OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents regarding multi licensing violations related to Oregon Fire Code (OFC) including the facility’s kitchen fire suppression system which put residents’ health and safety at serious risk. Findings include, but are not limited to: Review of a fire inspection report conducted by Witness 1 (Fire Inspector, Gresham Fire Department), dated 11/25/24 identified multiple OFC violations that could threaten the health, safety, or welfare of residents. That required immediate corrective action to be taken by the facility. On 11/26/24 at 4:41pm an immediate jeopardy was issued, and an immediate plan of correction was requested per OAR 411-054-0025 (4). 1. On 11/26/24 at 6:00 pm an immediate plan of correction was received and included the following: * Fire lane markings: River City Environmental, INC. will be onsite in the first two weeks of December to do the striping. This is dependent on weather and temperature. Contract is signed for work to be completed. * Two fire extinguishers are located in the kitchen, one is a class ABC and one is Level K as of 11/26/2024. All staff will be trained by the MTD (Maintenance Director)/Designee on their location and specific usage by 11/27/2024. * Automatic fuel shut off and duct work will be completed by PSI by December 4, 2024. Contract is signed and they are scheduled. * Escutcheon plate for the sprinkler system. Service was completed in April, 2024. The MTD or designee will keep service inspections in a binder accessible at the community. This will be audited monthly at CQI (Continuous Quality Improvement) meeting three times a month, then quarterly. * Manual pull fire alarm station had a key broken in the box. MTD immediately corrected this. * Egress fire doors do not close automatically. Will be assessed by Carpentry Phoenix and should be repaired by mid-December. * Kitchen fire door had holes drilled in it. Kitchen fire door is on order, there is an approximate four-week lead time on this door since it is a custom order. * Sprinkler system, escutcheon plate in ceiling. Will be repaired by PSI (Performance Systems Integration) by December 4, 2024. * PSI is the vendor for the kitchen. Work is scheduled to be done on 12/04/2024 per PSI. Sinceri Leadership have a call scheduled with PSI 11/27/2024 to follow up on any permits and communication with Fire Marshall. * Fire suppression systems were blocked in riser rooms. Storage in riser rooms was removed by the MTD on 11/26/2024. The MTD or designee will monitor weekly x four weeks, then monthly x three months to maintain compliance. The digital access code will be changed for the doors so that the ED and MTD only will have access. * Facility emergency plan is on site. A copy will be provided to the Fire Marshall by 12/02/2024. * Fire watch is provided throughout the community by a specified person every 15 minutes utilizing the log provided by the Fire Marshall. * At 5:00 pm on 11/26/2024 the gas was shut off to the kitchen and kitchen is not being used. 2. During a monitoring visit on 11/27/24 at 9:03 am, the facility, including the kitchen was toured, and the following areas continued to be out of compliance: * Fire Lane markings in the parking lot. * Automatic fuel shut off and duct work to the fire suppression system in the kitchen were not completed. * The facility continued to use a Panasonic II commercial grade microwave that was located under the hood vent and fire suppression system. * Escutcheon plate for the sprinkler system above the cooking area. * Eight egress fire doors located outside of the kitchen were not corrected. * Kitchen fire door was not replaced and/or repaired. * Facility emergency plan was onsite however it was not provided to the Fire Marshall. * Fire Watch logs failed to include checks every 15 minutes, failed to include full name of the person completing the watch, their job title and the areas observed and/or appropriate comments related to what was observed. During an interview with Witness 1 on 11/27/24 at 11:54 am, the Panasonic II commercial microwave was taken out of service per the recommendation from the Fire Inspector. The findings were discussed with Staff 1 (Administrator) and Staff 2 (Business Office Manager/Designee in Charge) on 11/27/24 at approximately 12:45 pm. They acknowledged the findings. 3. During a monitoring visit on 12/05/24, the facility, including the kitchen was toured and the following areas continued to be out of compliance: * Eight egress fire doors located outside of the kitchen were not corrected. * Kitchen fire door was not replaced and/or repaired. * Facility emergency plan was onsite; however, it was not provided to the Fire Marshall. The facility provided verification the kitchen fire door and egress doors were on order and the facility management plan was in process and would be submitted to the Fire Marshall by end of day 12/05/24. 4. On 12/06/24 at 8:51 am, Witness 1 reported to the facility and the Department “PSI has deemed the equipment to be in compliance, we will allow the kitchen to be used…the kitchen door is a violation…The fire watch shall continue based on the door egressing issues in each of the units.? On 12/06/24 at 4:31 pm the Department notified the facility that the kitchen could be opened for use. Although the immediate plan of correction received corrected the immediate health and safety risks of residents’, the facility would need to continue correcting the remaining OFC violations, follow the recommendations from the local fire jurisdiction and continue looking at their systems to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C160.