Print Inspection: RL006143

OAR 411-054-0010 (1-11) Licensing Standard (1) No individual, entity, or governmental unit acting individually or jointly with any other individual, entity, or governmental unit may establish, maintain, conduct, or operate a residential care or assisted living facility, use the term residential care or assisted living facility, or hold itself out as being a residential care or assisted living facility or as providing residential care or assisted living services, without being duly licensed as such. (2) Each license to operate a residential care or assisted living facility shall expire two years following the date of issuance unless revoked, suspended, terminated earlier, or issued for a shorter specified period. (3) Each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility. (4) A license may not be required for a building, complex, or distinct part thereof, where six or more individuals reside where activities of daily living assistance and health services are not offered or provided by the facility. (a) Facility representatives and written materials may not purport that such care and services are offered or provided by the facility. (b) Prospective and actual tenants must have no expectations that such care and services are offered or shall be provided by the facility. (c) The Department's Director shall determine whether a residential care or assisted living facility license is required in cases where the definition of a facility's operations is in dispute. (5) NOT TRANSFERABLE. No residential care or assisted living facility license is transferable or applicable to any location, facility, management agent, or ownership other than that indicated on the application and license. (6) SEPARATE BUILDINGS. Separate licenses are not required for separate buildings of the same license type located contiguously and operated as an integrated unit by the same licensee. Distinct staffing plans are required for each building. (7) IDENTIFICATION. Every facility must have distinct identification or name and must notify the Department of any intention to change such identification. (8) DESCRIPTIVE TITLE. A residential care or assisted living facility licensed by the Department may neither assume a descriptive title nor be held under any descriptive title other than what is permitted within the scope of its license. (9) RESIDENT DISPLACEMENT DUE TO REMODELING. The licensee must notify the Department 90 days prior to a remodel or renovation of part of a facility if there shall be a disruption to residents in the facility (for example: residents must be temporarily moved to another room overnight). During a non-emergent remodel, if any residents need to be moved from their rooms, the residents must continue to be housed in another area of the facility and may not be moved to another care setting. (a) NON-EMERGENT REMODEL. (A) For a non-emergent remodel, the licensee must submit a written proposal for remodeling or renovation to the Department. The proposal must include: (i) A specific plan as to where residents shall be housed within the existing facility. For those providers who have several buildings on the same campus, a move to a different building of the same license type within the campus setting is allowed, as long as the resident agrees to the move; (ii) A specific plan outlining the extended details of the renovation or remodeling; and (iii) A timeline for completion of the project. If the project is expected to take longer than three months, the licensee must provide a monthly update to the Department. The maximum time allowed for a renovation or remodel is one year from the date of the Department's approval. The Department may approve renovations that exceed one year. (B)The licensee must give the residents written notice 60 days prior to beginning any non-emergent remodel that shall displace the residents. The notice must include: (i) Where the residents shall be moved; (ii) The approximate length of time of the remodel; and (iii) Assurance that the residents shall be able to return to their own rooms when the remodel is completed, if the residents choose to do so. (C) The licensee must submit an outline of the work to be completed, construction documents, and any necessary drawings if required by the scope of work, to the Facilities Planning and Safety Program (FPS). FPS has 15 business days for review. (D) The licensee must comply with the rules in OAR chapter 333, division 675 (Project Plans and Construction Review) and all other structural requirements when remodeling. (E) Nothing in this rule is intended to preclude the Department from taking other regulatory action on a violation of the licensing requirements in these rules during the time of remodeling or renovation. (b) EMERGENT REMODEL OR CLOSURE. (A) When an emergency or disaster requires all residents of a facility or part of a facility to be immediately evacuated while remodeling occurs, the licensee must: (i) Provide the Department written details regarding the transfer of residents within two working days of the emergency or disaster; (ii) Submit a plan regarding the details for remodel or if necessary, a plan for permanent closure, to the Department within two weeks; (iii) Contact FPS to determine if drawings need to be submitted based on the scope of the remodel; and (iv) Assure that any residents who were transferred out of the facility shall be moved back to the facility when compliance with all building requirements of these rules is met. (B) All residents who have been transferred out of the facility must be notified in writing, at the last address known to the facility, as to when the residents shall be able to return to the facility. (C) The facility must ensure the safe transfer of residents from and back to the facility and bear all costs of the moves. (D) A refusal by a facility to allow a resident to return after the resident has been transferred out of the facility due to an emergent closure shall be regarded as an involuntary move out: (i) For an involuntary move out, the facility must comply with the requirements of OAR 411-054-0080; and (ii) The resident shall have all rights provided in OAR 411-054-0080. (E) In the event of an emergent closure, the Department may renew the existing license for a period not to exceed two years from the renewal date. (10) PERMANENT FACILITY CLOSURE. A facility is considered closed if the licensee is no longer providing services and the residents have moved out or must be moved from the facility. (a) The licensee must submit a written proposal for approval to the Department 60 days prior to permanent closure. The proposal must specify the plan for safe transfer of all residents. (b) The licensee must notify the residents at least 60 days prior to facility closure. (c) If the facility is closed and no residents are in the facility, the facility is considered unlicensed. (11) NOTICE OF BANKRUPTCY OR FORECLOSURE. The licensee must notify the Department in writing within 10 days after receipt of any notice of foreclosure or trustee notification of sale with respect to a real estate contract, trust deed, mortgage, or other security interest affecting the property of the licensee, as defined in OAR 411-054-0005. The written notice to the Department must include a copy of the notice provided to the licensee. (a) The licensee must update the Department in writing not less often than every 90 days thereafter until the matter is resolved and the default has been resolved and no additional defaults have been declared or actions threatened. The update must include: (A) The latest status on what action has been or is about to be taken by the licensee with respect to the notice received; (B) What action is being demanded or threatened by the holder of the security interest; and (C) Any other information reasonably requested by the Department related to maintaining resident health and safety. (b) The licensee must update the Department upon final resolution of the matters leading up to or encompassed by the notice of foreclosure or trustee notification of sale. (c) The licensee must notify the Department and all residents of the facility in writing immediately upon: (A) The filing of any litigation regarding such security interest, including the filing of a bankruptcy petition by or against the licensee or an entity owning any property occupied or used by the licensee; (B) The entry of any judgment with respect to such litigation; or (C) The outcome of the judgment or settlement. (C) The outcome of the judgment or settlement. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each residential care and assisted living facility was operated as a separate and distinct facility. Findings include, but are not limited to: During the survey, on 8/11/25 through 08/13/25, Staff 6 (MT) was observed working during the day shift on the MCC unit and the adjacent ALF unit that was across the hallway. In an interview on 08/13/25, Staff 6 stated he was scheduled as the MT for day shift on both the MCC unit and the ALF unit. The facility failed to ensure each residential care and assisted living facility was operated as a separate and distinct facility. In a meeting on 08/13/25, Staff 2 (Director of Nursing/RN) and Staff 4 (Resident Care Manager/LPN) were informed the facility could not share a staff with two separate licensed facilities on the same shift. They acknowledged the findings.

