Print Inspection: RL007195

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined that the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of 1 of 1 sampled resident (#5) who required a modified texture diet, and multiple unsampled residents who required modified texture diets. This placed the residents at risk for potential choking episodes and aspiration and constituted a threat to the residents’ health and safety. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 06/2025 with diagnoses including moderate vascular dementia with psychotic disturbance. During the entrance interview, the resident was identified as having had a choking event in September, which led to hospitalization for aspiration pneumonia. The resident’s clinical record was reviewed, and the following was identified: On 09/08/25, Resident 5 returned from a three-day hospitalization for aspiration pneumonia with orders for a minced and moist diet. On 10/08/25, Staff 1 (ED) provided documentation for the International Dysphagia Diet Standardization Initiative (IDDSI) Food Level 5/Minced & Moist, which she reported the facility followed for minced and moist diet texture orders. a. On 10/07/25, Resident 5 was served lunch that consisted of mixed vegetables, including corn. The vegetables were not minced to 4mm, as required by IDDSI Food Level 5. Corn is not allowed on IDDSI Food Level 5. b. On 10/08/25, Resident 5 was served lunch that consisted of soft-cooked broccoli florets that were not minced to 4mm. 2. During the entrance interview on 10/06/25, multiple residents were identified as requiring a mechanical soft diet texture. On 10/08/25, Staff 1 (ED) provided documentation for the National Dysphagia Diet (NDD) Level 2: Mechanically Altered, which she reported the facility followed for mechanical soft diet texture orders. On 10/07/25, lunch service was observed in the South dining room. Multiple unsampled residents with mechanical soft meals were served lunch that consisted of mixed vegetables, including corn. Corn is not allowed on NDD Level 2. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents, including ensuring residents received the appropriate therapeutic diet texture, was discussed with Staff 1 (ED) on 10/08/25 at 2:45 pm and with Staff 2 (RN/Health and Wellness Director) on 10/08/25 at 3:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation will include. a) Service plan for Resident 5 was updated to reflect their current diet orders. 2. The system will be corrected so that the violaton will no longer occur again by: a) The Lincesed Nurse in collaboration with the Resident Care Coordinators, Executive Director and Dining Services Manager will complete an audit of all residents diets to esure physician orders are followed. b) The community's UDS will be reviewed by the Executive Director and corrected to clearly reflect altered texture diets provided by the community. c) The community's move in orders will be reviewed and corrected by the Executive Director to esure diets that the community is able to provide are clear for providers and are consistant with the UDS. d) Education with the Dining Staff, Resident Care Coordinators and Licensed Nurse will be completed to include meal extensions. Meal extensions will be posted with the menu for dining staff and care staff in the kitchenette. e) The Care Conference Review form in PCC will be modified to include the residents current diet order. f) Once weekly, leadership team will use the dining room observation tool to ensure compliance. 3. Residents will evaluated at move in, 30 days of move in, quarterly, upon change of condition or any time new diet orders are received utilizing the communities 3rd check system. 4. The area needing correction will be evaluated by the Licensed Nurse and Dining Services Manager in collaboratoin with the Executive Director.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained in good repair. Findings include, but are not limited to: The exterior pathways in the center courtyards contained drop-offs along pathway edges. These drop-offs created a potential tripping and fall hazards for residents. On 10/07/25, the need to ensure exterior pathways were maintained in good repair was shown to and discussed with Staff 1(ED) and Staff 9 (Environmental Services Director). They acknowledged the findings.

1. The actions that will be taken to correct this rule violation are: a) All exterior pathways in courtyards have been modified with barkdust added to ensure there are no drop-offs. 2. The system will be corrected to that the violation wil not occur again by: a) The Facilities Maintenance Director and the Executive Director will walk the exterior pathways weekly and inspect them to ensure there are no drop offs or trip hazaards. b) Exterior pathways that have been identified with potential drop off or trip hazzards will be corrected immediately to ensure resident safety. 3. Weekly, the Facilities Maintenance Director and Executive Director will inspect the exterior walkways for drop offs. 4. The Facilities Maintenance Director and Executive Director wil be responsible to monitor exterior walkways for drop offs.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure 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 10/06/25 revealed the following: * Multiple doors had scrapes and missing paint on doors and door frames; * Multiple walls throughout the facility had scrapes and missing paint; and * Multiple pathway lights in the courtyard were broken. On 10/07/25, the need to ensure the facility’s interior and exterior were kept clean and in good repair was discussed with and shown to Staff 1 (ED) and Staff 9 (Environmental Services Director). They acknowledged the findings.

1. The actions that will be taken to correct this rule violation are: a) All doors and door frames with scratches will be repaired and painted, all walls with missing paint will be painted. b) All hand rails will be in good repair and painted. c) Pathway lights in the courtyard have been repaired or replaced. 2. The system will be corrected to that the violation wil not occur again by: a) The Facilities Maintenance Director and Executive Director will walk the interior of the community and identify any areas in need of paint or repair. b) Interior areas that have been identified as needing repair will be immediately addressed by the Facilities Maintenance Director. 3. Weekly, the Facilites Maintenance Director and Executive Director will walk the community to ensure the repairs have been completed and identify new areas that need to be addressed. 4. The Executive Director and Facilities maintenance Director will be responsible to monitor and ensure the rule is met.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

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 observation and interview, it was determined the facility failed to ensure units had entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. Findings include, but are not limited to: Observations made during the survey from 10/06/25 through 10/09/25 identified most resident units had a flathead locking mechanism which were not lockable by the individual. In an interview with Staff 1 (ED) on 10/07/25, it was reported none of the residents in the facility were given a key to their individual rooms. On 10/07/25, the need to ensure residents had a key to access their unit was discussed with Staff 1. She acknowledged the findings.

1. The actions that will be taken to correct this rule violation are: a) All resident units will have lockable lever entrance door handle with a key issued to the resident and/or designee. 2. The system will be corrected to that the violation wil not occur again by: a) Each resident unit will have a lockable lever entrance door handle installed and a key issued to the resident and/or designee. 3. Weekly, the Executive Director and Facilities Maintenance Director will inspect each units levered door handle to ensure it is working and in good repair. 4. The Executive Director and Facilities Maintenance Director will be responsible to ensure the corrections are completed and monitored.

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:

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to apply individually-based limitations (IBLs) when residents were not provided with a key to their room. Findings include, but are not limited to: During the survey, the MCC was home to 44 residents. During an interview on 10/08/25 at 1:25 pm, Staff 1 (ED) confirmed no residents currently had keys to their own apartments. She also confirmed no residents currently had IBLs in place, regarding not having possession of a key to their personal living units. On 10/09/25 the need to apply an IBL for any resident who was not provided a key to their own apartment, was discussed with Staff 1 (ED), staff 2 (RN/Health and Wellness Director) and staff 7 (Nurse Consultant). They acknowledged the findings.

1. The actions that will be taken to correct this rule violation are: a) All residents will be assessed by the Registered Nurse to determine if having an individual room key is a threat to the health and safety of that individual or others. b) If it is determined that the resident does not meet the assessment requirement and they do not have a designee, an Individual Based Limitation form will be submitted by the community to our designated policy analyst. 2. The system will be corrected to that the violation wil not occur again by: a) The residents service plan will be updated at time of move in, at 30 days, quarterly and upon change of condition.

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. 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 C160, C510, C513, H1518, and H1580.

1. Refer to C160, C510, C513, H1518, and H1580

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 411-057-0170(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 outdoor furniture was of sufficient weight, stability, design, and was maintained to prevent resident injury or aid in elopement. Findings include, but are not limited to: During an environmental walk-through of the facility grounds, including the memory care courtyards, on 10/06/25, the following was identified: * Eight lightweight folding tables were observed in the MCC courtyard; and * A lightweight folding chair was observed in the MCC courtyard. The outdoor furniture noted above was not of sufficient weight, stability, design, or maintained to prevent resident injury or aid in elopement. On 10/06/25, the need to ensure outdoor furniture was of sufficient weight, stability, design, and was maintained to prevent resident injury or aid in elopement was discussed during an environment tour with Staff 1 (ED). She acknowledged the findings.

1. The actions that will be taken to correct this rule violation are: a) All temporary tables and chairs in the courtyard were immediately removed. b) Any temporary table and chairs used for future outdoor events will be immediately moved to non resident accessable storage 2. The system will be corrected to that the violation will be corrected a) The Executive Director provided written education to the Life Enrichment Director, Life Enrichment Assistant, RCCs and Facilities Maintenance Director regarding the rule. 3. Weekly, the Executive Director and Facilities Maintenance Director will inspect the courtyards to ensure all outdoor furniture meets the rule. 4. The Executive Director, the Facilities Maintenance Director, The Life Enrichment Director and the Life Enrichment Assistant will be responsibe.

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: