Print Inspection: RL013266

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#2) whose weights were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 04/2008 with diagnoses including traumatic brain injury. Weight records, dated 01/02/26 through 07/02/26, progress notes dated 04/27/26 through 07/20/26, and meal monitoring records dated June 2026 and 07/01/26-07/30/26 indicated the following: * A 12-pound weight gain between 03/02/26 and 04/02/26, which constituted a 7.36% significant gain in one month. * A 23-pound weight loss between 04/02/26 and 06/02/26, which constituted a 13.14% significant weight loss in three months. * A 10-pound weight gain, between 06/02/26 and 07/02/26, which constituted a 6.57% significant weight gain in one month. A current weight at the time of survey was requested but not obtained. The service plan, dated 06/01/26, indicated the resident was independent with meals. The resident was provided with regular textures with some cut up items for easy chewing and swallowing. S/he could eat and drink on his/her own with minimal staff reminders. The resident used a scoop/high sided bowl for meals, and s/he required reminders to use utensils for non-finger food items. The resident had ongoing memory issues, with some intermittent confusion related to his/her diagnoses, but could make needs known, could state likes/dislikes, and could request seconds when s/he was still hungry. Multiple daily observations of the resident at meals and in the common areas between 07/28/26 and 07/30/26 showed the resident seated in his/her wheelchair in the living room or dining room for large chunks of the day. The resident was assisted to use the restroom and was able to wheel himself/herself to the dining room for meals. The resident was observed to eat 100% of food and fluids provided at meals and snacks, and the resident requested a second helping at two meals which s/he received and ate 100% of the seconds. Interviews with staff and the resident between 07/28/26 and 07/30/26 showed the following: Resident 2 indicated s/he received plenty to eat and drink and loved his/her snacks. The resident enjoyed the food that was served and had no complaints. Staff 1 (Administrator) indicated she had not noticed any decline in the resident’s intake, any increased swelling in extremities, any loose clothing, and the resident had had no illnesses. Staff 1 believed the weights that were recorded were not correct. She had calibrated the scale a few times but was unsure the last time the scale had been serviced. Staff 3 and 6 (Universal Workers) indicated the resident ate meals in the dining room. The staff further indicated the resident had a great appetite, rarely ate less than 100%, and would frequently ask for seconds when still hungry. Staff 3 and 6 stated the resident could eat on his/her own once items were delivered. The resident preferred to eat with his/her fingers but could use utensils without issues. The staff further indicated the resident had not had any major changes and had been eating and behaving as his/her usual self. Neither of the staff noticed any change in how the resident’s clothes fit, any change in appearance, or signs of weight loss or gain. Staff 7 (RN) indicated she was aware of the weight changes that were documented but did not believe they were accurate. The resident had not had any acute issues, no swelling or diagnoses that would affect his/her weight. There were no changes to the resident’s intake; s/he was routinely eating 100%. Staff 7 believed the scale was not giving accurate information and also that staff might not be using it properly. Staff 7 was confident the loss and gain noted with the resident’s recorded weights was not an actual change. No RN assessment could be located for the significant weight loss or significant weight gain. The facility failed to ensure an RN assessment was completed for the resident’s significant weight changes, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made were discussed with Staff 1 (Administrator) and Staff 7 (RN) on 07/30/26. The staff acknowledged the findings.

1. Forest Meadows had an established Weight Monitoring and Significant Weight Change Policy in place at the time of survey and provided it to the surveyor. Resident #2 will be reweighed using the facility's established procedure and a verified scale. The RN will complete and document a current nursing assessment, resident status, findings, and any indicated interventions/follow-up. Management has checked the facility scales, and professional calibration of both scales has been arranged; calibration/service records will be retained. 2. The facility determined that the existing policy was not consistently followed when significant weight changes were identified. Care staff are required to report abnormal findings, and the RN is responsible for weight-trend review, determination of clinical significance, assessment, interventions, provider communication when appropriate, and follow-up. The policy in effect during the survey used a 3-pound one-week verification threshold; the current policy strengthens that trigger to 2 pounds. Unexpected or significant changes will be rechecked promptly using consistent technique and the same calibrated scale, and the RN will complete and document the required assessment and follow-through. Staff and the RN will be re-educated on these requirements. 3. The RN will review all resident weights at least monthly. Significant or unexpected changes will be reviewed when identified, and residents with a significant change will be weighed weekly until stable and reassessed by the RN. The Administrator will review weight records and corresponding RN follow-up monthly for 90 days and quarterly thereafter. 4. The facility RN is responsible for weight-trend review, nursing assessment, clinical follow-up, documentation, interventions, and provider communication when indicated. The Administrator is responsible for ensuring the weighing schedule is followed, equipment is maintained/calibrated, staff training is completed, and the policy is followed.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. 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 in accordance with the Oregon Fire Code on alternate months, on alternating shifts, and other fire life safety training was completed on the alternating, non-drill months. Findings include, but are not limited to: Fire and life safety records, reviewed between 01/2026 and 07/29/2026, showed: * One drill was documented as completed in the last seven months; * Fire drills were not conducted on alternating months with fire life safety training; and * Drills were not conducted on alternating shifts to include all three shifts. The need to ensure fire drills were conducted on alternating months from life safety training and conducted on alternating shifts, was discussed with Staff 1 (Administrator) on 07/29/26. She acknowledged the findings.

1. Forest Meadows will continue its established fire-safety activities but will clearly distinguish and document qualifying fire drills from staff fire/life-safety instruction. The next required unannounced fire drill and the required alternate-month staff instruction will be completed and documented. Each drill record will include the date/time, simulated fire origin, escape route used, problems encountered, evacuation time, staff on duty/participating, number of occupants evacuated, and other required information. 2. A 12-month fire/life-safety compliance calendar will be used. Unannounced fire drills will be conducted every other month and rotated among the facility's day (6 a.m.-2 p.m.), evening (2 p.m.-10 p.m.), and night (10 p.m.-6 a.m.) shifts. Staff fire/life-safety instruction will be completed on the alternating non-drill months. Alternate exit routes will be used as appropriate, and the fire alarm will be activated during drills unless otherwise directed by the Fire Authority. The facility's additional monthly fire-safety practice may continue but will not be counted as a required drill unless all required drill elements are completed and documented. 3. The Administrator will review the fire/life-safety calendar and supporting documentation each month and sign the annual compliance tracker when that month's required activity and documentation are complete. Any missed or incomplete item will be corrected promptly. 4. The Administrator is responsible for scheduling, conducting or assigning, and documenting required fire drills and staff fire/life-safety instruction, maintaining the annual compliance tracker, and assuring required records are retained.

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 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (Administrator) on 07/29/26. There was no documentation that residents were provided fire training within 24 hours of admission and again at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 07/29/26, Staff 1 indicated she had talked to residents about fire training but did not have documentation of the discussion for the newest resident or for annual training. Staff 1 acknowledged the need to provide the residents with fire and life safety training and to document the training.

1. What actions will be taken to correct the rule violation for each example/resident? 1. The Administrator will audit the records of all current residents to verify documentation of required fire/life-safety instruction. If documentation cannot be located, the resident will be re-instructed, when cognitively able to participate, and the training will be documented. The newest resident's record will be specifically reviewed and corrected as needed. Residents whose mental capability does not allow them to follow the instruction will have that limitation documented. 2. Forest Meadows' normal admission practice includes showing new residents the exits, evacuation procedures, and designated meeting location. A standardized New Resident Fire & Life Safety Orientation Checklist will now be required to document completion within 24 hours of admission. The checklist records the date/time, topics reviewed, resident understanding/assistance needs, and staff completing the orientation. Annual resident fire/life-safety training will be tracked on a master calendar and documented on a training record showing content and attendance. A completed copy of each new-resident admission checklist will be sent to the Licensee/Owner as confirmation that the checklist was completed. 3. Admission fire/life-safety orientation will be completed and documented within 24 hours of each admission. The Administrator will review the annual resident training calendar monthly to identify upcoming or overdue annual training and correct missing documentation immediately. 4. The Administrator is responsible for assuring resident fire/life-safety instruction and documentation are completed within 24 hours of admission and at least annually, and for maintaining the admission checklist and annual training records. The Licensee/Owner's role is limited to receiving the completed new-resident checklist as confirmation of completion. 09/28/26

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. 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 to correct deficiencies within timeframes outlined in the accepted plan of correction. Findings include but are not limited to: Refer to C513.

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 courtyard surfaces were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways, courtyard, and gazebo area on 07/28/26 and 07/29/26 identified the following: * Multiple drop-offs of 2-5 inches were noted along pathway edges and in borders; * Two cracked areas of sidewalk were noted with lifting and uneven edges. One was near the end of the back ramp, and a second area was noted on the narrow sidewalk which ran to the left of the back ramp and against the building outside resident exterior doors; * Trash was noted on multiple shelves of an outdoor shelf at the bottom of the back ramp, inside planters, pots, and along the edge of the building facing the courtyard; and * Numerous cigarette butts were on the ground, in pots of dirt, and on lids. Additionally, several partially used/burned marijuana cigarettes were on the edges of an outdoor shelf at the back of the building. The need to ensure pathways around the facility were in good repair with no potential tripping hazards, and that the facility grounds were free of discarded items was discussed with Staff 1 (Administrator) on 07/29/26. Areas of concern were shown to Staff 1 on 07/29/26. She acknowledged the findings.

1. All litter, cigarette butts, discarded smoking materials, and other refuse identified in the courtyard/patio/planter areas will be removed and the grounds maintained free of litter. A concrete contractor is scheduled to meet with the facility on 08/11/26 to finalize the work. The cited cracked/lifted concrete and patio crack will be repaired or removed and replaced. After the concrete work is completed, bark will be professionally blown into the adjoining landscaped areas to bring the grade up along pathway edges and eliminate the cited drop-offs and uneven transitions. All cited exterior corrections will be completed no later than 09/28/26. 2. The Administrator will maintain a simple exterior grounds/repair log covering pathways, courtyard surfaces, landscaped edges, smoking areas, litter/refuse, and identified trip hazards. Staff will remove litter and smoking debris when observed during normal duties and report damaged or uneven walking surfaces to the Administrator. The Administrator will arrange outside repair services when work cannot be completed safely by facility staff and will track open repair items through completion. 3. The Administrator will visually inspect the exterior grounds and pathway conditions weekly until the cited concrete and grading/bark work is completed, and monthly thereafter. Litter or smoking debris will be removed when identified, and newly identified trip hazards will be addressed promptly. 4. The Administrator is responsible for the exterior grounds check, repair log, arranging and following up with outside contractors, and assuring the cited corrections are completed. Facility staff are responsible for routine cleanup and for promptly reporting exterior hazards they observe.

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 the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 07/28/26 and 07/29/26 showed the following areas in need of cleaning or repair: * Multiple carpet stains were noted in the hallways, common areas, and on the smoking porch. The stains varied in size and included brown, red, and black stains. Carpet stains were noted in the medication room as well; *Multiple gouges, chips, and scratches were noted to doors and door frames throughout the facility and on walls in the dining room. The walls in the dining room additionally had some debris and spills on the edges of the decorative framing on the lower sections; * Multiple sprinkler heads on the smoking porch had thick cobwebs, dust, debris, and dead insect build-up; * There was a strong urine odor, dark splatters and drips on the railing along the back ramp off the smoking porch. A large, partially dried and discolored puddle was under the stained area of railing; * The common bathroom near room 2 had a large lip between the bathroom tile and the interior of the shower stall. The caulking along the edge of the shower stall was brown and discolored with some missing pieces, as well. Debris was noted along the edge of the walk-in shower. The shelving in the bathroom was peeling or scraped, with exposed particle board; * Multiple dining room chairs had dark stains on the fabric seats and back, debris was noted in the edges of the chairs, and some spills/splatters were noted to arms and chair legs. Two chairs in the medication room had large tears with exposed foam and/or dark stains to the fabric; * Multiple chairs on the smoking porch with blue cushions had cigarette burns and holes in the cushions; and * The blue recliner in the living room had multiple dark stains on the seat and the arms, and the sectional sofa had torn, frayed fabric along the top edge of the seat back on the short side of the sofa. A small tear was noted at the edge of the footrest and there was a large section on the top edge where the vinyl was worn and the fabric layer underneath was exposed. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 07/29/26. She acknowledged the findings.

1. The urine-affected back patio/ramp/AC area has been pressure washed and the odor, residue, and visible mess removed. New outdoor patio carpet has been purchased for replacement, and replacement cushions have been ordered for the patio chairs with cigarette-burn damage. Cited indoor carpet areas will be cleaned. Wheelchair-damaged/splintered doorways, walls, and bathroom/shower-area surfaces will be sanded, repaired, sealed/painted as appropriate, and left smooth, intact, and cleanable; deteriorated caulking/grout and damaged bathroom shelving will be repaired or replaced as needed. The smoking-porch area and sprinkler-head areas will be cleaned of cobwebs, dust, and debris. Cited furniture will be cleaned, repaired, or replaced as needed. A qualified outside upholstery/vinyl service is being sought for the sectional; if it cannot be satisfactorily repaired, it will be replaced. All cited cleaning and repairs will be completed no later than 09/28/26. 2. A practical environmental cleaning/repair system will be used for this 15-bed facility. The housekeeper will complete routine housekeeping duties, and all staff will report odors, spills, damaged surfaces, torn upholstery, or other cleaning/repair concerns when observed. If the housekeeper is unavailable or unable to safely perform a specific task, the Administrator will reassign the task to an available staff member who can safely perform it or arrange an outside service. The Administrator will keep a simple open-item repair/cleaning log until each item is completed. 3. Resident and common-use areas will be observed during routine daily housekeeping and caregiving duties. The Administrator will review the condition of common areas, bathrooms, doors/walls, furniture, carpets, and smoking/patio areas weekly until all cited corrections are completed and monthly thereafter. Odors, sanitation concerns, or damaged surfaces/furniture will be addressed promptly when identified. 4. The Administrator is responsible for assuring environmental cleaning and repairs are completed and for monitoring open items to completion. The housekeeper and other assigned facility staff are responsible for tasks within their abilities and job assignments; outside contractors or vendors will be used when specialized repair or cleaning is required.

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 the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility on 10/21/26 at 2:30 pm showed the following areas in need of cleaning or repair: * Multiple gouges, chips, and scratches were noted to several residents’ doors and door frames throughout the facility and on walls in the dining room. Decorative framing on walls throughout the facility had dust and debris on the edges; * There was a urine odor in the common television area and common bathrooms; * The common bathroom near Room 2 had a large lip between the bathroom tile and the interior of the shower stall. The caulking along the edge of the shower stall was brown and discolored with some missing pieces, as well. Discoloration was observed around the sink base; *The common bathroom near Room 5 had discoloration around the toilet and sink base; * The common bathroom near Room 8 had discoloration around the toilet and sink base, dirty linens on the floor, discolored shower curtain and liner, and dried brown matter on the cupboard door above the toilet; * Multiple dining room chairs had dark stains or food matter on the fabric or wood seats, debris was noted in the edges of the chairs, and some spills/splatters were noted to arms and chair legs; and * The blue recliner in the living room had multiple dark stains on the seat and the arms. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 10/21/26 at 3:35 pm. She acknowledged the findings.