The MCC and adjacent ALF have a DHS waiver for this rule dated 8/28/25.

OAR 411-054-0010 (1-11) Licensing Standard (1) No individual, entity, or governmental unit acting individually or jointly with any other individual, entity, or governmental unit may establish, maintain, conduct, or operate a residential care or assisted living facility, use the term residential care or assisted living facility, or hold itself out as being a residential care or assisted living facility or as providing residential care or assisted living services, without being duly licensed as such. (2) Each license to operate a residential care or assisted living facility shall expire two years following the date of issuance unless revoked, suspended, terminated earlier, or issued for a shorter specified period. (3) Each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility. (4) A license may not be required for a building, complex, or distinct part thereof, where six or more individuals reside where activities of daily living assistance and health services are not offered or provided by the facility. (a) Facility representatives and written materials may not purport that such care and services are offered or provided by the facility. (b) Prospective and actual tenants must have no expectations that such care and services are offered or shall be provided by the facility. (c) The Department's Director shall determine whether a residential care or assisted living facility license is required in cases where the definition of a facility's operations is in dispute. (5) NOT TRANSFERABLE. No residential care or assisted living facility license is transferable or applicable to any location, facility, management agent, or ownership other than that indicated on the application and license. (6) SEPARATE BUILDINGS. Separate licenses are not required for separate buildings of the same license type located contiguously and operated as an integrated unit by the same licensee. Distinct staffing plans are required for each building. (7) IDENTIFICATION. Every facility must have distinct identification or name and must notify the Department of any intention to change such identification. (8) DESCRIPTIVE TITLE. A residential care or assisted living facility licensed by the Department may neither assume a descriptive title nor be held under any descriptive title other than what is permitted within the scope of its license. (9) RESIDENT DISPLACEMENT DUE TO REMODELING. The licensee must notify the Department 90 days prior to a remodel or renovation of part of a facility if there shall be a disruption to residents in the facility (for example: residents must be temporarily moved to another room overnight). During a non-emergent remodel, if any residents need to be moved from their rooms, the residents must continue to be housed in another area of the facility and may not be moved to another care setting. (a) NON-EMERGENT REMODEL. (A) For a non-emergent remodel, the licensee must submit a written proposal for remodeling or renovation to the Department. The proposal must include: (i) A specific plan as to where residents shall be housed within the existing facility. For those providers who have several buildings on the same campus, a move to a different building of the same license type within the campus setting is allowed, as long as the resident agrees to the move; (ii) A specific plan outlining the extended details of the renovation or remodeling; and (iii) A timeline for completion of the project. If the project is expected to take longer than three months, the licensee must provide a monthly update to the Department. The maximum time allowed for a renovation or remodel is one year from the date of the Department's approval. The Department may approve renovations that exceed one year. (B)The licensee must give the residents written notice 60 days prior to beginning any non-emergent remodel that shall displace the residents. The notice must include: (i) Where the residents shall be moved; (ii) The approximate length of time of the remodel; and (iii) Assurance that the residents shall be able to return to their own rooms when the remodel is completed, if the residents choose to do so. (C) The licensee must submit an outline of the work to be completed, construction documents, and any necessary drawings if required by the scope of work, to the Facilities Planning and Safety Program (FPS). FPS has 15 business days for review. (D) The licensee must comply with the rules in OAR chapter 333, division 675 (Project Plans and Construction Review) and all other structural requirements when remodeling. (E) Nothing in this rule is intended to preclude the Department from taking other regulatory action on a violation of the licensing requirements in these rules during the time of remodeling or renovation. (b) EMERGENT REMODEL OR CLOSURE. (A) When an emergency or disaster requires all residents of a facility or part of a facility to be immediately evacuated while remodeling occurs, the licensee must: (i) Provide the Department written details regarding the transfer of residents within two working days of the emergency or disaster; (ii) Submit a plan regarding the details for remodel or if necessary, a plan for permanent closure, to the Department within two weeks; (iii) Contact FPS to determine if drawings need to be submitted based on the scope of the remodel; and (iv) Assure that any residents who were transferred out of the facility shall be moved back to the facility when compliance with all building requirements of these rules is met. (B) All residents who have been transferred out of the facility must be notified in writing, at the last address known to the facility, as to when the residents shall be able to return to the facility. (C) The facility must ensure the safe transfer of residents from and back to the facility and bear all costs of the moves. (D) A refusal by a facility to allow a resident to return after the resident has been transferred out of the facility due to an emergent closure shall be regarded as an involuntary move out: (i) For an involuntary move out, the facility must comply with the requirements of OAR 411-054-0080; and (ii) The resident shall have all rights provided in OAR 411-054-0080. (E) In the event of an emergent closure, the Department may renew the existing license for a period not to exceed two years from the renewal date. (10) PERMANENT FACILITY CLOSURE. A facility is considered closed if the licensee is no longer providing services and the residents have moved out or must be moved from the facility. (a) The licensee must submit a written proposal for approval to the Department 60 days prior to permanent closure. The proposal must specify the plan for safe transfer of all residents. (b) The licensee must notify the residents at least 60 days prior to facility closure. (c) If the facility is closed and no residents are in the facility, the facility is considered unlicensed. (11) NOTICE OF BANKRUPTCY OR FORECLOSURE. The licensee must notify the Department in writing within 10 days after receipt of any notice of foreclosure or trustee notification of sale with respect to a real estate contract, trust deed, mortgage, or other security interest affecting the property of the licensee, as defined in OAR 411-054-0005. The written notice to the Department must include a copy of the notice provided to the licensee. (a) The licensee must update the Department in writing not less often than every 90 days thereafter until the matter is resolved and the default has been resolved and no additional defaults have been declared or actions threatened. The update must include: (A) The latest status on what action has been or is about to be taken by the licensee with respect to the notice received; (B) What action is being demanded or threatened by the holder of the security interest; and (C) Any other information reasonably requested by the Department related to maintaining resident health and safety. (b) The licensee must update the Department upon final resolution of the matters leading up to or encompassed by the notice of foreclosure or trustee notification of sale. (c) The licensee must notify the Department and all residents of the facility in writing immediately upon: (A) The filing of any litigation regarding such security interest, including the filing of a bankruptcy petition by or against the licensee or an entity owning any property occupied or used by the licensee; (B) The entry of any judgment with respect to such litigation; or (C) The outcome of the judgment or settlement. (C) The outcome of the judgment or settlement. 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 maintain a written fire drill record to document fire drills. Findings include, but are not limited to: Fire drill and fire and life safety records from 02/27/25 through 07/03/25 were reviewed. The following was identified: In an interview with Staff 2 (Assistant Administrator) and Staff 11 (Maintenance Manager) on 08/12/25 at 9:00 am, Staff 2 stated the facility conducted a fire drill every month and alternated the location of the simulated fire between the MCC and another area of the building. She also explained that during the drills affecting the MCC, staff from other units assisted with fire drill response on the MCC. The Fire and Life Safety form the facility used to document the fire drills did not specifically indicate, for the MCC drills, the following: MCC-specific staff members on duty and participating; Number of occupants evacuated (how many MCC residents participated); and Problems encountered, comments relating specifically to MCC residents who resisted or failed to participate in the drills. The need to keep a written fire drill record to document fire drills and fire drill response specifically for the MCC was reviewed with Staff 2 and Staff 11 on 08/12/25 at 9:00 am. They acknowledged the findings.

All fire drills were completed timely for the building and documented. Going forward, memory care fire drills will be documented separately as required. This process will be overseen by the Assistant Administrator. Audited monthly for compliance and results reported to the Quality Assurance Committee.

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 411-057-0140(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 C130, C420

1. What actions will be taken to correct the rule violation for each example/resident? Refer to C130 and C420 10/13/25

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 411-057-0160(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 observation, interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, residents were observed needing varying degrees of assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which some residents attended. Some residents did not attend the activities and, instead, stayed in their rooms or watched TV or listened to music in the living room area. The facility also offered entertainment from outside performers which the residents seemed to enjoy. The facility utilized two forms to evaluate the resident: the “Life Enrichment Assessment – Memory Care” and the quarterly evaluation/service plan. Resident 2’s evaluation did not address the following areas: Adaptations necessary for the resident to participate. The activities section of Resident 1, 2 and 3’s service plan lacked a specific activity plan that detailed what, when, how and how often the facility should offer and assist the resident with activities that was based on the information gathered in the resident’s activity evaluation. The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing/RN) and Staff 4 (Neighborhood Care Manager/LPN). They acknowledged the findings.

The 3 residents will have their individual activity plans updated. All residents individual activity plans will be audited and updated as needed. Resident assessments and individual activity plans will be reviewed quarterly to assure compliance. The Life Enrichment Manager will be responsible. Audits will be reviewed by the Quality Assurance Committee.

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 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure MCC residents had access to a secure outdoor space. Findings include, but are not limited to: During a tour of the courtyard on 08/11/25, one door was observed that exited the courtyard into a common hallway. An elevator and a stairway were accessible in the common hallway. The door was locked and required that a code be entered to access the hallway from the courtyard. The code was posted next to the keypad. Posting the code represented a risk for any MCC resident who could use the code to exit the secure courtyard. The security risk created by posting the door code was discussed on 08/14/25 with Staff 1 (Administrator), Staff 2 (Director of Nursing/RN) and Staff 4 (Neighborhood Care Manager/LPN). They acknowledged the findings.

The keypad code posting for the center door from the Memory Care outdoor area to the building has been adjusted to have a security cover. Audits of door security will be done twice monthly for one month or until substantial compliance is complete. The Assistant Administrator will be responsible. Audits will be reviewed by the Quality Assurance Committee.

OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). This Rule is not met as evidenced by: