Print Inspection: RL010573

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions recommended by outside providers and the service plan was adjusted, if necessary, for 1 of 1 sampled resident (# 1) who received home health services. Findings include, but are not limited to: Resident 2 moved into the MCC in 07/2025 with diagnoses including mild dementia and congestive heart failure. During the acuity interview on 04/06/26 at 1:45 pm, Resident 2 was identified to have a pressure ulcer and a foley catheter and as receiving home health services. The resident's clinical record, from 01/06/26 through 04/06/26, was reviewed, and staff were interviewed. The following was identified: Resident 2 was receiving home health services due to having a pressure wound and foley catheter. The following transcriptions of the outside provider’s recommendations were identified in the residents’ progress notes: * 01/08/26: New wound care orders, drink Ensure three to four times daily, and offload at all times; * 01/20/26 and 01/30/26: Encourage the resident to lay in bed to relieve pressure to wounds; * 01/29/26: Absolutely no shearing forces or sliding of any sort, lift and transfer resident; * 02/06/26: Encourage the resident to elevate lower extremities when able; * 02/18/26: Monitor temperature to ensure it comes down, keep wound covered, when left open in brief with incontinence, it increases risk of infection; and *02/20/26: Keep dressing intact and not get wet, provide bed baths to maintain the dressing dry. Documentation revealed staff reviewed the above recommendations; however, there was no documented evidence direct care staff were informed of the recommendations or that the service plan was adjusted. In an interview on 04/08/26 at 9:08 am, Staff 3 (LPN) confirmed the interventions recommended by the outside provider were not communicated to staff, and the service plan was not updated. The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after receiving outside provider services were provided recommendations was discussed with Staff 1 (Administrator) on 04/09/26 at 1:45 pm. He acknowledged the findings.

1. Change to a wall box for all outside provider notes. Med Tech's retrained on transcription of outside provider notes. 2.The RCC checks daily to assure documentation and any changes to care plan are followed timely. The nurse reviews weekly for coordination of care. For outside community providers an envelope with a provider communication form, face sheet, and current med list will be sent. Any concerns from the community will be noted for the outside provider to see. When the resident returns these are reviewed for any changes to medications or plan of care. 3. At least monthly review of systems to assure adequacy and efficiency in the system. 4. RCC, RN, and Administrator

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. 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 ensure fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: On 04/08/26 at 10:00 am, fire drill records from 10/2025 through 03/2026 were reviewed with Staff 5 (Facilities Services Director). He confirmed the facility had not conducted a fire drill during evening or night shifts. On 04/08/26 at 1:00 pm, Staff 6 (Business Office Manager) confirmed there was no documentation of fire and life safety instruction to staff on alternate months of fire drills. The need to ensure fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts, and fire and life safety instruction was provided to staff on alternate months was reviewed with Staff 1 (Administrator), Staff 2 (Regional RN), Staff 3 (LPN), Staff 4 (Resident Care Manager), Staff 5, Staff 6, and Staff 9 (Lead MT) on 04/08/26 at 3:15 pm. They acknowledged the findings.

1.Fire Drills are held every other month and Fire Safety Training at All Staff meeting on the alternate months. Alternating shifts implemented for fire drills. Fire Safety done 3/15/2026. Fire Drill Scheduled for NOC shift on 5/14/2026. Updated forms in use. Designated safety point is the front parking lot. or the side parking lot depending on fire location. Orientation checklist has fire safety and fire locations performed by the Maintenance director for all new staff. 2. The system is corrected to follow the above plan for fire drills and twice yearly emergency drills. 3. At least monthly review of Fire and Life safety Drills. 4. Maintenance director is responisble to ensure fire and emergency drills are completed on alternative months. Administrator to assure oversight.

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 C420.

Refer to C420

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(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C290.

Refer to C290

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: