoses including memory loss. Review of the resident’s clinical record, staff and resident interviews and observations were conducted during the survey. Resident 3’s initial evaluation indicated s/he was independent in all ADLs and IADLs except medication management. S/he didn’t have a history of wandering or elopement; however, s/he was issued a Wanderguard device, a device worn on the resident’s person that alerted staff when a resident attempted to leave all egresses on the first floor. Review of RN assessments completed on 02/24/26, prior to moving into the assisted living, and 04/01/26 determined the resident was independent in cognition and required no assistance for elopement or wandering. Review of Resident 3’s physician orders upon moving into the assisted living didn’t indicate the resident was prescribed any medications for a progressive dementia diagnosis. The initial service plan dated 02/26/26, 30-day service plan dated 04/01/26, and the quarterly service plan dated 05/27/26 indicated the resident had a Wanderguard. S/he stated “[s/he] does not know why [s/he] has to wear it and expresses that [s/he] is upset about having to wear it and would like to speak with [his/her] PCP about it. [Resident name] has not displayed any wandering or exit-seeking behaviors or any attempts to elope since moving into the community.” There were no clear instructions to staff on how to respond when Resident 3’s Wanderguard alerted staff and there were no instructions on how to support the resident’s desire to go outside of the assisted living community. The facility completed an additional elopement risk evaluation dated 04/01/26, and determined the resident was not at risk and presented as “alert and oriented, did not verbally express the desire to go home, was able to verbalize the importance of not leaving the community without first informing staff/requesting assistance, and did not wander (move around without a particular purpose or direction). During an interview and observation with the resident on 06/09/26 at 12:49 pm, the resident wore the Wanderguard on his/her left wrist. When asked about the device, s/he stated, “oh this thing, I don’t know why, they just said I have to wear it, I don’t know it’s really stupid.” During an interview on 06/09/26 at 1:28 pm, Staff 12 (CG) reported, the resident’s Wanderguard had alerted staff because the resident was trying to go to church services in another licensed facility across the parking lot. Staff 12 reported they were told to redirect resident back into the building. Staff 12 further reported they were told they can’t escort the resident to church services. “[S/he] was upset and didn’t understand why [s/he] wasn’t able to go to church or leave the building.” During an interview on 06/09/26 at 3:40 pm, Staff 10 (CG) reported “A Wanderguard, I don’t know anything about that. Does [s/he], oh yeah, [s/he] does.” When asked if the device had alerted staff in the past, Staff 10 reported, “oh no, cause [s/he] is mainly in [his/her] room most of the time. I don’t know why [s/he] has it honestly.” During an interview on 06/10/26 at 11:47 am, Staff 3 (Interim Assisted Living Director) reported a Wanderguard was used for “any dementia diagnosis, whenever someone has left the facility or was lost or the doctor puts on the physician orders when they come in that they are at risk and not allowed to leave due to cognitive decline, it’s a requirement.” Staff 3 confirmed Resident 3’s diagnosis upon moving into the assisted living was memory loss which was not a progressive dementia diagnosis. Staff 3 stated, she “would look into this.” The need to ensure individuals had the freedom and support to control his or her own schedule and activities was discussed with Staff 1 (Senior ED) Staff 2 (Associate ED) ) Staff 3, Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? The facility will immediately review the resident’s current service plan, Wanderguard use, and any related risk rationale to verify that the device is supported by a documented assessed need and the resident’s preferences and legal representative consent, if applicable. If the Wanderguard was placed or used without proper service planning, the facility will convene the service planning team, review the resident’s current needs and risks, and update the person-centered plan to reflect the least restrictive approach necessary. 2. How will the system be corrected so this violation will not happen again? The facility will implement a required review process for all safety-related devices and restrictions, including Wanderguard, to ensure they are only used when based on an assessed need, clearly described in the service plan, and reviewed at least quarterly or sooner if the resident’s condition changes. Staff will be retrained on HCBS rights, individual freedom and support, informed choice, and the requirement that any limitation must be documented as an individualized support. 3. How often will the area needing correction be evaluated? The area needing correction will be evaluated weekly for 90 days, then monthly for 3 months, and at least quarterly thereafter during routine service plan review. The evaluation will verify that the Wanderguard remains appropriate, the resident’s preferences are honored, and any restriction continues to meet person-centered and assessed-need requirements. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will have overall responsibility for compliance and oversight. The Director of Health Services, Health Services Coordinator, Quality Assurance and Compliance Coordinator, and Assisted Living Director will monitor service plan implementation, the case manager/service planning lead will ensure the Wanderguard is reviewed in the person-centered plan, and direct care staff will report any concerns about wandering risk, device use, or resident preference changes immediately.