Print Inspection: RL011870

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure effective methods of responding to and resolving resident complaints related to dining services. Findings include, but are not limited to: On 05/13/26 at 9:03 am, an unsampled resident reported being “pre-diabetic” and required a diet that adhered to two milligrams of sodium per day. S/he verbalized wanting, “thirty-two ounces of protein a day” and stated that substituting carbohydrates with that amount of protein would help his/her goal of not becoming diabetic. The unsampled resident stated s/he had talked with Staff 1 (Administrator) and Staff 12 (Dietary Manager) about ensuring s/he received 32 ounces of protein to his/her diet. Staff 12 told the unsampled resident she could provide him/her a “Salisbury steak.” This was not an option for the unsampled resident as a serving of Salisbury steak contained four milligrams of sodium, which exceeded the physician’s prescribed daily sodium amount. The resident stated s/he was not currently receiving the amount of daily protein requested. The unsampled resident identified that there had been a process of resolving resident complaints through the resident council meetings. However, there had not been a note taker for the council meetings since 01/2026. S/he verified that the previous process of resolving complaints from the residents were that after the council notes were typed and accepted, the note taker would take the complaints to the correct department at the facility. At the next meeting, the issues would be reviewed by the residents who would then agree or disagree that the complaint had been resolved. Resident Council minutes, dated 01/20/26, were reviewed. The process of resolving complaints from residents were verified. Staff 1 reported that there had not been a note taker for the meeting since 01/20/26. On 05/13/26 at approximately 3:45 pm, Staff 12 stated that if the resident had any concerns relating to their dietary needs or wants, the system was that the resident told the Administrator, and the Administrator conveyed the message to the Dietary Manager. On 05/13/26 at 3:59 pm, Staff 1 and Staff 2 (RN) verified they had previously communicated the dietary concerns of residents to Staff 12. The need to ensure effective methods of responding to and resolving resident complaints was discussed with Staff 1, Staff 2, and Staff 3 (RCC) on 05/13/26 at 2:50 pm. They acknowledged the findings.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents lived in a home-like environment related to receiving hot meals for multiple sampled and unsampled residents who relied on the facility to prepare and serve their meals. Findings include, but are not limited to: In an interview on 05/13/26 at 9:03 am, an unsampled resident reported the meals were served “cold to lukewarm.” The current system for the residents’ meal service was the meals would be plated in the kitchen, and the kitchen staff would announce over the intercom when it was ready to be picked up by the assisted living staff. The plates of food were covered and set on a cart outside of the kitchen for staff to pick up. The unsampled resident identified that there were no problems with the meals until they “lost the hot table” during the winter of 2025. S/he described the previous system as food was placed in a steam table, which kept everything warm, and residents had a better choice of what they wanted. There was no steam table observed in the dining room during the lunch meal, nor was there any other system observed to be in place to keep the food warm. The menu reflected the following options for lunch on 05/13/26: * Homestyle meatloaf, roasted zucchini, mashed potatoes, poppy seed dinner roll, cherry cheesecake bar; or * Thyme chicken breast, peas and carrots, buttered rice. On 05/13/26 at 12:35 pm, after all of the residents received their lunch, the surveyors requested a sample tray. A covered plate of meatloaf, mashed potatoes, and gravy was provided. Staff 12 (Dietary Manager) reported the kitchen had “run out of the rest of the food.” At 12:37 pm, the meatloaf’s temperature was 122.2 degrees F, and the temperature of the mashed potatoes and gravy was 113.5 degrees F. Per the Food Sanitation Rules, in order for food to be palatable, hot food should be served at 140 degrees. The need to ensure residents lived in a home-like environment, which included receiving hot meals, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 05/13/26 at 2:50 pm. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the residents’ care needs, provided clear direction to staff, and were implemented for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the assisted living facility in 06/2022 with diagnoses of age-related osteoporosis and a history of fractures. During the acuity interview on 05/11/26, the resident was identified as recently being admitted onto hospice services and having re-occurring skin issues. The resident’s clinical record, including the service plan dated 03/09/26, was reviewed. Resident 3 was observed, and staff were interviewed. The service plan was not reflective of the resident's current needs, lacked clear instruction to staff, or was not being implemented in the following areas: * Placement of recliner remote relating to fall interventions; * Current activity interests; * Beverage preferences; * Behaviors and what they communicated; * Repositioning every two hours; and * Oral hygiene. Resident 3 was observed in a common area, sitting in a recliner, with the television on. Staff checked on the resident often and provided short one-on-one time with him/her while the resident was awake. Resident 3 was observed drinking three beverages, including orange juice, apple juice, and nutritional supplements, throughout the survey. Staff were observed to offer or provide repositioning during Resident 3’s waking hours but were not repositioning the resident when s/he was sleeping. On 05/13/26, between 10:20 am and 4:00 pm, Resident 3 was observed sleeping in the same position in the common area recliner. On 05/13/26 at 11:03 am, Staff 9 (CG) reported the resident enjoyed both the television programs that were observed playing during the survey, Resident 3’s beverage preferences, how the resident communicated pain, and how she was able to brush Resident 3’s teeth. This was not reflected in the resident’s service plan. The need to ensure the resident’s service plan was reflective of their current needs, provided clear direction to staff, and was implemented was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 05/13/26 at 2:50 pm. They acknowledged the findings. 2. Resident 1 moved into the assisted living facility in 07/2025 with diagnoses including atrial fibrillation and presence of a cardiac pacemaker. The resident’s 02/10/26 through 05/12/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The service plan, dated 05/08/26, was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Fall interventions, including use of a cane; * HH service information; and * Ambulation status, including use of a cane. During the survey, the resident was observed to use a wheelchair for ambulation, and on 05/12/26 at 1:05 pm, Staff 5 (MT) and Staff 10 (CG) confirmed the resident used the wheelchair as the primary device for ambulation. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 05/13/26 at 1:50 pm. They acknowledged the findings.

To correct this issue, we are implementing a triple check system involving floor staff, RCC, RN and ED to ensure the accourancy of the service plans to ensure that they are accourately reflecting the care that the resident needs and the care that the staff are providing. These triple check meetings will meet monthly. The RN, RCC, and ED will be responsible for ensuring this is done.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On 05/11/26 the acuity interview identified the following: * The facility was home to 28 residents; * Two residents required two staff members for transfer or care at all times; and * One resident required two staff members for transfer or care PRN. The facility’s staffing plan reflected the following: * Day Shift: One MT and three CGs; * Evening Shift: One MT and two CGs; and * Night Shift: One MT and one CG. The staffing schedule, dated 05/04/26 through 05/10/26, was reviewed and the following staff numbers were noted during the day shift: * 05/04/26 – two CGs; * 05/07/26 – one CG; * 05/08/26 – two CGs; * 05/09/26 – one CG; and * 05/10/26 – two CGs. On 05/13/26 at 1:20 pm, Staff 1 (Administrator) reported although she did help the direct care staff during four of the five above dates, she was also in her office working. Staff 1 acknowledged she was not working as a CG during the entire shift from 5:45 am to 2:00 pm. The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 05/13/26 at 2:50 pm. They acknowledged the findings.

To correct this tag, we are currently in the process of onboarding 3 more direct care employees. But if ED is the person that is covering a shift, the ED needs to be only doing care giving not working in the office too. The RCC and ED will be responsible for ensuing that all shifts are covered appropriately.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. 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 staff were provided fire and life safety training on alternate months of the fire drills and that the fire drills included documentation of the required elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 04/2026 was reviewed on 05/12/26 and 05/13/26. The following was identified: a. There was no documented evidence all staff were provided fire and life safety training every other month. b. Fire drill documentation did not include one or more of the following required elements: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Escape route used; and * Evidence alternate routes were used during fire drills. The need to provide fire and life safety training for all staff on alternate months of fire drills, as well as the need to address all required elements in fire drill documentation, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/13/26 at 1:50 pm. They acknowledged the findings.

To correct this tag, staff will be required to complete every other month inservices regarding fire and life safety. The inservices will be provided by the facility or from Oregon Care Partners. The Fire drills will be more accurately documented, including but not limited to, the problems encounteder, comments relating to residents who resisted or failed to participate in the drills, the escape route used and evidentce alternate routes were used during the fire drill. The Maintenance director, RCC and ED will be responsible for ensuring this rule is met.

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 411-054-0300 (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 interior materials and surfaces were kept clean. Findings include, but are not limited to: On 05/12/26 at 10:30 am, the interior of the facility was toured. Observations identified the following: * Multiple areas of dark stains were observed on the carpet throughout the facility hallways. On 05/13/26 at 10:50 am, the areas were shown to Staff 4 (Maintenance Director). Staff 4 acknowledged the carpet throughout the facility had dark stains. On 05/13/26 at 1:50 pm, the need to keep interior materials and surfaces clean was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

This tag will be corrected, by the carpets will be put on a monthly shampooing schedule. All surfaces will be monitored every month to make sure that they are in good condition and is a smooth cleanable surface. The Maintenance director and the ED will be responsible for ensuring that this correction is made and this rule is met.

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 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exited the facility. Findings include, but are not limited to: On 05/12/26 between 10:20 am and 10:50 am, the main front exit doors, exit doors leading to the outdoor courtyard in the assisted living, and exit doors leading to the inner courtyards were observed. The exit doors did not have alarms or other acceptable systems to alert staff when residents exited the facility. On 05/13/26 at 10:50 am, the exit doors were shown to Staff 4 (Maintenance Director). Staff 4 confirmed the facility did not have a system that alerted staff for security purposes or when residents exited the facility. The need to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exited the facility was discussed. Staff 1 (Administrator) and Staff 2 (RN) on 05/13/26 at 1:50 pm. They acknowledged the findings.

This tag has been corrected, door alarms have been added to all exit door. This rule will be monitored weekly to ensure that they stay in working condition. Maintenance, RCC and ED will be responisible for making sure that this rule continues to be met.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: