Print Inspection: CHOW003800

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the physician or other legally recognized prescriber was notified when a resident refused to consent to a medication or treatment order for 2 of 2 sampled residents (#s 1 and 5) who had medications and treatments administered by the facility. Findings include, but are not limited to: 1. Resident 5 was admitted the facility in 02/2024 with diagnoses including epilepsy, schizophrenia, and bipolar disorder. The resident's 03/01/25 to 04/14/25 MARs and progress notes were reviewed, and the following was identified: Staff documented the resident refused the following medications and treatments: * Clozapine (for epilepsy/seizures), on four occasions; * Amantadine (for anti-parkinson), on one occasion; * House health shake (for supplement), on 16 occasions; and * Sodium chloride (for electrolyte), on five occasions. In an interview with Staff 4 (Community Nurse/LPN) on 04/16/25 at 11:22 am, they confirmed there was an order from the prescriber to notify them monthly of all refusals. Staff 4 acknowledged there was no documented evidence staff notified the prescriber of the above refusals for the month of March. The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Administrator in Training), and Staff 3 (Community Nurse/RN) on 04/16/25. They acknowledged the findings, and no further information was provided. 2. Resident 1 was admitted to the facility in 07/2024 with diagnoses including paraplegia. The resident's 03/01/25 to 04/14/25 MARs and current medication and treatment orders were reviewed. The following was identified: The resident had a signed physician order which included directions for staff to notify the physician monthly for refusal of any medications. Staff documented the following medication and treatment refusals between 03/01/25 to 03/31/25: * Senna (for constipation): on five occasions; * Vitamin B1 (supplement): on one occasion; * Vitamin B12 (aid for forming blood cells): on one occasion; * Buprenorphine/naloxone (opioid blocker): on one occasion; * Omeprazole (for heartburn): on one occasion; * Potassium Chloride (supplement): on one occasion; * SSD Chloride: (for wound infection): on 14 occasions; * Acetaminophen (for pain): on one occasion; * Boost (for weight loss): on 28 occasions; * Pregabalin (for pain): on one occasion; and * Wound care treatment: on seven occasions. During an interview on 4/15/25 at 11:05 am with Staff 5 (Community Nurse/LPN), she confirmed there was no documented evidence the physician was notified of Resident 1’s March refusals for medications and treatments. The need to notify the practitioner of resident medication refusals was discussed with Staff 1 (ED), Staff 2 (Administrator in Training), Staff 3 (Community Nurse/RN) on 04/16/25. They acknowledged the findings.

Regional RN Consultant, Regional Director of Operations, and Executive Director have met with the clinical team—including the RN, two LNs, and an RCC—to review move-in orders and processes. An immediate plan has been implemented to audit all MARs and physician orders. During this review, residents who did not have a documented order for PCP notification upon refusal of medications were identified. These orders will be added to the MARs and all necessary refusal notification orders will be updated within seven days. Regional RN and Community RN are currently auditing all MARs, with the audit expected to be completed by May 1, 2025. All move-in orders that include medication refusal notifications will go through a 3rd check process, with a 4th and final review completed by both the Regional RN and the Community RN. Going forward, this process will be incorporated into the daily clinical routine for all residents. During clinical meetings, the missed medication report will be reviewed, and if a resident requires PCP notification—either monthly or per missed dose—this will be documented in the MAR and followed up on the next day. Daily faxes to PCPs regarding refusals will also be reviewed in clinical to confirm that all required notifications have been sent. Move-in orders and MARs that include refusal notifications will be audited at 30-day, 60-day, and quarterly intervals for all residents. These audits will be conducted by Kelly Gardens’ nurses and aligned with each service plan update and the quarterly medication order review, prior to orders being sent to the PCP for review and signature. RCCs are responsible for initially adding the refusal notification order to the MAR upon move-in. A second RCC or the SSD will perform the 2nd check, the LN will complete the 3rd check, and the Community RN or RNC will conduct the 4th and final check. RCCs will also run the daily missed medication report and verify that refusal notification faxes were sent to the PCP. If the RCC is not available, the LN will oversee this process. Weekly audits and reviews of clinical meetings and processes will continue to be conducted by the Regional RN.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract. Findings include, but are not limited to: Upon entrance of the facility, a copy of the staffing plan was requested. The facility provided a copy of the staffing plan on 04/14/25, which included the following information: * Day shift: six CG’s and two MT’s; * Evening shift: six CG’s and two MT’s; and * Night shift: four CG’s and one MT. The Specific Needs Contract stated, “Contractor shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift.” The facility had 33 residents serviced by the contract, which would equate to 11 direct care staff for day/evening, and six for night shift. In an interview with Staff 1 (ED) and Staff 2 (Administrator in Training) on 04/15/25 at 9:30 am, it was stated the facility was using a “combination” of the ABST tool, contract and acuity at the facility to determine appropriate staffing levels. The need to ensure the facility was staffing to meet the requirements under the Specific Needs contract was discussed with Staff 1, Staff 2 and Staff 3 (Community Nurse/RN) on 04/16/25 at 12:00 pm.

Regional Director of Operations, in conjunction with the Executive Director (ED) and the Resident Care Coordinator (RCC), immediately reviewed the staffing schedule and identified open shifts, as well as those requiring additional direct care staff to meet the requirements of the specialty needs contract. Job postings have been published on Indeed, and the ED, along with the RCC, has been actively interviewing candidates to increase staffing coverage and ensure compliance with the required staffing ratios outlined in the contract. As of April 24th, a total of five (5) Caregivers have been hired. April 15th ED has conducted in-service training with the RCCs, emphasizing the importance of maintaining appropriate staffing ratios and outlining the proper call-out procedures. The training also reinforced the need for a proactive approach to recruitment in order to ensure the community is fully staffed at all times on all three (3) shifts. Moving forward, the ED will meet weekly with the RCCs to review the staffing schedule. These meetings will help ensure that staffing ratios are consistently met and that any upcoming open shifts are identified and filled proactively to prevent gaps in coverage. The Executive Director will be responsible for ongoing monitoring of staffing levels to ensure that the required staffing ratios are maintained at all times.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract and consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. This is a repeat citation. Findings include, but are not limited to: Upon entrance of the facility, a copy of the staffing plan was requested. The facility’s posted staffing plan and staffing schedule from 06/08/25 through 06/14/25 were reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (ED) on 06/18/25 at 1:24 pm. The following was identified: * Day shift: 11 CGs and two MTs; * Evening shift: 11 CGs and two MTs; and * Night shift: six CGs and one MT. The Specific Needs contract stated, “Contractor shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift.” The facility had 33 residents serviced by the contract, which would equate to 11 direct care staff for day/evening, and six for night shift. One resident serviced by the contract was in the hospital. In an interview on 06/18/25 at 11:00 am, Staff 6 (MT) indicated she had been working alone as a MT and responsible for all three floors during day shift on 06/15/25. She acknowledged there was no second MT on the day shift for coverage. Following this interview, the facility staffing schedule was requested and reviewed for additional dates, 06/15/25 through 06/17/25, and identified four shifts that were not covered on 06/15/25, including MT day shift. Although the posted staffing plan matched the Special Needs Contract, review of the facility schedule from 06/08/25 through 06/17/25 revealed the facility failed to staff per the posted staffing plan on six shifts, or 10% of the total shifts reviewed. The need to ensure consistent staffing to meet or exceed the posted staffing plan requirement under the Specific Needs contract and consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week was discussed with Staff 1, Staff 2 and Staff 3 (Community Nurse/RN) on 06/18/25 at 3:50 pm and 4:28 pm. They acknowledged the findings.

Effective immediately, Executive Director with Regional Director of Operations has reviewed schedule for June and July to ensure in compliance with staffing ratios outlined in the Specialty Needs Contract, as well as daily staffing postings. Upon review and identification of open shifts, Executive Director worked with the Staffing Coordinator to adjust the schedule. This included utilizing part-time and on-call staff, and offering existing staff opportunities to pick up additional shifts. In addition, Executive Director and Staffing Coordinator identified need to hire 4 more Caregivers to ensure adequate coverage, especially during staff vacations or illnesses. Executive Director will be reviewing schedule daily with the Resident Care Coordinator during morning stand-up meetings. Resident Care Coordinator is expected to notify Executive Director of any call-outs and confirm who is covering each shift to ensure all shifts are adequately staffed. Furthermore, Regional Director of Operation will meet with the Executive Director every Tuesday and Friday to review weekly schedule and ensure that all open shifts are filled and that staffing ratios are maintained throughout the week, including weekends. Executive Direcotr, Staffing Coordinator responsible for ensuring all necessary corrections are completed. Executive Director will provide staffing updates and report any concerns to the RDO twice weekly.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract and consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. This is a repeat citation. Findings include, but are not limited to: Upon entrance of the facility, a copy of the staffing plan was requested. The facility’s posted staffing plan and staffing schedule from 06/08/25 through 06/14/25 were reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (ED) on 06/18/25 at 1:24 pm. The following was identified: * Day shift: 11 CGs and two MTs; * Evening shift: 11 CGs and two MTs; and * Night shift: six CGs and one MT. The Specific Needs contract stated, “Contractor shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift.” The facility had 33 residents serviced by the contract, which would equate to 11 direct care staff for day/evening, and six for night shift. One resident serviced by the contract was in the hospital. In an interview on 06/18/25 at 11:00 am, Staff 6 (MT) indicated she had been working alone as a MT and responsible for all three floors during day shift on 06/15/25. She acknowledged there was no second MT on the day shift for coverage. Following this interview, the facility staffing schedule was requested and reviewed for additional dates, 06/15/25 through 06/17/25, and identified four shifts that were not covered on 06/15/25, including MT day shift. Although the posted staffing plan matched the Special Needs Contract, review of the facility schedule from 06/08/25 through 06/17/25 revealed the facility failed to staff per the posted staffing plan on six shifts, or 10% of the total shifts reviewed. The need to ensure consistent staffing to meet or exceed the posted staffing plan requirement under the Specific Needs contract and consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week was discussed with Staff 1, Staff 2 and Staff 3 (Community Nurse/RN) on 06/18/25 at 3:50 pm and 4:28 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to: C 363 and C 510.

Refer to: C 363 and C 510

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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 the grounds were orderly and free of litter and refuse. Findings include, but are not limited to: The facility grounds were toured on 04/14/25 at 11:30 am and 04/15/25 at 10:50 am. The following was identified: Multiple cigarette butts were observed on the ground in the courtyard area off of the dining room and in the parking lot area of the covered driveway. In an interview with Staff 1 (ED) and Staff 2 (Administrator in Training) on 04/14/25 at 2:00 pm, they acknowledged there were multiple residents who resided at the facility who were smokers and often did not smoke in the designated smoking area. The need to ensure the facility ensured the grounds were kept orderly and free of litter and refuse was discussed with Staff 1 and Staff 2 on 04/16/25 at 12:00 pm. They acknowledged the findings.

Executive Director, in collaboration with the Maintenance Director, conducted a walkthrough of the community grounds and cleaned exterior areas, removing litter and cigarette butts from the premises. All residents were notified on April 15th via memo, and again during the Resident Council Meeting on April 16th, that smoking is only permitted in designated areas. A recurring work order has been entered into TELS for the Maintenance Director to perform an outdoor walkthrough every Wednesday. During these inspections, the grounds will be checked to ensure they are free of litter, cigarette butts, and other debris. If a resident is observed smoking in a non-designated area, they will be redirected to the appropriate smoking area. Executive Director will receive weekly email notifications through TELS confirming the completion of these tasks. In addition, the Executive Director will conduct weekly walkthroughs to ensure the facility remains clean and well-maintained. Going forward, the Executive Director will be responsible for overseeing and ensuring the ongoing completion of this task.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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 the grounds were orderly and free of litter and refuse. This is a repeat citation. Findings include but are not limited to: The facility grounds were toured with Staff 1 (Regional Director of Operations) and Staff 2 (Executive Director) at 11:00 am, and then again at 3:30 pm on 06/18/25. The following was identified at all observations: * Multiple cigarette butts and litter were observed on the ground in the courtyard area off of the dining room and in the parking lot area of the covered driveway; * A metal food can filled with cigarette butts was covered with a cardboard lid next to the dining room door; and * A pressure washer, multiple hoses, and other maintenance equipment were stored in the resident use courtyard. In an interview with Staff 1 and Staff 2 on 06/18/25 at 3:30 pm, they acknowledged there were multiple residents who resided at the facility who were smokers and often did not smoke in the designated smoking area. The need to ensure the facility ensured the grounds were kept orderly and free of litter, refuse, and maintenance equipment was discussed with Staff 1 and Staff 2 on 06/18/25. They acknowledged the findings.

Executive Director and Regional Director of Operations met with the Maintenance Director to address exterior building deficiencies identified during recent re-survey. Standardized maintenance checklist—is now in place for Maintenance Director to ensure property is twice a day monitored and cleaned, with special attention to trash, cigarette butts, pet waste. Executive Director also performs daily walkthroughs, verifying that equipment (hoses, pressure washers, toolboxes, etc.) is properly stored in storage and that grounds remain orderly and litter-free. In addition, Executive Director scheduled meeting with landscaping company to plan weed removal, getting new barkdust and bush/tree trimming. Staff will be re-trained to enforce the smoking policy and residents will be redirected to designated areas, and “No Smoking” signs has been installed at the entrance, with staff monitoring compliance. Executive Director and Maintenance Director will oversee implementation and compliance with plan of correction.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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: