Print Inspection: RL012776

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’ right to receive services in a manner that protected their privacy and dignity for 1 of 2 sampled residents (#5) whose care was observed and for 1 of 3 sampled residents (#5) who required full assistance with meal intake. Findings include, but are not limited to: Resident 5 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and was identified during the acuity interview on 06/29/26 as requiring two-person staff assistance for care. 1. During the survey, on 06/29/26, the following was observed: Staff 18 (CG) and Staff 22 (CG) were observed between 1:51 pm and 2:11 pm to provide incontinence care to Resident 5. Both staff assisted with transferring the resident from the wheelchair to the bed using a Hoyer lift and removed soiled brief, pants, and linens from the resident. The resident’s lower body was completely undressed. The resident resided in a semi-private room. During the provision of personal care, the resident's roommate was in the direct line of sigh. There was no privacy curtain or other privacy device in place to protect the resident's privacy during the provision of care. On 06/30/26 at approximately 2:15 pm, the above observation was shared with Staff 1 (ED). Staff acknowledged the facility failed to protect the resident’s privacy during the personal care. 2. During the survey, on 06/30/26, the following was observed: Staff 21 (MA) and Staff 22 (CG) were observed between 8:28 am and 9:32 am assisting the resident with meal intake. Staff 21 initially provided feeding assistance while the resident was seated in a wheelchair, and Staff 21 remained in a standing position. Staff 21 then left the area and Staff 22 later returned and provided feeding assistance. However, Staff 22 intermittently provided feeding assistance throughout breakfast by offering one bite at a time. After each bite, Staff 22 would leave the resident to do other tasks and then returned multiples times to continue assisting with the meal. At one point during the meal, the resident remained in the dining room without assistance with meal intake for more than 10 minutes. The resident finished breakfast at 9:32 am, consuming 100% of the meal and requiring more than one hour to complete. During the observation, both staff provided feeding assistance while in a standing position. The facility failed to ensure dignity during the meal observation. On 06/30/26 at approximately 2:15 pm, the above observation was shared with Staff 1 (ED). Staff acknowledged the facility failed to protect the resident’s dignity during the care.

General rights: 1.Privacy Curtains have been installed in every shared room by our maintenance team to ensure that at any time their rights are protected to have privacy during provision of care- Resident coordinators, leads and staff reviewed general privacy rights to ensure compliance. Audits of all the rooms will be done bi-weekly scheduled by enviromental services, maintenance and quailty assurance personal. During any room changes or move outs maintenance team will ensure privacy divider is in place. 2.To ensure dignity during meal time the RC or lead will assign a team memebr during shift report to be present for the entire meal to ensure any residents whom have assistance with cueing or feeding are met with efficency and dignity. In the event of the need for additional staff the recreation team will assign a team memebr at meal times to those individuals who need to be provided feeding assitance. Which includes but is not limited to sitting for the duration of the meal, sitting at eye level, making eye contact, communicating with the resident and assisting with feeding at a pace that is appropiate for the resident not to be rushed or left alone while eating. The shift planner used with each change of shift report will record what staff member will be on duty for the dining room daily, resdient coordinator/lead or designee will review daily to ensure compliance.

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:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence and personal care for 1 of 2 sampled residents (# 5) whose care was observed. Findings include but are not limited to: Resident 5 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and was identified during the acuity interview on 06/29/26 as requiring two-person staff assistance for care. During the survey on 06/29/26, the following was observed: Staff 18 (CG) and Staff 22 (CG) were observed between 1:51 pm and 2:11 pm to provide incontinence care to Resident 5. The resident was lying in bed. Both staff removed soiled brief, pants, and linens from the resident with gloved hands. Both staff provided incontinence care. It was noted the resident had a moderate amount of bowel movement. Both staff cleaned fecal matter from the resident, applied clean incontinence products and powder treatment, and performed dressing changes using the same gloves. In addition, both staff touched the resident’s clean blanket and held the resident’s hand while wearing the same gloves. After completion of care, both staff removed their gloves. Throughout the observation, staff failed to change their gloves or perform hand hygiene between clean and dirty tasks. The need to ensure infection prevention and control practices were followed during personal care was discussed with Staff 1 (ED) on 06/30/26 at approximately 2:15 pm. Staff acknowledged the findings.

Infection Prevention and Control: a)Based on observation it was determined the facility failed to establish and maintain infection prevevtion and control protocols to provide a safe, sanitary, and comfortable enviroment. Hygiene and sanitation policy revision has occurred. Staff are to be reeducated to ensure they understand and implement the more clearly stated rules. Which include but are not limited to: Always perform hand hygiene and put on fresh gloves to avoid contaminating clean clothes, supplies and the residents with soiled gloves. Even when the gloves look visually clean, they are not and contamination can occur. Gloves need to be worn and changed frequently. If you are completing bowel care or changing a resident after an incontinence episode, you need to change your gloves right away before touching anything else. Soiled briefs, wipes, and trash are to be immediately placed in black garbage bags. Black garbage bags are to be tied to the rolling soiled laundry carts and taken with you to the rooms. After each incontinence or bowel care, the bag needs to be taken out and changed to ensure cleanliness and pleasant smells for all residents, family members and staff.Resident coordinators, leads and quality assurance personnel to maintain random drop ins to ensure compliance is the standard, with a minimum but not limited to at least once a week. Regular and randomly assigned audits will also take place to ensure protocols for sanitation and appropiate wear are being followed. Quality assurance personnel or Executive Director to review findings monthly at resaidnet coordinator and lead meetings.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval Temporary rule language in effect until 02/05/2027 (2) The facility must not interfere with a good faith disclosure of information by an employee, volunteer concerning abuse or other action affecting a resident’s safety or welfare, as described in OAR 411-054-0028(4). (3) The Department must visit and inspect every licensed facility to determine whether the facility is maintained and operated in accordance with these rules. (a) The Department must inspect every facility at a minimum: (A) No less than 90 days and no more than 120 days after an initial license is issued or after a change of ownership of a facility. (B) Upon receipt of a license renewal application fee. (C) For each year during which a facility does not have a full survey, the Department must conduct an in-person inspection of the kitchen and other areas where food is prepared for residents. (b) Inspections may be conducted at other times as determined by the Department. (c) Facilities not in compliance with these rules must submit a plan of correction that satisfied the Department, within 10 business days of receipt of the inspection report. (d) Facilities must correct deficiencies within timeframes outlined in the accepted plan of correction. (e) Failure to be in substantial compliance upon reinspection may result in regulatory action to compel compliance. (f) Achieving substantial compliance is ultimately the facility’s responsibility, whether or not a plan of correction was followed. (g) The Department may impose sanctions for failure to comply with these rules. (4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to correct deficiencies within the timeframes outlined in the accepted plan of correction. Findings include, but are not limited to: Refer to C513 and Z142.

C0455: Based on observation and interview, it was determined the facilty failed to correct deficiencies within the timeframes outlined in the accepted plan of correction. Finding include but are not limited to: Refer to C513 & Z142 Facility has/will ensure compliance is met by compliance date.

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 all exterior pathways were maintained in good repair. Findings include, but are not limited to: The MCC included nine separate cottages which housed residents. Each building had its own enclosed outdoor courtyard area for resident use. The facility grounds were toured on 06/29/26 at 9:50 am. The following was identified: There were multiple exterior pathways with drop-offs measuring two inches or greater, from the level of the walking surface to the adjacent planting bed. These drop-offs created a potential fall hazard for residents. On 06/30/26 at 12:45 pm, a facility walk-through was conducted with Staff 2 (Maintenance Coordinator). He observed the drop-offs and stated plans to correct the problem. Subsequently, maintenance personnel were observed working to improve the deficient areas. On 07/01/26 at 10:15 am, the need to ensure all exterior pathways were maintained in good repair was discussed with Staff 1 (ED). She acknowledged the findings.

General Building Exterior: The MCC included nine sperate cottages which housed residents. Each building has its own inclosed courtyard area for resident use. The facility grounds were toured and identified multiple pathways with drop-offs measuring 2 inches or greater, from the level of the walking surface to the adjacent planting bed. These drop-offs created a potential fall hazard for residents. Our Maintenance Director and team have compacted 1/4 inch gravel installed to the elevation of the pathways throughout campus where the drop-offs were indentified. The maintenance team will be maintaining these pathways seasonally to ensure compliance year round.

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 materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The MCC was comprised of nine separate cottages. The facility was toured on 06/29/26 at 9:50 am. The following was identified: * Scratches and gouges on wood furniture and fixtures in dining rooms and common areas; * Damage and scrapes on plaster drywall in hallways and common areas; and * Heavy damage with large tears on vinyl and upholstered covers of furniture in resident areas. On 06/30/26 at 12:45 pm, a facility walk-through was conducted with Staff 2 (Maintenance Coordinator). He observed the areas listed above, acknowledged the findings, and stated plans to correct the deficiencies. On 07/01/26 at 10:15 am, the need to ensure all materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED). She acknowledged the findings.

Doors, Walls: a)Scratches and gouges on wood furniture and fixtures in dining rooms and common areas; Scratches on all wood furniture have been touched up with appropiate wood stain by our maintenance team. Gouges in/on surfaces, and drywall have been patched and painted campus wide by the mainenance team. Such repairs are on a maintenance schedule ongoing.

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 materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to: The MCC was comprised of nine separate cottages. The facility was toured on 09/16/26 at approximately 10:30 am. Chairs, recliners, and sofas in resident areas of cottages were observed with stains, spills, tears, and/or scratches. On 09/16/26 at 11:15 am, Staff 2 (Maintenance Coordinator) reported the facility had ordered covers for the chairs, but they had not arrived yet. On 09/16/26 at approximately 2:00 pm, the need to ensure all materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.

C513: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Chairs, reccliners, and sofas in resident common areas of cottages were observed with stains, spills, tears, and/or scratches; New sofas, chairs, and recliners have been purchased and ordered for replacement of all identified pieces in need of replacment in said cottages- Preventative covers that were previously purchased will be utilized to protect new furniture from spills and stains, and cat scratches. Doors, Walls: a)Scratches and gouges on walls, doors and fixtures in dining rooms and common areas; Scratches/gouges on all walls and doors have been touched up with appropiate paint or wood stain by our maintenance team. Gouges in/on surfaces, and drywall have been patched and painted campus wide by the mainenance team. Such repairs are on a maintenance schedule ongoing.

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 C200, C295, C510, and C513.

Refer to plan of correction for C200,295,510,513

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 and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C513.

refer to C513