Print Inspection: RL006117

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 08/12/25 at 9:30 am, the facility kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following: * Multiple walls throughout; * Caulking behind two-compartment sink and dish machine area * Interior of small reach-in refrigerator; * Bottom section of metal rolling cart; * Bottom two shelves of rolling cart storing clean fry pans; * Wall behind and under sink in dish machine area; * Floor drains; * Pipes and walls in three-compartment sink area; * Walls, floor and sink-basin in mop storage area; * Pipes of mechanical equipment area; * Several ceiling lights and vents; and * Flooring around and under appliances, shelving, perimeter, and tile grout lines. b. The following areas needed repair: * Wall under dish machine had an approximate three-inch gap that extended several feet between the top of the tile cove base and white wall paneling which created an opening/hole; * Several walls, corners and door jamb in the dry storage room were gouged and scraped; and * Exit/entrance doors and or jambs had scraped paint in multiple areas. The areas that required cleaning and repair were observed and discussed with Staff 1 (Administrator) and Staff 4 (Dietary Director) on 08/12/25 at 11:20 am. The findings were acknowledged.

Staff will be given a cleaning schedule to be done daily, weekly and monthly. Staff will be inserviced by 10/12/2025 on the new cleaning protocols. Maintenance will paint and caulk and fix all areas of concern. Kitchen manager will do daily walk throughs and will audit bi-weekly to ensure all areas are clean. Kitchen manager will update cleaning task sheet. Kitchen manager will monitor weekly and evaluate to ensure all tasks are on the checklist. Administrator and kitchen manager will be responsible for monitoring.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). 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, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 8, 9 and 10) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 08/12/25. There was no documented evidence Staff 8 (CG) hired 08/28/25, Staff 9 (MT) hired 05/28/25, and Staff 10 (CG) hired 05/06/25, had demonstrated competency in some or all of the following required areas and within 30 days of hire including: * Role of service plans in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment and observation and reporting. Additionally, there was no documented evidence Staff 8, 9, and 10 had completed First Aid certification and abdominal thrust training. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 5 (Front Office Manager) on 08/12/25 and with Staff 1 (Administrator) on 08/13/25. The findings were acknowledged.

Revised competency checklist for onboarding staff. All staff checklists will be audited and any missing trainings will be completed by 10/12/2025. All training components have been audited and trainings have been added to the checklist. The onboarding checklist will be audited and changed as needed. Administrator and BOM will be responsible for monitoring.

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:

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 per OFC and to instruct staff in fire and life safety topics on alternate months from fire drills. Findings include, but are not limited to: Facility fire drill and fire and life safety records from 02/2025 through 07/2025 were reviewed with Staff 3 (Maintenance Director) on 08/12/25 at 12:00 pm. The facility’s fire drill records lacked one or more of the following required components: *Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; *Number of occupants evacuated; and * Documentation fire and life safety instruction for staff was completed on alternating months of the fire drills. The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed Staff 1 (Administrator), Staff 2 (RN), and Staff 3 on 08/12/25 at 1:30 pm. They acknowledged the findings.

Training calendar will be revised and implemented. Training will occur upon hire and throughout the year monthly. BOM and Maintenance Director will audit trainings to ensure staff training is being done. BOM and Maintenance Director will audit quarterly. Administrator, BOM and Maintenance Director will be responsibe for monitoring/completing.

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 ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and to re-instruct residents on fire and life safety 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: Facility fire drill and fire and life safety records from 02/2025 through 07/2025 were reviewed with Staff 3 (Maintenance Director) on 08/12/25 at 12:00 pm. During the review of the fire drill records Staff 3 reported the facility does not have a written record for annual re-instruction of general fire safety procedures. The need to re-instruct residents on general fire safety procedures at least annually, per the OFC requirements was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 on 08/12/25 at 1:30 pm. They acknowledged the findings.

Revised training checklist will be implemented. A resident signature line will be added to the checklist to ensure each resident has signed off of the training. Maintenance will ensure training is done upon admittance, monthly and annually. Maintenance will evaluate monthly, quarterly and annually for training. Administrator and Maintenance Director will be responsible for 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 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year, in accordance with Oregon Fire Code (OFC) and other applicable state and local codes as required. Findings include, but are not limited to: Facility fire drill and fire and life safety records from 02/2025 through 07/2025 were reviewed with Staff 3 (Maintenance Director) on 08/12/25 at 12:00 pm. During the review of the fire drill records it was confirmed the facility was not conducting fire drills and fire and life safety training for staff in accordance with the OFC. Survey requested Staff 1 (Administrator) and Staff 3 provide documentation of the emergency preparedness drills conducted at the facility over the previous 12 months. Staff 3 was unable to explain or provide documentation that included analysis and response to potential emergency hazards including but not limited to the evacuation of the facility. Staff 3 confirmed the facility had not conducted drills for the emergency preparedness plan at least twice a year.? The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with OFC and other applicable state and local codes as required was reviewed with Staff 1 and Staff 3 on 08/12/25 at 1:30 pm. They acknowledged the findings.

Emergency preparedness plan will be updated annually. All emergency procedures will be written in accordance with OFC. Drills will be performed twice annually. A resident training calendar will be put in place to ensure training is scheduled. Emergency preparedness will be updated and evaluated annually. Administrator and Maintenance Director will monitor.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exterior surfaces and pathways were maintained in good repair. Findings include, but are not limited to: Observations of the exterior courtyard, pathways surrounding the building, and facility entrance on 08/11/25 showed the following: * Uneven surfaces were noted to the right and left of the front entrance where the concrete had cracked and separated or was broken; * Concrete seams in multiple areas in the front entrance area had raised areas; * Multiple drop-offs of 2-4 inches along several pathway edges; * A 10X2 inch section of paver stones were missing in the courtyard next to the exterior door ramp creating a potential tripping hazard; and * The exterior ramp, leading from the dining room to the courtyard, was open on both sides and had an approximate 10-inch drop at the start of the ramp to a one-inch drop at the end. The need to ensure pathways and exterior surfaces were maintained in good repair and did not have potential hazards was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director) during a tour of the exterior grounds on 08/11/25 at 3:25 pm. The findings were acknowledged.

All exterior areas of the community will be addressed and fixed. Maintenance will create a calendar in TELS for regular scheduling of tasks. Maintenance will utilize the TELS system to schedule regular and monthly maintenance tasks to ensure compliance. Maintenance will evaluate weekly, monthly and annually. Administrator and Maintenance Director will be responsible for monitoring.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior and exterior surfaces and all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair. Findings include, but are not limited to: Observations of the facility on 08/11/25 revealed the following: a. First Floor Neighborhood (Rooms 101-110) and kitchenette: * Gouged, scraped doors and/or jambs were observed in the following areas: entry/exit doors to neighborhood, housekeeping room, and resident rooms 101, 102, 104, 105, 108, and 110; * The common bathroom had an accumulation of dust/lint on the ceiling vent; * Carpet stains in front of room 109; and * Stains on the backs of two loveseats in the common area. * Kitchenette: - The wood encasing the coffee maker was missing laminate from the bottom edge. Particle board was exposed, and was degrading in several places; - Brown stains were visible in the cabinet underneath the sink; and - An accumulation of food and brown matter was observed in the basins and drains of the two-compartment sink. b. First Floor Neighborhood (Rooms 114-126) and kitchenette: * Gouged, scraped doors and/or jambs were observed in the following areas: exit doors to outside, entrance to neighborhood, common bathroom, tub bathing room, and resident rooms 116, 117, 118, 121, and 123; * Carpet stains in common areas and halls near rooms 117, 120, 125, and 126; * Laundry room had an accumulation of lint/debris behind the dryer, an approximate 1X2 inch hole in the flooring underneath the sink, and lint/dust accumulated on the ceiling vent; and * The common bathroom had an accumulation of dust/lint on the ceiling vent. * Kitchenette: - Wall corners next to the refrigerator were gouged; - The wood encasing the coffee maker, was missing laminate from the bottom edge. Particle board was exposed, and was degrading in several places; and - An accumulation of brown matter was observed in the basins and drains of the two-compartment sink. c. Second Floor Neighborhood (Rooms 201-210) and kitchenette: * Gouged, scraped doors and/or jambs were observed in the following areas: common bathroom, and resident rooms 201, 202, 203, 205, 206, 207, 208, 209, and 210; and * Room 203 had small holes in the wall under the exterior room identifier plate. * Kitchenette: - The wood encasing the coffee maker was missing laminate from the bottom edge. Particle board was exposed, and was degrading in several places. d. Second Floor Neighborhood (Rooms 211-222) and kitchenette: * Gouged, scraped doors and/or jambs were observed in the following areas: stairwell, entrance to neighborhood, and resident rooms 211, 212, 215, 218, 219, 220; * Carpet stains in halls in front of rooms 213 and 221; * Wall alcove near Room 221 had an approximate 18X6 inch damaged section; and * Stairwell near Room 218 had an accumulation of dead bugs, spiders/webs in the window sills. * Kitchenette: - An approximate 6X1 inch strip of flooring was missing in front of the refrigerator; - The wood encasing the coffee maker was missing laminate from the bottom edge. Particle board was exposed, and was degrading in several places; - The open cabinet underneath the coffee maker had an accumulation of debris; and - An accumulation of brown matter was observed in the drains of the two-compartment sink. e. Third Floor Neighborhood (Rooms 301-312) and kitchenette: * Gouged, scraped doors and/or jambs were observed in the following areas: trash room, entry doors, and resident rooms 301, 304, 305, and 307; * The common bathroom had an accumulation of dust/lint on the ceiling vent; * Walls vents near the exit door and trash room had an accumulation of dust/lint; and * The wall in the common area near room 308 had black scrapes. * Kitchenette: - The wood encasing the coffee maker was missing laminate from the bottom edge. Particle board was exposed, and was degrading in several places; - An approximate 12X8X8 section of flooring was missing in front of and underneath the right side of the refrigerator; and - The wall next to the refrigerator had gouged areas. f. Third Floor Neighborhood (Rooms 314-325) and kitchenette: * Gouged, scraped doors and/or jambs were observed in the following areas: housekeeping room, trash room, resident rooms 315, 317, 320, 321, 323, 324; * Carpet stains in front of rooms 317 and 324; and * Peeling paint on the white shelf ledge (open to the second floor). * Kitchenette: - Approximate 6X1/2 inch strips of flooring was missing in front of the refrigerator; - An accumulation of brown matter was observed in the basins and drains of the two-compartment sink; and - The cove base next to the refrigerator was coming apart from the wall. g. Third Floor Common Area: * Scraped elevator door jambs; * Peeling paint on stairwell; * An accumulation of bugs and cob webs on window screen; and * Carpet stains in multiple areas. h. Dining Room: * Spiders/webs were observed on the ceiling in several areas; * Debris was visible in several ceiling lights; * The interior of the microwave had food splatters; * The cloth coverings on the buffet table had an accumulation of food matter; * Gouges and scrapes were observed on walls underneath the windows, near door leading to courtyard, and several pillars; and * A black, scrape was observed on the wall opposite the elevator. i. Common bathrooms off the dining room: * Doors had gouged and scraped areas; * Women’s bathroom had scraped paint behind the toilet and dust on the ceiling vent; * Men’s bathroom had discolored caulking around the toilet base and dust on the ceiling vent. j. Second floor conference room, and common areas on the second and third floors had carpet stains in multiple areas. k. The emergency stairwells on both sides of the building had an accumulation of dirt, debris, bugs, spiders, and webs. l. An accumulation of bugs, spiders and webs were visible on windows/screens and siding of the building. m. An approximate six-foot metal handrail, located adjacent to a ramp leading into the outdoor courtyard, was unsecured and could easily tip over when grabbed. This caused a potential accident hazard. The surveyor toured the interior and exterior environment with Staff 1 (Administrator) and Staff 3 (Maintenance Director) on 08/11/25 at 3:25 pm. They acknowledged the findings.

1st Floor neighborhood (rooms 101-110 and kitchenette) door jambs, entry and exit doors to housekeeping, resident rooms, 101, 102, 104, 105, 108, and 110 will be sanded and painted. Vents will be cleaned weekly in all common bathrooms. Carpet in front of 109 will be cleaned. Stains on the back of two loveseats in the common area will be cleaned and checked daily and as needed. Housekeeping task list will be updated to add bathroom vent and carpet cleaning weekly, furntiure cleaning as needed and checked daily for stains. Maintenance Director will keep doors and door jambs painted and free from gouges. Maintenance Director will do daily walk throughs, weekly and monthly audits to ensure cleaning is being done. Housekeepers will monitor daily and weekly according to task list. Administrator and Maintenance Director The kitchenette coffee makers and the encasements will be removed totally from the kitchenettes on all floors. Counter will be fixed and sealed once removed. Sink and cupboards will be cleaned a stain free. We have switched coffee vondors and coffee pots will not be returning to the kitchenettes. Maintenance will replace countertop are to cover any open or scuffed areas. Sink cleaning and wiping cupboards will do daily walk throughs to ensure areas are clean and stain free. Administrator and Maintenance Director. 1st Floor neighborhood (rooms 114-126). Exit doors to ourside, entrance to beighborhood, common bathroom, the tub bathing room and residendent room will be painted. Carpet stains in common area and halls near 117, 120, 125, & 126 will be shampooed. Maintenance will paint all gouged doors and jambs. Carpets will be cleaned weekly an on a as needed basis. Maintenance and housekeepers will do daily walk throughts and will follow their task seets to ensure areas are clean. Administrator and Maintance Director. 1st Floor laundry room. Vent and lint cleaning behind the dryer, the ceiling vent and the ceiling vent in the common bathroom will be cleaned weekly by housekeeping. 1/2 inch hole in the flooring underneath the sink will be replaced by maintenance. Kitchenette coffee maker will be removed. Counter will be fixed upon removal of coffee pots. Sinks and cuboards will be cleaned daily/weekly. Maintenance and housekeepers will do daily walk throughs and will follow their task sheets to ensure areas are clean, lint free and stain free. Maintenance and housekeepers will do daily, weekly and monthly checks to ensure cleaning is getting done. Administrator and Maintenance Director 2nd Floor Neighborhood (rooms 201-210 and kitchenette). Door jambs, scraped doors in the common area bathroom and resident rooms 201, 202,203, 205, 206, 207, 208, 209 and 210 will be painted. Room 203 identifier plate holes will be filled and painted. Kitchenette coffee maker and encasement will be removed. Counter will be repaired by maintenance. Maintenance and housekeepers will have updated task lists with the dditional cleaning tasks added. Maintenance will do daily, weekly and monthly walk throughs to enure tasks are being completed. Aministrator and Maintenance Director 2nd Floor neighborhood (rooms 211-222 and kitchenette). Door jambs scraped doors in the stairwel, entrance to neighborhood and resident rooms 211, 212, 215, 218, 219, and 220 will be filled and painted. Carpet stains in front of rooms 213 and 221 will be shampooed. Wall alcove near room 221 will be filled and painted. Stairwell near room 218 will have spider webs and bugs cleared from window sills. Coffee maker and encasement will be removed. Counter will be repaired by maintenance. Cabinets will be cleaned of all debris. Sink will be cleaned of debris. Maintenance and housekeepers will add carpet cleaning, wiping window sills, and wiping cabinets and drawers to their task list. Maintenance will do daily, weekly and monthly walk throughs to ensure cleaning is being done. Housekeepers will add additional cleaning tasks to their checklist. 3rd Floor Neighboor (rooms 301-312 and kitchenette). Door jambs, scraped doors in the stairwell, entrance to neighborhood and resident rooms 301, 304, 305, and 307 will be filled and painted. The common bathroom ceiling vent will cleaned of all lint and dust. The wall near 308 will have the black marks cleaned and painted if necessary. Coffee maker and encasement will be removed and counter top repaired. a 12X8X8 flooring section will be replaced and repaired by maintenance in front of and underneath right side of fridge. Wall next tp the fridge will be repaired and painted. Maintenenac and housekeepers will add additional cleaning to their task lists. Maintenance will do daily, weekly and monthly walk throughs to ensure cleaning is being done. Administrator and Maintenance Director 3rd Floor Neighborhood (rooms 314-325 and kitchenette). Door jambs, scraped doors in the housekeeping room, trash room and resident rooms 315,317,320,321,323, 324will be repaired and painted. Carpet stains in front of rooms 317 and 324 will be shampooed. Peeling paint on the ledges will be repaired and painted. A 6x1/2 inch flooring piece that is missing in front of the fridge will be repaired by maintenance. Sinks and basins will be cleaned of all brown matter. Cove base next to fridge will be repaired by maintenance. Maintenance and housekeepers will add additional cleaning to their task lists as needed. Maintenance will do daily, weekly and monthly walk throughs to ensure cleaning is being done. Administrator and Maintenance Director 3rd Floor Common Area scraped elevator door jambs, peeling paint on the stairwell! be repaired and painted. Bugs and cobwebs will be cleaned from window screens. Carpet stains will be shampooed throughout multiple areas. Maintenance and housekeepers will add bug and cobweb removal from window screens to their weekly cleaning tasks. Maintenance will do daily, weekly and monthly walk throughs to ensure cleaning is being done. A new pest control service has been hired to help with spiders and bugs. They will come monthly. Administrator and Maintenance Director Dining room. spiders/webs will be cleaned from the ceiling. Ceiling lights will be cleaned. Dietary will clean microwave after each meal service. Cloth table coverings will be removed and washed daily. Gouges and scraped walls under windows, near door leading to courtyard and severa pillars will be repaired and painted. Black scrape on the wall opposite elevator will be painted. Dietary will add bug and covweb removal from the ceilings to their weekly cleaning tasks. Clth removal and washing will take place daily and will be added to the task sheet. Ceiling lihts will be cleaned and maintained by maintenance. Microwave cleaning will be put on the task sheet to be done after each meal service. Dietary Manager will do daily, weekly and monthly walk throughs to ensure cleaning is being done. Administrator, Maintenance Director and Dining Services Director. Common bathrooms off the dining room. Gouged and scraped doors will be repaired and painted. Women's bathroom will be painted behind the toilet and the ceiling vent will be cleaned and dust free. Men's bathroom had discolored caulking around toilet base and dust in the ceiling vent. The area will be cleaned and recaulked by maintenance. Housekeepers will add the common area bathroom ceiling vent cleaning to their task sheet. NOC shift will have the common area bathrooms added to their tasks as well. Maintenance Director will monitor cleaning task sheets to ensure added tasks are getting done daily, weekly and monthly. Administrator and Maintenance Director Second floor conference room, common areas on the second and third floors had carpet stains throughout. Carpet cleaning will be done. The emergency stairwells on both sides of the building had debris, cobwebs, bugs and spiders/webs in them. An accumulation of bugs, spiders and webs on window screens and siding of the building. A new pest control company has been hired to debug the building. This will control the spiders and webs. A six foot metal handrail was unsecured located adjacent to the ramp leading to the courtyard. Maintenanc will be building a new handrail for both sides. All cleaning tasks, carpet cleaning and spider webs removal will be added to housekeeping task sheets. Pest control will monitor the building monthly and spray when nexessary to keep the bugs and spiders away. Maintenance will monitor and review daily, weekly and monthly to ensure cleaning is being done. Administrator and Maintenance Director

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0300 (6)(b-f) Common Use Areas: Social (6) COMMON-USE AREAS. (b) DINING AREA. The building must have a dining area with the capacity to seat 100 percent of the residents. The dining area must provide 22 square feet per resident for seating, exclusive of service carts and other equipment or items that take up space in the dining area. This rule is exclusive of any separate private dining areas. (c) SOCIAL AND RECREATION AREAS. An ALF must include lunge and activity areas for social and recreational-use totaling a minimum of 15 square feet per resident. (d) COOKING STOVE. If a stove is provided in the activities or common-use area, and is available for resident-use, a keyed, remote switch, or other safety device must be provided to ensure staff control. (e) RESIDENT LAUNDRY FACILITIES. Laundry facilities must be operable and at no additional cost to the resident. Resident laundry facilities must have at least one washer and dryer. (f) MAILBOX. Each resident or unit must be provided a mailbox that meets US Postal Service requirements This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure stoves in neighborhood common area kitchens were keyed off/locked to ensure staff control. Findings include, but are not limited to: The environment tour on 08/11/25 at 11:00 am revealed stoves in several of the neighborhood kitchenettes were keyed to ensure staff control. However, the stoves were not keyed off, could be turned on, and no staff member was observed to be using the stoves or to be in the kitchenettes. The need to ensure stoves in neighborhood kitchenettes had a system to ensure staff control was discussed during a tour with Staff 1 (Administrator) and Staff 3 (Maintenance Director) on 08/11/25 at 3:25 pm. They acknowledged the findings and Staff 3 locked all the stoves.

Team leaders and caregivers will be given keys to ensure all stoves are locked. Staff will be given keys to ensure stoves are off and locked. Staff will check the stoves daily to ensure they are locked during rounds. Administartor, RCC's, Team Leads and Care Staff will monitor during rounds.

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