Print Inspection: CHOW006501

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 interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured the care time and care elements that staff were providing to each resident as outlined in each individual service plan for 1 of 6 sampled residents (#4) whose ABST data was reviewed. Findings include, but are not limited to: ABST data for Residents 1, 2, 3, 4, 5, and 6 were reviewed during the survey. Inaccuracies in care times and care elements for Resident 4 were identified through observation and interview, including, but not limited to: * Transferring in or out of bed or chair; * Repositioning in bed or chair; * Providing non-drug interventions for pain management; * Assisting with leisure activities; * Monitoring physical conditions or symptoms; and * Safety checks and fall prevention. In an interview on 09/03/25 at 2:50 pm, Staff 1 (ED) and Staff 5 (Regional Director of Operations) acknowledged the findings for Resident 4. The need for the ABST to accurately capture care time and care elements that staff were providing to residents was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Wellness Director/LPN), and Staff 5 (Regional Director of Operations) on 09/05/25 at 10:07 am. They acknowledged the findings.

C362 1.) Review and audit ABST entries for all residents (including Residents 1–6) to ensure actual care elements and time match each individual’s service plan. 2.) Conduct weekly random audits of ABST data for 25% of residents to verify accuracy of care time and task capture. 3.) Weekly for 8 weeks, Then monthly thereafter 4.) Executive Director, RN,RCS,MRM

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:

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, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated when a resident experienced a significant change of condition and failed to ensure they were staffing to the levels generated by their ABST. Findings include, but are not limited to: a. The ABST was not updated when Resident 4 experienced a significant change of condition on 07/15/25. b. The facility’s posted staffing plan, staffing schedule, and ABST-generated staffing plan were reviewed on 09/03/25. The facility’s posted staffing plan was: * Day shift: 5 CGs and 2 MTs; * Swing shift: 4 CGs and 2 MTs; and * Overnight shift: 2 CGs and 1 MT. The ABST-generated staffing plan was: * Day shift: 8 total direct care staff; * Swing shift: 7 total direct care staff; and * Overnight shift: 2 total direct care staff. The posted staffing plan did not match the ABST-generated staffing plan; therefore, the facility was not staffing to the level indicated by the ABST. The need to ensure ABST data was updated when residents experienced significant changes of condition and the ABST-generated staffing plan was implemented was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Wellness Director/LPN), and Staff 5 (Regional Director of Operations) on 09/05/25 at 10:07 am. They acknowledged the findings.

C362 1.) Complete an immediate ABST evaluation for Resident 4 reflecting their significant change of condition from 07/15/25. Update the facility's posted staffing plan to reflect the current ABST-generated staffing needs. Adjust scheduled staffing to ensure alignment with ABST-determined staffing levels for each shift. 2.) Implement a communication protocol requiring the RN or Wellness Director to initiate an ABST update within 48 hours of any identified significant change in condition. ABST updates will be scheduled alongside quarterly/COC service plan reviews. 3.) Daily review 4.) Executive Director, RN,RCS,MRM

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 411-054-0300 (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 exterior surfaces were maintained in good repair. Findings include, but are not limited to: Observations, from 09/02/25 through 09/04/25, of the exterior of the facility revealed the following: * Concrete pathways near the entrance of the facility were observed with broken pieces of concrete and uneven surfaces; and * Multiple drop-offs greater than 1 inch were observed along pathway edges around the perimeter of the building and outside courtyard. These drop-offs created potential fall hazards. On 09/04/25, the building's exterior was toured with Staff 1 (ED), Staff 5 (Regional Director of Operations), and Staff 6 (Maintenance Director). They acknowledged the findings.

C610 1.) Hire a licensed contractor to repair broken, uneven, and hazardous pathway sections to meet accessibility standards. Puchase bark, and rock to fill in drop offs around Side Walk ledges. 2.) Implement a documented weekly inspection of all exterior pathways, courtyard areas, and perimeter walkways. Train all facility staff to recognize and report outdoor hazards such as cracks, drop-offs, and uneven pavement. 3.) Weekly 4. Executive Director, Maintenance Director

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)(a-b) General Building Interior (4) GENERAL BUILDING INTERIOR. The design of an ALF must emphasize a residential appearance while retaining the features required to support special resident needs as outlined in this rule.(a) RECEPTION AREA. A reception area must be visible and accessible to residents and visitors when entering the doors of the main entrance to the ALF.(b) CORRIDORS. Resident-use areas and units must be connected through temperature controlled common corridors.(A) Resident-use corridors exceeding 20 feet in length to an exit or common-use area, must have a minimum width of 72 inches.(B) Corridors shall not exceed 150 feet in length from any resident unit to a seating or other common-use area.(C) Handrails must be installed at one or both sides of resident-use corridors. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the design of the ALF supported resident needs relating to the installation of handrails at one or both sides of resident-use corridors. Findings include, but are not limited to: The interior of the building was toured on 09/02/25 at 10:40am. There were two corridors on the first floor, connected to side entrances of the courtyard, which lacked a handrail on one or both sides. On 09/04/25, the need to ensure handrails were accessible to residents along all corridors was discussed with Staff 1 (ED), Staff 5 (Regional Director of Operations), and Staff 6 (Maintenance Director). They acknowledged the findings.

C611 1.) Install handrails along both sides (or at minimum, one continuous side) of the two non-compliant corridors connected to the courtyard entrances.Installation will comply with ADA and state design specifications (height, length, grip). 2.)Include handrail presence and condition in the facility’s monthly preventive maintenance checklist.Train all staff to report missing, loose, or damaged handrails and environmental hazards as part of ongoing fall prevention. 3.) Monthly 4.) Executive Director, Maintenance Director

OAR 411-054-0300 (4)(a-b) General Building Interior (4) GENERAL BUILDING INTERIOR. The design of an ALF must emphasize a residential appearance while retaining the features required to support special resident needs as outlined in this rule.(a) RECEPTION AREA. A reception area must be visible and accessible to residents and visitors when entering the doors of the main entrance to the ALF.(b) CORRIDORS. Resident-use areas and units must be connected through temperature controlled common corridors.(A) Resident-use corridors exceeding 20 feet in length to an exit or common-use area, must have a minimum width of 72 inches.(B) Corridors shall not exceed 150 feet in length from any resident unit to a seating or other common-use area.(C) Handrails must be installed at one or both sides of resident-use corridors. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure 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 was clean and in good repair. Findings include, but are not limited to: During the survey, from 09/02/25 through 09/04/25, the following was observed: * Multiple doors and door frames throughout the facility were observed with scratches and damaged paint; * Ceiling tiles near apartments 102, 130, and 134 had brown stains; * Apartment 107’s window blinds were damaged; * The side exit door in the dining room was damaged and unable to shut properly; * The courtyard fountain was broken and non-functional; and * An excess of cobwebs and bird debris was observed throughout the exterior of the building. On 09/04/25, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents was clean and in good repair was discussed with Staff 1 (ED), Staff 5 (Regional Director of Operations), and Staff 6 (Maintenance Director). They acknowledged the findings.

C613 1.) Repaint or refinish scratched/damaged doors and frames throughout the facility. Replace or repair damaged window blinds in apartment 107.Repair or replace the damaged dining room side exit door to ensure proper functionality and secure closure. Evaluate and repair the broken courtyard fountain or remove if deemed non-functional and no longer needed.Clean all cobwebs and bird debris from the exterior of the building, including eaves, windows, and entry points. 2.) Implement or reinforce use of a maintenance work order system to ensure timely identification and completion of repairs.Train staff on promptly reporting environmental issues such as damage, dirt, odors, or malfunctioning equipment. Conduct a weekly visual inspection of high-traffic resident areas and building perimeter to proactively identify and resolve physical plant concerns. 3.) Weekly 4.) Executive Director, Maintenance Director

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 411-054-0300 (6)(b-f) Common Use Areas: Social (6) COMMON-USE AREAS. (b) DINING AREA. The building must have a dining area with the capacity to seat 100 percent of the residents. The dining area must provide 22 square feet per resident for seating, exclusive of service carts and other equipment or items that take up space in the dining area. This rule is exclusive of any separate private dining areas. (c) SOCIAL AND RECREATION AREAS. An ALF must include lunge and activity areas for social and recreational-use totaling a minimum of 15 square feet per resident. (d) COOKING STOVE. If a stove is provided in the activities or common-use area, and is available for resident-use, a keyed, remote switch, or other safety device must be provided to ensure staff control. (e) RESIDENT LAUNDRY FACILITIES. Laundry facilities must be operable and at no additional cost to the resident. Resident laundry facilities must have at least one washer and dryer. (f) MAILBOX. Each resident or unit must be provided a mailbox that meets US Postal Service requirements This Rule is not met as evidenced by: Based on observations and interviews, it was determined the facility failed to ensure the stove in the second-floor diner had a keyed, remote switch or safety device to ensure staff control. Findings include, but are not limited to: During the survey, from 09/02/25 through 09/04/25, the stove in the second-floor diner was observed to be on and was able to be used without a key, remote switch, or other safety device to ensure staff control. On 09/24/25, the need to ensure the stove in the second-floor diner had a keyed, remote switch or safety device was discussed with Staff 1 (ED), Staff 5 (Regional Director of Operations), and Staff 6 (Maintenance Director). They acknowledged the findings.

C622 1.) Install a keyed switch safety shut-off device on the stove in the second-floor diner to ensure staff-only access and prevent resident use without supervision. 2.) in-service training to all staff regarding: Safe appliance use in common areas. How to operate and monitor safety shut-off devices. Emergency response in the event of misuse 3.) Weekly 4.) Executive Director, Maintenance Director

OAR 411-054-0300 (6)(b-f) Common Use Areas: Social (6) COMMON-USE AREAS. (b) DINING AREA. The building must have a dining area with the capacity to seat 100 percent of the residents. The dining area must provide 22 square feet per resident for seating, exclusive of service carts and other equipment or items that take up space in the dining area. This rule is exclusive of any separate private dining areas. (c) SOCIAL AND RECREATION AREAS. An ALF must include lunge and activity areas for social and recreational-use totaling a minimum of 15 square feet per resident. (d) COOKING STOVE. If a stove is provided in the activities or common-use area, and is available for resident-use, a keyed, remote switch, or other safety device must be provided to ensure staff control. (e) RESIDENT LAUNDRY FACILITIES. Laundry facilities must be operable and at no additional cost to the resident. Resident laundry facilities must have at least one washer and dryer. (f) MAILBOX. Each resident or unit must be provided a mailbox that meets US Postal Service requirements This Rule is not met as evidenced by:

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: Based on observation and interviews, it was determined that the facility failed to have a setting that was physically accessible to individuals. Findings include but are not limited to: During a tour of the assisted living environment on 09/02/25 and 09/03/25, the following was identified: There were four doors in the facility that exited to the outside center courtyard. The doors were reported by multiple residents to close quickly, causing residents in motorized chairs to get stuck in the doorway and to have to maneuver their way through the door to or from the courtyard. Resident 3 and Witness 3 each reported on 09/04/25 getting skin injuries to their arms while going out one of the doors to the courtyard. Resident 4 reported on 09/03/25 that s/he used to take the electric wheelchair outside to the courtyard, but the door would shut too quickly and hit the wheelchair, making it difficult to access. Resident 4 stated that s/he no longer went to the courtyard due to the difficulty with the doors. Each of the four exit doors leading to the courtyard was reported to be difficult to navigate with wheelchairs, creating a situation that limited many residents' access to the outside courtyard area. The need for the setting to be physically accessible to residents was discussed with Staff 1 (ED), Staff 2 (RN ), Staff 5 (Regional Director of Operations ), and Staff 3 (Wellness Director/LPN) on 09/04/25. They acknowledged the findings.

H1515 1.) We adjusted and slowed the door mechanisms on all courtyard and high-use doors to ensure safer, more controlled operation for residents using mobility devices. We implemented a procedure for residents to call for staff assistance when entering or exiting if additional support is needed. 2.) Exterior and high-use doorways are now included in the monthly Environmental Accessibility QA to ensure door speed, resistance, and accessibility remain within appropriate standards. Staff have been trained on: Recognizing and maintaining accessible pathways 3. Monthly inspections 4. Maintenance Director, ED

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: