Print Inspection: RL011646

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs and created opportunities for active participation in the community at large for multiple sampled and unsampled residents. Findings include, but are not limited to: During the survey, the facility was home to 16 residents. Review of the RCF activities calendar for 04/2026 showed the following: * Musical performances were scheduled Mondays at 12:15 pm; * Snacks & Chats were scheduled Wednesdays at 2:30 pm; * Social visits with a community volunteer were scheduled Fridays at 12:15 pm; * Bingo was scheduled Tuesdays, Thursdays and Saturdays at 2:15 pm; and * There were no scheduled activities on Sundays. There was only one activity offered on each day of the week. No activities were scheduled before 12:00 pm or after 4:30 pm. During an interview on 04/30/26, Staff 1 (Administrator) stated there were no designated activity staff but said care staff and management were responsible for leading activities. During the survey, residents and staff were observed participating in the Snacks & Chats activity on 04/29/26 at 2:39 pm. Staff 1 stated there was no bingo activity on 04/30/26 due to a lack of interest from residents. On 04/30/26 at 3:30 pm, the need to ensure an activities program based on individual and group interests that created opportunities for active participation in the community at large was discussed with Staff 1 and Staff 2 (RCC). They acknowledged the findings.

1) A variety of daily activities will be planned for residents to be provide engagement in individual and / or group activities. Part of our plan will be to schedule resident meetings for event planning to collect suggestions from residents and have conversations that will help us identify activities that they would enjoy engaging in. 2) Regular activity planning meetings will be held to include direct care staff, kitchen, activity and administrators so that we are getting feedback from a variety of staff perspectives. 3) Our activity calendar will be reviewed at least monthly and updated with activities that occurr in addition to our regularly scheduled activities. 4) Administrator will oversee activity program to ensure ongoing compliance.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity 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 conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Six months of fire drill and fire and life safety training records from 11/2025 to 03/2026 were reviewed on 04/29/26 at 1:20 pm with Staff 2 (RCC). The following was identified: * The facility had conducted one fire drill on 01/31/26. Staff 2 confirmed the facility had no further documented evidence a fire drill was conducted over the last six months. * There was no documented evidence staff were provided with fire and life safety training every other month. In an interview with Staff 2 on 04/29/26 at 1:20 pm, he acknowledged the facility had not conducted fire drills every other month or provided fire and life safety instruction to staff on alternate months. The need to ensure fire drills and fire and life safety training were conducted per the OFC was reviewed with Staff 1 (Administrator) and Staff 2 on 04/30/26 at 2:10 pm. They acknowledged the findings.

1) Fire drills and Fire Life Safety training will be done alternately so that each occurs every other month. When choosing the times of the fire drills we will rotate to help include newer staff as well. The Fire drills will be unannounced and staff will not have prior knowledge that a drill might occur or what time. Fire life and Safety training topics will be expanded beyond Fire safety to include a variety of topics for disasters or other occurences that staff might have to respond to. 2) Staff designated to safety duties will team with administration to ensure compliance to drill and safety training scheduling. This will create a partnership of accountability with administration to support ongoing scheduling and implementation for compliance. 3) We will provide a schedule to staff of the calendar for which months are designated fire drill months (and what shift is due that month) versus fire life and safety training so they are also able to help administration ensure they are carried out, The staff will not be made aware of the actual date or time of the drill so that they are unannounced. 4) Administrator will monitor monthly to ensure training and drills are being done in the months that they are due as well as reviewing topics to verify a variety of training topics are made available to the team.

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: