Print Inspection: CHOW013028

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to the dining staff when sanitizing the dining room environment. Findings include, but are not limited to: On 07/13/26 during lunch service, a staff member was observed wiping his nose with the back of his hand, touching his person several times, then using the same hand to clean multiple dirty tables with a cleaning rag and solution from a sanitizing bucket without performing hand hygiene after touching his person or re-dipping in the sanitizing solution between clean and dirty tasks. To ensure facility staff were maintaining adequate levels of sanitizing solution for cleaning the dining room and to mitigate the effects of the staff member touching his face and not completing hand hygiene, a follow up observation and interview was completed with Staff 6 (Dining Services Director) on 07/15/26 at 9:20 am. It was revealed the facility had been using test strips that expired in 2021 “for a long time.” Therefore, there was no way to determine the effectiveness of the sanitizer. The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to the dining staff when sanitizing the dining room environment was discussed with Staff 6 on 07/15/26 at 9:30 am and Staff 1 (ED), Staff 2 (Administrator), Staff 3 (LPN) and Staff 4 (RCC) on 07/16/26 at 11:15 am. They acknowledged the findings.

1) The staff member observed was immediately retrained on infection control protocols. Test strips for sanitizer effectiveness were immediately replaced and in place prior to survey exit. 2) All kitchen staff will complete thorough infection control training prior to being placed on the schedule. Sanitizer test strips will be checked for expiration on routine kitchen walkthrough. 3) This will be monitored for staff at the time of hire and on a monthly basis. Test strips will be checked weekly during the scheduled kitchen walkthrough. 4) This will be the responsibility of the Dining Services Director and Executive Director, or designee.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure 4 of 4 newly hired staff completed all required pre-service training prior to beginning their job responsibilities. Findings include but are not limited to: Employee training records were requested and reviewed with Staff 2 (Administrator) on 07/14/26 at 11:00 am. The following was identified: There was no documented evidence Staff 13 (MT), Staff 14 (CG), Staff 15 (CG) and Staff 16 (Dietary Aide), hired 05/12/26, 05/12/26, 05/21/26 and 06/08/26, respectively, had completed the following required pre-service orientation topics prior to beginning their job responsibilities: * Staff 13 – Abuse reporting requirements, fire safety and emergency procedures and the approved HCBS course; * Staff 14 – Abuse reporting requirements, infectious disease prevention, approved HCBS course, approved LGBTQIA2S+ course and approved pre-service dementia training; * Staff 15 – Abuse reporting requirements, infectious disease prevention and approved HCBS course; and * Staff 16 - Resident rights and values of CBC care, abuse reporting requirements, fire safety and emergency procedures, food handler’s certificate, written job description, infectious disease prevention, approved HCBS course, approved LGBTQIA2S+ course and approved pre-service dementia training. The need for staff to complete all required pre-service orientation training and required pre-service dementia training was discussed with Staff 1 (ED), Staff 2, Staff 3 (LPN) and Staff 4 (RCC) on 07/16/26 at 11:15 am. They acknowledged the findings.

1) All employee files were audited for compliance with pre-service training requirements. Any employees out of compliance completed the required training to regain compliance. 2) Employee training records will be maintained on a community “Training Tracker” to ensure continued compliance. Newly hired employees will be required to complete all pre-service training prior to beginning job specific training. 3) This will be monitored at the time of hire and reviewed on a weekly basis for accuracy and completeness. 4) This will be the responsibility of the Business Office Manager and Executive Director, or designee.

OAR 411-054-0070 (3-4) Staffing Requirements and Training ? Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure 3 of 3 sampled new hired staff had documentation of competency demonstrated in all required job areas within the first 30 days of hire. Findings include, but are not limited to: Employee training records were requested and reviewed with Staff 2 (Administrator) on 07/14/26 at 11:00 am. The following was identified: There was no documented evidence Staff 13 (MT), Staff 14 (CG), Staff 15 (CG), hired 05/12/26, 05/12/26, 05/21/26, respectively, had completed the following required competency topics withing the first 30 days of hire: * Staff 13 – Changes associated with normal aging, first aid and abdominal thrust; * Staff 14 -providing assistance with ADLs, first aid and abdominal thrust; and * Staff 15 – first aid and abdominal thrust. The need to ensure newly hired direct care staff had documentation of satisfactory performance in all required areas within 30 days of hire was reviewed with Staff 1 (ED), Staff 2, Staff 3 (LPN) and Staff 4 (RCC) on 07/16/26 at 11:15 am. They acknowledged the findings.

1) All direct care employee files were audited for compliance with 30-day training requirements. Any employees out of compliance completed the required training to regain compliance. 2) Employee training records will be maintained on a community “Training Tracker” to ensure continued compliance. Newly hired employees will be required to complete all 30-day training prior to beginning working independently. 3) This will be monitored at the time of hire and reviewed on a weekly basis for accuracy and completeness. 4) This will be the responsibility of the Business Office Manager and Executive Director, or designee.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire ? Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to verify 3 of 3 sampled newly hired staff (#s 17, 18, and 19) demonstrated satisfactory performance in any duty they were assigned within the first 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Training records were requested and reviewed with Staff 1 (ED) on 10/02/26 at 12:15 pm. There was no documented evidence Staff 17 (CG), hired on 09/01/26; Staff 18 (CG), hired on 08/18/26; and Staff 19 (CG), hired on 08/11/26, demonstrated knowledge and performance in the following required areas within the first 30 days of hire: * Role of the service plan; * Providing assistance with ADL’s; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving, and sanitation; and * First Aid and abdominal thrust training. The need to ensure the facility verified newly hired direct care staff had demonstrated satisfactory performance in assigned duties within 30 days of hire was reviewed with Staff 1 (ED) on 10/02/26 at 12:15 pm. He acknowledged the findings.

1) All required 30-day training records for current staff have been completed and reviewed. 2) All newly hired staff will be required to complete all required 30-day training and have the records reviewed and approved by supervisor prior to working independently in their role. 3) This will be evaluated twice weekly during staff training meetings. 4) Monitoring this will be the responsibility of the Assisted Living Director and Executive Director, or designee.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the written fire drill record included all required elements according to the Oregon Fire Code. Findings include, but are not limited to: Three months of facility fire drill records from 04/2026 to 06/2026 were reviewed on 07/14/26 and revealed the following: The 04/07/26 and 06/13/26 fire drills lacked documented evidence of escape routes used, evacuation time-period needed, staff members on duty and participating and the number of occupants evacuated. The need to ensure documentation of all required elements on written fire drill records was reviewed with Staff 1 (ED) on 07/14/26 at 10:30 am and Staff 1, Staff 2 (Administrator), Staff 3 (LPN) and Staff 4 (RCC) on 07/16/26 at 11:15 am. They acknowledged the findings.

1) Fire drill process and form were immediately reviewed with Maintenance Director and Executive Director, and staff signature page was added. 2) The community fire drill form will continue to be utilized with the addition of a page for staff to sign for participation. The form utilized includes escape routes used, evacuation time needed and number of residents evacuated. Location of fire drills in the community will be altered to include more residents. 3) Fire drills will continue to be conducted on a monthly basis and will be evaluated for completeness following each drill. 4) This will be the responsibility of the Maintenance Director and Executive Director, or designee.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval Temporary rule language in effect until 02/05/2027 (2) The facility must not interfere with a good faith disclosure of information by an employee, volunteer concerning abuse or other action affecting a resident’s safety or welfare, as described in OAR 411-054-0028(4). (3) The Department must visit and inspect every licensed facility to determine whether the facility is maintained and operated in accordance with these rules. (a) The Department must inspect every facility at a minimum: (A) No less than 90 days and no more than 120 days after an initial license is issued or after a change of ownership of a facility. (B) Upon receipt of a license renewal application fee. (C) For each year during which a facility does not have a full survey, the Department must conduct an in-person inspection of the kitchen and other areas where food is prepared for residents. (b) Inspections may be conducted at other times as determined by the Department. (c) Facilities not in compliance with these rules must submit a plan of correction that satisfied the Department, within 10 business days of receipt of the inspection report. (d) Facilities must correct deficiencies within timeframes outlined in the accepted plan of correction. (e) Failure to be in substantial compliance upon reinspection may result in regulatory action to compel compliance. (f) Achieving substantial compliance is ultimately the facility’s responsibility, whether or not a plan of correction was followed. (g) 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 observation, interview, and record review, it was determined the facility failed to correct deficiencies within timeframes outlined in the accepted plan of correction. Findings include, but are not limited to: Refer to C 372 and C 513.

Refer to POC for C372 and C513

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 take measures in the prevention of the entry of rodents, flies, mosquitoes, and other insects as well as failed to ensure the facility grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to: Observations of the facility exterior on 07/13/26 at 9:15 am and 07/14/26 at 2:30 pm identified the following: * An empty garbage bag, glass beads and an accumulation of dirt were identified on the fourth-floor terrace patio; * Multiple common area sliding glass doors and multiple resident apartments with sliding glass doors on the fourth, fifth, sixth, and seventh floors failed to have a screen to prevent the entry of rodents, flies, mosquitoes, and other insects; * Multiple windows and sliding glass doors on the fourth, fifth, sixth, and seventh floors were observed to have an accumulation of cobwebs and/or an accumulation of bird excrement on the exterior of the windows; and * The walkway to the entrance of the building had an accumulation of bird excrement. The need to ensure the facility took measures to prevent the entry of rodents, flies, mosquitoes, and other insects, the grounds were free of litter and refuse and outside surfaces were maintained in good repair was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 07/14/26 at 2:30 pm. They acknowledged the findings.

1) The maintenance team immediately cleaned exterior areas containing cobwebs and front entrance prior to survey exit. 4th floor exterior was immediately cleaned and cleared of any debris. Bids are being gathered to replace any missing screen doors or window screens. 2) Routine exterior cleaning has been scheduled to ensure continued compliance. Screens will be periodically checked with routine maintenance, and all staff have been trained in reporting any missing screens to maintenance. 3) Cleanliness of the community exterior and common area screens will be monitored on a weekly basis. Screens in resident living spaces will be monitored on an as needed basis. 4) This will be the responsibility of the Maintenance Director and Executive Director, or designee.

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: ased on an interview at 12:13 pm on 10/02/26 with Staff 1 (ED), it was confirmed the facility had received an extension for the allegation of compliance until 11/04/26.

Deparment approved extension from original POC

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 the interior of the facility was clean and maintained in good repair. Findings include, but are not limited to: The residents in the RCF resided on floors four through seven and dined in the dining room located on the Terrace floor. The facility was toured on 07/13/26 at 9:15 am and 07/14/26 at 2:30 pm, and the following was observed: a. Terrace dining room: * Multiple dining chairs were observed to have torn and/or peeling upholstery. b. Fourth floor: * Stained cushions on the couch in the sitting area; * Hole in the drywall of the dining area; * Two lights were burned out in the dining area; and * Sliding glass door tracks in the dining area had an accumulation of dirt/debris. c. Fifth floor: * In the hallway by room 515, there was a metal protrusion in the wall above the chair rail; and * Sliding glass door tracks in the dining area had an accumulation of dirt/debris. d. Sixth floor: * Sliding glass door tracks in the dining area had an accumulation of dirt/debris; and * A chair in the dining area was missing the back of the chair. e. Seventh floor: * The chair at the puzzle table in the sitting area had worn/cracked vinyl. The need to ensure the interior of the facility was clean and maintained in good repair was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 07/14/26 at 2:30 pm. They acknowledged the findings.

1) All common area sliding door tracks were cleaned immediately. Any burnt out lights were changed. Wall damage and metal protrusion were immediately repaired/removed prior to survey exit. All damaged/worn chairs were replaced. 2) Areas noted have been added to community walkthrough checklist to ensure any needed repairs are caught in a timely manner. Sliding door tracks have been added to housekeeping list to occur 3-5 days/week. 3) Monitoring will occur on a weekly basis. 4) This will be the responsibility of the Maintenance Director and Executive Director, or designee.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 the interior of the facility was clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: The residents in the RCF resided on floors four through seven and dined in the dining room located on the Terrace floor. The facility was toured on 10/02/26 at 10:00 am, and the following was observed: a. Terrace dining room: * A brown fabric chair located at the entrance to the Terrace dining room was soiled with urine and stained; * Multiple dining chairs were observed to have torn and/or peeling upholstery; * Multiple ceiling tiles had brown stains and one ceiling tile was missing; * The fire sprinkler in the ceiling was missing the ceiling mount; * All windows and windowsills had an accumulation of dirt, debris, and cobwebs; * Bookcases and shelves had an accumulation of dust and debris build-up; * The window curtains were torn in some areas and/or were soiled; * There was a white fan in the back of the dining room with an accumulation of dust; * There was a broken chair and a broken table in the back of the dining room; * There were exposed electric wires in the ceiling near the patio door and hanging chandelier; * There was an exposed electrical box on the floor near the kitchen entrance; and * There was a metal wire tied around one of the patio door handles, preventing it from opening. b. The Chapel (which was used by all residents) had multiple chairs that had torn upholstery. c. Common area located near the post office on the Terrace floor: * The large round granite table was chipped and had blue tape over the rough edges, which created an uncleanable surface. d. Fourth floor: * There was stained fabric on the couch and two occasional chairs in the sitting area; * Two lights were burned out in the dining area; and * The sliding glass door tracks in the dining area had an accumulation of dirt, debris, spiders, and cobwebs. e. Fifth floor: * Three was a chair with a torn seat and stains in the dining room; and * The sliding glass door tracks in the dining area had an accumulation of dirt, debris, spiders, and cobwebs. f. Sixth floor: * The sliding glass door tracks in the dining area had an accumulation of dirt, debris, spiders, and cobwebs; and * Two chairs in the dining area had stained fabric chairbacks; and * The slider door was missing the door handle. g. Seventh floor (common area - puzzle room) * A red and orange striped chair had stained fabric. The need to ensure the interior of the facility was clean and maintained in good repair was discussed with Staff 1 (ED) on 10/02/26. He acknowledged the findings.

1) All soiled or damaged furniture has been removed from the community. All damaged ceiling tiles have been replaced, and missing ceiling tiles have been reinstalled. Dining room areas on terrace, 4th, 5th and 6th floors have been deep cleaned to remove any build up of dust and cobwebs. Any visible electrical wiring has been capped and secured to ensure safety. Any identified burnt out light bulbs have been replaced. 2) This system has been corrected with a scheduled maintenance/housekeeping walkthrough twice weekly to identify and resolve any concerns in a timely manner. Cleaning has been scheduled to take place in all dining rooms twice weekly, to include any doors and door tracks. 3) This area will be evaluated twice weekly during scheduled community walkthroughs with maintenance and housekeeping. 4) Monitoring and continued compliance will be the responsibility of the Executive Director, or designee.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: Observations on 07/13/26 and 07/14/26 revealed exit doors to the fourth, fifth, and sixth floor patios located in the dining room areas failed to have an alarm or other acceptable system to alert staff when residents exited the building. On 07/14/26 at 2:30 pm, the need to ensure exit doors were equipped with an audible alarm or other acceptable system was discussed with Staff 1 (ED) and Staff 5 (Director of Maintenance). They acknowledged the findings.

1) All doors noted have been equipped with an audible alarm device. 2) Audible alarm devices have been installed and will be tested to ensure functionality during community walkthroughs. 3) Monitoring will occur for each audible alarm on a weekly basis. 4) This will be the responsibility of the Maintenance Director and Executive Director, or designee.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 2 of 4 sampled newly hired staff (#s 13, 14, 15, and 16) whose training records were reviewed. Findings include, but are not limited to: Refer to C370.

See plan of correction for C370.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training ? Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: