Print Inspection: RL003776

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents’ right to privacy related to protected health information and a safe and homelike environment related to seating in the outdoor area for multiple sampled and unsampled residents. Findings include, but are not limited to: 1. Observations of the MCC were made from 04/14/25 to 04/16/25. The following was identified: * The MCC consisted of an open front desk area where staff conducted phone calls and other business related to the care of residents. The desk area was in between the MCC dining room and common room, where residents were observed to spend most of the day. Residents’ family members and outside provider staff were observed in these common areas as well. There was no barrier between the desk area and the residents’ common areas, and conversations could be overheard throughout the MCC. * Staff were observed conducting phone conversations with providers and family members, as well as having conversations with each other, using sampled and unsampled residents’ personally identifiable information and discussing health and service needs in the front desk area. The need to ensure residents’ right to privacy related to protected health information was discussed with Staff 1 (Administrator) on 04/16/25. She acknowledged the findings. ?2. Observations of the exterior courtyard were made, and interviews were conducted with staff between 04/14/25 and 04/16/25. The facility was endorsed as a secure MCC and was home to 15 residents. The building and its residents had access to an outdoor recreation area which wrapped around two sides of the MCC. The outdoor recreation area was approximately 75 feet by 110 feet with a pavement walking path connecting the two areas. Initial observations of the courtyard revealed no outdoor furniture for resident use, comfort and/or safety. On 04/14/25 at 10:20 am, Staff 1 (Administrator) reported an unsampled resident’s family recently asked about the lack of furniture in the courtyard. On 04/15/25 at 12:03 pm, Resident 1’s family reported it would be nice to have a place to sit in the courtyard. Resident 1’s family added, “Who doesn’t want to sit outside on a nice day?” On 04/16/25 at 9:37 am, Staff 6 (Med Aide/CG) reported there were five residents who required walkers for safety and three residents who had recent falls or were at risk for falls. During the same day at 11:30 am, Staff 14 (Activity Director) reported the activity department brought furniture to the courtyard for outdoor activities; however, the furniture was not to be left in the courtyard because it was too light and could aid in a resident’s elopement. Staff 14 identified four residents who would be interested in sitting outside independently, and stated most residents would be interested if cued. Of the residents identified by Staff 14, three of them were identified as fall risks and/or required a walker for safety. The need to ensure the residents’ right to a safe and homelike environment related to accessible outdoor furniture was discussed with Staff 1 and Staff 2 (ED) on 04/16/25 at 12:37 pm. They acknowledged the findings.

C200 1. A memo was written to staff on 4/15/2025 regarding resident's privacy and utilizing room numbers. Education was done with staff on Residents Rights, completed 5/1/2025 Courtyard furniture of two heavy benches were placed in the courtyard a safe distance from the fences. 2. Other business such as phone calls for families, medical providers etc that require more privacy will be moved to the medroom. In person conversations can be moved to resident apartments or the conference room on an as needed basis. Courtyard furniture will remain in its placed locations at all times. 3. The areas needing correction will be monitored daily. 4. The medaides and other leaders such as the Administrator/RN will be responsible to see that the corrections are completed/monitored.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

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 maintain effective infection prevention and control protocols for 1 of 1 sampled resident (#2) dependent on staff for ADL care and for multiple sampled and unsampled residents related to dining services. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2023 with diagnoses including dementia and history of stroke and was identified in the acuity interview on 04/14/25 as dependent on staff for toileting and/or incontinence care. At 1:47 pm on 04/15/25, Staff 7 (CG) and Staff 12 (RN) were observed providing toileting assistance for Resident 2. Both staff were observed to don single-use gloves without first performing hand hygiene. Staff 7 pulled down the resident’s pants and brief, and both staff assisted him/her with transferring to the toilet. Staff 7 assisted the resident with wiping. Wearing the same gloves, Staff 7 wiped the resident’s hands. Staff 12 assisted the resident to stand, and Staff 7 then provided perineal care and applied barrier cream. Wearing the same gloves, she pulled up the resident’s brief and pants, and both staff assisted him/her to a wheelchair. Without changing soiled gloves or performing hand hygiene, Staff 7 removed Resident 2’s eyeglasses, then combed his/her hair. Staff 7 then wheeled the resident to the MCC common area still wearing the soiled gloves. Surveyor at that point requested Staff 7 remove the soiled gloves and perform hand hygiene. During an interview at the same time, Staff 7 stated she had received training in infection control, but “I forget. I get busy.” The need to maintain effective infection prevention and control protocols was discussed with Staff 1 (Administrator) on 04/16/25. She acknowledged the findings. ?2. Lunch service was observed on 04/14/25 and 04/15/25. a. Staff were observed setting tables with napkins and silverware, serving meals and beverages, touching residents and removing dirty dishes without changing their gloves or performing hand hygiene. b. Direct care staff were observed serving food to residents without donning a protective barrier over potentially contaminated clothing. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (Administrator) on 04/16/25. The findings were acknowledged.

C295 1. A memo was written for staff on 4/17/25 that included the proper times to change gloves when completeing care and when/where to wear gloves. Staff to also complete Hand Hygeine Training on Relias. A dining services memo for staff was written on 4/16/25 that included the following changes; proper hand hygiene, no gloves while serving, and reminder to don an apron during meal times. More apron's were provided for staff on 4/29/2025 to ensure enough for all meals. 2. Immediate and ongoing monitoring of these areas will ensure that this violation does not happen again. 3. Daily monitoring of meals to ensure aprons are worn and hand hygiene is performed. Quarterly staff audits to review hand hygiene and glove usage during resident personal care. 4. The administrator will be responsible for monitoring the areas and completing audits.

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 411-054-0090 (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 conduct fire drills in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety staff training on alternate months. Findings include, but are not limited to: On 04/14/25, a review of fire drills and fire and life safety records dating from 10/2024 through 03/2025 identified the following: a. There was no documented evidence the facility was conducting fire drills every other month in the MCC. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. The need to ensure fire drills were conducted in accordance with the OFC and fire and life safety instruction was provided to staff on alternate months of fire drills was discussed with Staff 1 (Administrator) and Staff 2 (Executive Director) at 1:20pm on 04/16/25. They acknowledge the findings, and no additional documentation was provided.

C420 1. Staff fire and life safety training was completed at All Staff meeting on 04/18/25. A Fire drill is scheduled for 5/2/2025. 2: Fire drills will be scheduled in the MCC every other month. A yearly fire and life safety training guide has been completed and trainings will be scheduled in opposing months from drills. 3. Monthly audits will be conducted to ensure that drills and training have been completed. 4. The Maintenace Director and the Director of People and Operations

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 conduct fire drills in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: On 08/05/25, fire and life safety records dated 06/15/25 through 07/2025 were reviewed. There was no documented evidence the facility conducted fire drills every other month. On 08/05/25 at 2:31 pm, Staff 1 (Administrator) stated the facility completed a drill in the MCC in 07/2025; however, she was unable to provide documentation of the drill. The need to ensure fire drills were conducted in accordance with the OFC was discussed with Staff 1 at 2:56 pm on 08/05/25. She acknowledged the findings.

1. A fire drill with full evacuation was completed on August 14th 2025 at 2:00pm. Fire, life and safety education will also be completed at the all staff meeting on 8/20/2025 so that the community is back on track. 2. Administrator, Maitenance Director or designees will set dates for future drills 1-2 months in advance. 3. Administrator, Maintenance Director or designees will review quarterly for passed quarter and upcoming quarter. 4. Maintenance Director, Adminstrator or designees will be responisble for ensuring corrections are completed and monitored.

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 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building at least annually, with a written record of the content of the training sessions and the residents attending per the Oregon Fire Code (OFC). Findings include, but are not limited to: On 04/14/25 fire and life safety records were reviewed and revealed the following: There was no documented evidence the facility was providing instruction at least annually to residents regarding fire and life safety procedures and responsibilities. During an interview on 04/15/25 at 1:10 pm, Staff 1 (Administrator) and Staff 2 (ED) stated they were not aware that residents needed to be trained at least annually in fire and life safety protocols. The need to re-instruct residents on fire and life safety at least annually as per the OFC requirements was discussed with Staff 1 and Staff 2 at 1:20 pm on 04/16/25. They acknowledged the findings, and no additional documentation was provided.

C422 1. A fire training sheet was created, lamenated and posted on the back of door of each resident apartment, completed 4/22/2025. 2. The training sheet will be reviewed quarterly or at change of condition care conferences with residents/and or their responsible party with a signature line to acknowledge training. 3. Reviewed with each care conference. 4. The administrator and RN will be responsible for the monitoring.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. 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 observation and interview, 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 420 and Z 173

Refer to POC for C420 and Z0173.

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 (4)(a-b) General Building Interior (4) GENERAL BUILDING INTERIOR. The design of a RCF 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 RCF. (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. A CF may request an exception to this requirement, which shall be reviewed and decided on a case-by-case basis. (B) Corridors shall not exceed 150 feet in length from any resident unit to a seating or other common-use area. A CF may request an exception to this requirement, which shall be reviewed and decided on a case-by-case basis. (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 resident-use corridors had handrails installed at one or both sides. Findings include, but are not limited to: The interior of the building was toured on 04/14/25. The resident-use corridor, which included apartment numbers 162, 164 and 166, was observed to be without a handrail on at least one side for approximately 25 feet. On 04/16/25 at 9:37 am, Staff 6 (Med Aide/CG) confirmed multiple unsampled residents used walkers, two unsampled residents used the handrails for behavior management and/or exercise and residents walked the hallway. The need to ensure handrails were installed along resident-use corridors was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 04/16/25 at 12:31 pm. They acknowledged the findings.

C511 1. 4/22/2025 Walkthrough with RHAL Management, A hand rail will be ordered and installed. 2. The hand rail will be in place and maintained. 3. Area will be evalauted during weekly community walkthroughs. 4. The Administrator and Maintenance Director.

OAR 411-054-0200 (4)(a-b) General Building Interior (4) GENERAL BUILDING INTERIOR. The design of a RCF 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 RCF. (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. A CF may request an exception to this requirement, which shall be reviewed and decided on a case-by-case basis. (B) Corridors shall not exceed 150 feet in length from any resident unit to a seating or other common-use area. A CF may request an exception to this requirement, which shall be reviewed and decided on a case-by-case basis. (C) Handrails must be installed at one or both sides of resident-use corridors. This Rule is not met as evidenced by:

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain hot water temperatures in residents' units within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to: The building was toured on 04/15/25, and temperatures in resident apartments 154, 157, and 164 were measured at 108, 109.8, and 106.8 degrees Fahrenheit, respectively. During an interview at approximately 9:20 am on 04/16/25, Staff 2 (ED) confirmed the facility did not have documentation to demonstrate a system of monitoring the hot water temperatures. The need to ensure hot water temperatures in resident units were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1 (Administrator) and Staff 2 on 04/16/25 at 12:31 pm. They acknowledged the findings.

C545 1. Hot water heater temperatures were turned up on 4/16/2025. Water temperature logs were found and education done with the Maintenance Director on procedures for water temp checks 4/23/2025 2. Water temperatures will be reviewed and logged weekly. 3.Water temps will be monitored weekly. Logs will be audited monthly. 4. The Maintenance Director will test the water weekly, The Administrator will audit monthly to ensure completion.

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure individual rights of privacy for multiple sampled and unsampled residents. Refer to C200, Example 1.

H1510 Refer to MCC plan of correction for C200. Refer to MCC plan of correction for C200. Refer to MCC plan of correction for C200. Refer to MCC plan of correction for C200.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for multiple sampled and unsampled residents who shared bathrooms. Findings include, but are not limited to: In an interview at 3:30 pm on 04/15/25, Staff 1 (Administrator) confirmed ten of the eleven MCC units had shared bathrooms. Observations of the shared bathrooms on 04/15/25 revealed lever-type door handles with no method to ensure resident privacy during use of the bathroom. The need to ensure privacy in individual resident units was discussed with Staff 1 on 04/16/25. She acknowledged the findings.

H1517 1. 04/22/2025 Walkthrough done with RHAL Management, door handles with locking capability to be ordered for the shared bathrooms, the locking locks will be installed on all bathroom doors upon arrival. 2. The system will be corrected once all locked handles have been installed. 3. The handles will be evaluated on weekly community walkthroughs to ensure working properly. 4. The Administrator and Maintenance Director

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents had a key to their units for all sampled and unsampled residents. Findings include, but are not limited to: Review of Resident 1 and 2’s current service plans, dated 03/10/25 and 02/10/25, respectively, indicated neither had a key to their unit. In an interview at 3:30 pm on 04/15/25, Staff 1 (Administrator) stated residents and/or their families were offered a key at move-in, and it was noted in their service plan if they declined it. She stated none of the residents currently had a key to their units. The need to ensure residents had a key to their units was discussed with Staff 1 on 04/16/25. She acknowledged the findings.

H1518 1. Resident keys for each individual apartment have been ordered and will be distributed to current residents. 2. Keys will be given to all residents upon admit, with the suggestion to keep in a top drawer if they do not wish to carry with them when leaving their room. Service plan will show their wishes. 3. At each quarterly service plan staff will ensure resident has a key at their disposal should they want to use it. 4. Andminstrator and RN

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C295, C420, C422, C511, and C545.

Z142 Refer to MCC plan of correction for C200 (pg. 1), C295 (pg. 2), C420 (pg. 3), C422 (pg. 4), C511(pg. 5) and C545 (pg. 6). Refer to MCC plan of correction for C200 (pg. 1), C295 (pg. 2), C420 (pg. 3), C422 (pg. 4), C511(pg. 5) and C545 (pg. 6). Refer to MCC plan of correction for C200 (pg. 1), C295 (pg. 2), C420 (pg. 3), C422 (pg. 4), C511(pg. 5) and C545 (pg. 6). Refer to MCC plan of correction for C200 (pg. 1), C295 (pg. 2), C420 (pg. 3), C422 (pg. 4), C511(pg. 5) and C545 (pg. 6).

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 420.

Refer to POC for C420 and Z0173.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 3, 4, 9 and 10) completed all required pre-service orientation training topics; failed to ensure 4 of 4 newly-hired direct care staff (#s 3, 4, 9 and 10) completed all required pre-service dementia training before independently providing personal care or other services; and failed to ensure 3 of 4 newly-hired direct care staff (#s 3, 4 and 10) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 13 (Director of People and Operations) on 04/15/25 and 04/16/25. The following was identified: a. There was no documented evidence Staff 3 (Med Aide), hired 02/24/25, Staff 4 (Med Aide), hired 01/20/25, Staff 9 (CG), hired 02/03/25, and Staff 10 (CG), hired 02/01/25, completed one or more of the following required pre-service orientation topics prior to beginning job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; * Infectious Disease Preventions; and * HCBS course. b. There was no documented evidence Staff 3, Staff 4, Staff 9 and Staff 10 completed one or more of the following required pre-service dementia training topics prior to providing care and services independently: * Environmental factors that are important to a resident’s well-being; * Family support and the role the family may have in the care of the resident; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. c. Staff 3, Staff 4, and Staff 10 lacked documented evidence they had completed all the required training and demonstrated competency in all job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * 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 * Other duties as applicable. In an interview on 04/15/25, Staff 1 (Administrator) and Staff 13 acknowledged Staff 3 and Staff 4 received medication pass training, but the facility could not find the documentation of the demonstrated competencies. On 04/15/25 at 2:45 pm, Staff 3 confirmed she received training from Staff 6 (Med Aide/CG), and they had completed a checklist for all the Med Aide training provided. Staff 1 provided documentation for medication pass training to the survey team on 04/16/25. The need to ensure all newly-hired staff completed pre-service orientation prior to performing any job duties, completed pre-service dementia care training before independently providing personal care or other services and demonstrated competency in job duties within 30 days was discussed with Staff 1 and Staff 2 (ED) on 04/16/25 at 1:01 pm. They acknowledged the findings.

Z155 1. All required staff have been assigned the additional pre-service dementia training. Competencies for job specific duties were recreated on 4/16/2025 for those that were missing. Sample staff needing items such as food handlers, first aid etc. have been completed courses and provided certificates, 4/27/2025. 2.Alzheimer's Disease and Related Disorders, The Environment and Ethical and Family Issues have been added to our Pre-Service checklist to ensure completion prior to providing personal care to a resident. The checklist will then be signed off on by both the Director of People's and Operations as well as the Employee's Supervisor to ensure all required documntation and education has been completed. 3.The training records will be monitored upon hire and audited quarterly. 4. The Director of People and Operations and Administrator

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: Resident 1 and 2's current service plans, dated 03/10/25 and 02/10/25, respectively, were reviewed. Both service plans were found to be lacking information and staff instructions related to an individualized nutrition and hydration plan. The need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator) on 04/16/25. She acknowledged the findings.

Z163 1. ISP's were written for the sample resident #1 and #2 for a nutrition and hydryation plan. 2. Community is switching to a new platform for assessments and service plans (ECP) that will include nutrition and hydration as part of the assessment. 3. This will be evaluated upon move-in, quarterly, and at any change of condition. 4. Administrator and RN

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: Resident 1 and 2's current service plans, dated 03/10/25 and 02/10/25, respectively, and “personal interests/social history” assessments were reviewed. There was no documented evidence the facility had evaluated and developed individualized plans based on the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions, if necessary. The need to ensure each resident was evaluated for activities and an individualized activity plan was developed was discussed with Staff 1 (Administrator) on 04/16/25. She acknowledged the findings.

Z164 1.ISP's were written for sample residents #1 and #2 for an individualized activity plan. 2. Community is switching to a new platform for assessments and service plans (ECP) that will include individualized activity plan. Activity staff will complete social history questionaire and create individualized activity plan for each individual resident. 3. This will be evaluated upon move-in, quarterly, and at any change of condition.. 4. Administrator and RN

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by:

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation areas were no less than six feet in height. Findings include, but are not limited to: The facility was endorsed as a secure MCC for residents with a diagnosis of dementia. The building and its residents had access to an outdoor recreation area. The outdoor recreation area was toured on 04/14/25. The fencing was a combination of vinyl and brick which surrounded the perimeter of the secured area. The fence was measured in multiple spots and had different height measurements based on the type and location of the fencing, with multiple areas measuring below six feet. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height was discussed with Staff 1 (Administrator) and Staff 15 (Maintenance Director) on 04/14/25 at 10:20 am. They acknowledged the height of the fence was less than six feet in areas. The facility locked the outdoor recreation area for resident safety while the areas of fencing under six feet were addressed.

1. The fencing in the MCC courtyard was brought to 6ft 4/15/2025. 2. The fencing will remain at 6ft, and will be monitored for compliance. 3. The area will be evaluated during weekly community walkthroughs.. 4. Maintenance Director and Administrator

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation areas were no less than six feet in height. This is a repeat citation. Findings include, but are not limited to: The facility was endorsed as a secure MCC for residents with a diagnosis of dementia. The building and its residents had access to an outdoor recreation area. The outdoor recreation area was toured on 08/05/25. The fencing was a combination of vinyl and brick which surrounded the perimeter of the secured area. The fence was measured in multiple spots and had different height measurements based on the type and location of the fencing. Multiple areas of the vinyl fence, including the vinyl gate, measured below six feet. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height was discussed with Staff 1 (Administrator) on 08/05/25 at 9:58 am and at 2:59 pm. She acknowledged the height of the fence was less than six feet in areas.

1. The fencing in the MCC couryard will be brought to 6ft. 2. The fencing will remain and 6ft, and will be monitored for compliance. 3. The area will be evaluated monthly by the Maintenance Director, Administrator or designees. 4. The Mainentance Director, Administrator or designees will be responsible for monitoring.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by:

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of their rooms at any time for multiple sampled and unsampled residents. Findings include, but are not limited to: During the survey from 04/14/25 to 04/16/25, observations revealed Rooms 150, 157, 158, 159, 160, 164 and 166 were locked from the outside at various times, preventing residents from entering their rooms without assistance from staff. During interviews on 04/15/25 and 04/16/25, Staff 5 (Med Aide), Staff 6 (Med Aide), and Staff 7 (CG) stated resident room doors were locked because some residents wandered into others' rooms. On 04/15/25 at 12:28 pm, an unsampled resident in the dining room was observed stating s/he needed to use the restroom and walking toward his/her room. Staff 1 (Administrator) approached the resident, stating, “I need to unlock the door for you” and unlocked the resident’s room. The need to ensure residents were not locked outside of their rooms was discussed with Staff 1 on 04/16/25. She acknowledged the findings.

Z176 1. A memo was written 4/21/2025 with instructions about all apartment doors being left unlocked. The two residents that were a wandering risk are no longer here. 2. All residents current and upon admit will be assessed for wandering risk and activities that they enjoy. Staff will be educated and service plans will be put in place to monitor, redirect as needed, and engage residents in an activity of interest; for all residents assesed to be a wandering risk. 3. This area will be evaluated quarterly with the evaluation of care needs. 4. Administrator and RN

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: