Print Inspection: RL013294

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a modified special diet that was appropriate to the residents' needs and choices for 1 of 1 sampled resident (#1) who received thickened liquids. Findings include, but are not limited to: Resident 4 moved into the facility in 10/2022 with diagnoses including dementia and dysphagia (swallowing impairment). The resident’s clinical record, dated 04/27/26 through 07/27/26, was reviewed, staff were interviewed, and the resident was observed. The following was identified: The resident had a signed physician’s order dated 07/14/26 for thickened liquids. The resident’s service plan stated, “prefers to drink milk with [his/her] meals” and instructed staff to provide “water and juice” with all meals. In an interview on 07/29/26 at 12:49 pm, Staff 6 (CG) and Staff 15 (MT) confirmed Resident 4 preferred thickened juice or milk to thickened water, though only thickened water had been available to the resident recently. On 07/28/26 at 1:20 pm, Staff 5 (Dining Services Director) stated the facility previously ordered thickened apple juice, and Resident 4 “went through it too fast.” At 1:00 pm on 07/29/26, Staff 5 confirmed the resident was served only thickened water for approximately the past two months, as this was the last time thickened juice had been ordered. During the survey dates of 07/27/26 through 07/29/26, Resident 4 was provided with only thickened water for hydration. Unsampled residents in the cottage were provided with juice, soda, and/or milk, in addition to water. The need to provide a modified special diet that was appropriate to residents' needs and choices was reviewed with Staff 1 (ED) on 07/28/26 at 3:30 pm and 07/30/26 at 11:30 am. He acknowledged the findings.

1. A diet audit will be completed to ensure the service plan, orders, and diet map all have current diet information listed. 2. The Executive Director and Dining Services Director will receive additional training on ordering and maintaining stock of pre-thickened beverages per physicain order. 3.The Dining Services Director will review the inventory and order additional thickened liquids weekly with each order. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained all required elements for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 05/2026 with diagnoses including dementia. Resident 1’s move-in evaluation was reviewed, and the following was identified: The document failed to address the following required elements: * Pronouns and gender identity; * Customary routines related to sleeping and eating; * Mental health issues, including history of treatment and effective non-medication interventions; * Personality, including how the person copes with change or challenging situations; * Pain – pharmaceutical and non-pharmaceutical interventions; and * Nutritional habits. The need to ensure the initial evaluation contained information addressing all required elements was reviewed with Staff 1 (ED) on 07/30/26 at 2:27 pm. He acknowledged the findings.

1. Resident #1's pronouns, gender identity, customary routines, mental health issues, personality, and pain management were documented in the initial evaluation entered on 05/26/26, the initial evaluation indicated that sleeping routine and preferences were unknown at time of move-in and to observe sleep patterns. 2. The Wellness Director(s), Wellness Nurse(s), and Executive Director will receive additional training on the OR Health and Service Evaluation. 3. The Wellness Director(s) and Executive Director will review with each move-in. 4. The Executive Director will be responsible for ensuring compliance.

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 residents' needs and preferences and provided clear direction to staff regarding the delivery of services for 2 of 6 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 05/2026 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan, dated 06/26/26, and subsequent interim service plans were completed during the survey. Observation of ADL care from 07/27/26 through 07/30/26 identified the following: Resident 1 used a power wheelchair to assist with mobility, required staff assistance with toileting with the use of a front-wheeled walker for balance support, used a recliner chair when sleeping, ate a minimal amount of food, and did not wear compression stockings. Review of the service plan, dated 06/26/26, identified the service plan was not reflective of the resident’s current care needs or preferences and did not provide clear direction to staff in the following areas: * Mobility device(s) used and level of assistance required for mobility; * Routine with toileting assistance; * Use of a recliner for sleeping; * Eating routines, including preferred meals and food consumption amounts; * Wearing compression stockings; and * Resistance to care or services, including strategies to mitigate behaviors. The need to ensure resident service plans were reflective of current care needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED) on 07/30/26 at 2:27 pm. He acknowledged the findings. 2. Resident 4 moved into the facility in 10/2022 with diagnoses including dementia and dysphagia (swallowing impairment). The resident’s clinical record, dated 04/27/26 through 07/27/26, was reviewed, staff were interviewed, and the resident was observed. The following was identified: During the acuity interview on 07/27/26 at 2:30 pm, Staff 3 (Wellness Nurse/LPN) stated Resident 4 had a modified diet texture and thickened liquids, received hospice services, and required two-person assistance with transfers. The resident was observed on 07/28/26 at 1:00 pm and required two-person assistance with transfers, grooming, and dressing. The resident’s service plan, dated 05/28/26, was not reflective of the resident’s current status in the following areas: * Patch for smoking cessation; * Assistance with dressing and grooming; and * Weight loss. The resident’s service plan did not provide clear direction to staff regarding the delivery of service in the following areas: * Diet texture, including snacks; * Use of clothing protector during meals; * Hospice frequency and assistance with showering; and * Air mattress. The need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was reviewed on 07/30/26 at 11:30 am with Staff 1 (ED). He acknowledged the findings.

1. The service plan for resident #1 and #4 will be updated. All resident service plans will be reviewed for accuracy and updated as needed. 2. The Wellness Director(s) and Executive Director will receive additional training on the service plan process. 3. Area will be reviewed with each service plan update per the QA - Health Services Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

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 maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 resident (#1) who required assistance with ADL cares and for multiple sampled and unsampled residents during meal service. Findings include, but are not limited to: Throughout the survey, dated 07/27/26 through 07/30/26, the following observations were made to determine adherence to universal precautions for infection control: a. Multiple meals were observed between 07/27/26 and 07/30/26. * In cottage D, staff were observed carrying and rinsing dirty dishes, touching soiled napkins, handling clean dishes, delivering food and beverages to residents, and touching resident walking devices, all without performing hand hygiene between dirty and clean tasks. * In cottage C, staff were observed delivering food and drinks which were uncovered from the kitchenette to resident rooms. b. On 07/29/26 at 1:02 pm, Staff 7 (CG) was observed assisting a resident with a transfer, handling a soiled brief, assisting with perineal care, donning a clean brief, and carrying a bag with the soiled brief, all while wearing the same gloves. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene during dining services, covering food when delivering to residents’ rooms, and hand hygiene during ADL care, was discussed with Staff 1 (ED) on 07/30/26 at 2:27 pm. He acknowledged the findings.

1. Dining Services and Care Staff will receive additional training on handwahing and covering meals when delivering outside of the dining area. 2. Refer to #1 and #3. 3. The Dining Services Director will complete a meal evaluation and observe handwashing and delivery service weekly per the QA Dining Services Review Schedule. The Wellness Director(s) will complete the Caregiver Skills Observation upon hire and annually per the QA Health Services Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 2 of 6 sampled residents (#s 1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 10/2022 with diagnoses including dementia and dysphagia (swallowing impairment). The resident’s clinical record, dated 04/27/26 through 07/27/26, was reviewed, staff were interviewed, and the resident was observed. The following was identified: The resident had a signed physician’s order, dated 07/14/26, for nectar-thick liquids. On 07/28/26 at 12:30 pm, Resident 4 was served honey-thick water with his/her lunch. In an interview on 07/28/26 at 1:20 pm, Staff 5 (Dining Services Director) confirmed the water was pre-thickened and designated as honey-thick. She stated she was not aware the resident’s order stated nectar-thick, not honey-thick, and confirmed there was no nectar-thick liquid available in the facility. The need to ensure all treatments were carried out as prescribed was reviewed with Staff 1 (ED) on 07/28/26 at 3:30 pm and on 07/30/26 at 11:30 am. He acknowledged the findings. 2. Resident 1 moved into the community in 05/2026 with diagnoses including dementia and a recent history of hypotension. Review of the clinical record indicated the resident had the following physician orders dated 07/20/26: * Losartan 25 mg – one tablet by mouth twice daily for blood pressure; * Metoprolol succinate 25 mg – one tablet every day for heart; and * Both medications had parameters to hold when the resident’s systolic blood pressure was less than 100, the diastolic blood pressure was less than 60, or heart rate was less than 60. Resident 1 received the following medications when his/her blood pressure was below the physician-prescribed holding parameters: * Metoprolol on 07/06/26 at 5:00 pm; and * Losartan on 07/24/26 at 8:00 am. Resident 1’s medication was held when his/her blood pressure was above the physician prescribed holding parameters: * Losartan on 07/08/26 at 8:00 am. On 07/30/26 at 11:14 am, Staff 3 (Wellness Nurse/LPN) acknowledged the resident’s medication orders were not carried out as prescribed. The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED) on 07/30/26 at 2:21 pm. He acknowledged the findings.

1. Medication parameters were reviewed for resident #1 and #4. All medicaitons with hold parameters will be reviewed for clear direction to staff. 2. The Med-Tech's will receive additional training on hold parameters and proper documentation when holding a medication. 3. The Wellness Director(s) and Wellness Nurse(s) will provide clear instructions per the Orders Policy and the Wellness Director(s) will audit weekly per the QA - Health Services Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements staff were providing to residents for 5 of 6 sampled residents (#s 1, 2, 3, 4, and 6.). Findings include but are not limited to: Observations of Residents 1, 2, 3, 4, and 6, interviews with direct care staff from 07/28/26 through 07/30/26, and review of Resident 1, 2, 3, 4, and 6’s service plans and acuity-based staffing tool (ABST) evaluations identified the residents’ allotted care minutes were not reflective of care time and/or care elements needed in one or more of the 22 care areas of the ABST. The need to ensure the ABST accurately captured the care time and care elements for all residents in each of the 22 ADL areas was discussed with Staff 1 (ED) on 07/30/26. He acknowledged the findings.

1. The ABST will be updated to reflect appropriate care time for resident #1, 2, 4, and 6. The ABST will be reviewed with each service plan update for accuracy. 2. The Wellness Director(s) and Executive Director will receive additional training on the ABST portal. 3. The ABST will be reviewed for each resident upon move-in and with each service plan update. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills per Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drill and fire and life safety records from 01/2026 through 06/2026 were requested and reviewed with Staff 1 (ED) on 07/28/26 at 1:48 pm. The facility’s fire drill records lacked one or more of the following required components: * Date and time of the drill; * Location of simulated fire; * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time needed; and * Number of occupants evacuated. The need to ensure fire drills were conducted per OFC and included a written record of all required components of the fire drill was discussed with Staff 1 on 07/28/26 at 1:48 pm. He acknowledged the findings.

1. A fire drill will be conducted with documentation that meets all requirements. 2. The Maintenance Director and Executive Director will receive additional training on the Fire and Life Safety Training and Drills Flowchart and the Fire Drill and Evacuation Checklist. 3. The Maintenance Director will complete the drill and applicable documentation monthly per the QA - Maintenance Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

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 on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drill and fire and life safety records from 01/2026 through 06/2026 were requested and reviewed with Staff 1 (ED) on 07/28/26 at 1:48 pm. During the review of the fire drill records the following was identified: Resident 1 moved into memory care in 05/2026. There was no documented evidence the facility provided fire and life safety instruction to the resident within 24 hours of admission. On 07/30/26 at 9:56 am, Staff 1 confirmed the facility did not have documentation that residents were re-instructed on general fire safety procedures annually. The need to instruct residents of general fire safety procedures within 24 hours of admission and re-instruct residents at least annually per the OFC requirements was discussed with Staff 1 on 07/30/26 at 9:56 am. He acknowledged the findings.

1. The Fire and Life Safety Annual Resident Safety Training will be complated with documentation including residents in attendance and residents not in attendance due to cognitive or mental capabilities. 2. The Maintenance Director and Executive Director will receive additional training on the Annual Resident Safety Training and Documentation. 3. The Executive Director will ensure the New Resident Safety Orientation Checklist is completed with each new move-in and the Maintenance Director will ensure the annual training is completed per the QA Maintenance Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

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 and accesses to the RCF common use areas, entrance and exit ways were made of hard, smooth material, were accessible and maintained in good repair. Findings include, but are not limited to: 1. The exterior courtyard in Cottage C was observed on 07/28/26 at 9:00 am. A drop-off which exceeded one inch in depth was observed along the walkway in the courtyard. An unsampled resident utilizing a four-wheel walker for mobility was observed on 7/28/26 at 10:05 am, stepping down into the flower bed to smell a flower. The non-sampled resident was unsteady stepping over the drop off back to the pathway. On 7/30/26 at 11:05 am, the courtyard was toured with Staff 18 (Maintenance Director). Staff 18 acknowledged drop offs. The need to ensure drop-offs were less than an inch was discussed with Staff 1 (ED) on 07/30/26 at 11:50 am. He acknowledged findings. 2. The exterior courtyard in Cottage B was observed on 07/28/26 at 9:30 am, and the following was identified: * The sidewalk had a crack approximately 24 inches long and up to one inch in height which created an unsmooth surface. On 07/28/26 at 9:25 am, an unsampled resident was observed ambulating along the sidewalk and caught his/her toe on the unsmooth surface. * Drop-offs which exceeded one inch in depth were noted along the courtyard pathway. The need to ensure drop-offs were less than an inch and all exterior pathways were made of hard, smooth material and maintained in good repair was discussed with Staff 1 (ED) on 07/30/26. 3. During the relicensure survey, dated 07/27/26 through 07/30/26, the facility’s interior and exterior were toured. The facility consisted of four separate and distinct cottages labeled A, B, C, and D. Two of the cottages, C and D, had interior courtyards that were accessible via sliding glass doors. The threshold of each sliding glass door was approximately 1.5 inches tall and was not flush with the facility’s flooring. Therefore, the interior courtyards were not accessible to residents who used wheelchairs or walkers. During an interview on 07/28/26 at approximately 1:37 pm, Staff 7 (CG) reported there were three residents who used the interior courtyard in cottage D. Two of the residents could independently access the area; however, the third resident required caregiver assistance to cross the raised threshold with his/her walker. The need to ensure all accesses to the RCF common use areas and exit ways were made of hard, smooth material and accessible was discussed with Staff 18 (Maintenance Director) on 07/30/26 at 1:08 pm. He acknowledged the findings.

1. Ramps will be installed in the courtyards of Cottage C & D for wheelchair and walker accessibility without staff assistance. The sidewalk crack and drop-off will be repaired. 2. The Maintenance Director and Executive Director will receive additional training on the Quarterly Building Inspection. 3. The Maintenance Director and Executive Director will review quarterly with the QA - Quarterly Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

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 and all equipment necessary for the health, safety, and comfort of residents was kept clean and in good repair and was free of unpleasant odors. Findings include, but are not limited to: The facility was toured on 07/28/26 through 07/30/26. The following was identified: a. Cottage A: * Multiple recliner chairs in common areas had worn seat springs that lacked support when residents were sitting in them and had broken footrests; * Ceiling light fixtures in the TV common area were not flush to the ceiling and were hanging down; * Damage, scratches, and marks on the handrail near room 7 and room 7's door; and * The washer and dryer were not working. b. Cottage B: * Two recliner chairs had broken vinyl on the seat resulting in an uncleanable surface; * Flooring next to and behind the toilet in B7 was discolored and had a build-up of an unknown substance; and * Unpleasant odors were present in B7 throughout the survey. c. Cottage C: * Unpleasant odors were present throughout the survey. The need to ensure all interior materials, surfaces, and equipment were kept clean and in good repair and was free of unpleasant odors was discussed with Staff 1 (ED) on 07/30/26. He acknowledged the findings for Cottages A, B and C.

1. All areas identified in the survey will be repaired and/or replaced as needed. 2. The Maintenance Director and Executive Director will receive additional training on the Quarterly Building Inspection. 3. The Maintenance Director and Executive Director will review quarterly with the QA - Quarterly Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the setting was physically accessible to individuals. Findings include, but are not limited to: Refer to C510, example 3.

Refer to C510.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements, including pronouns and gender identity for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to C252.

Refer to C252.

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: C240, C295, C362, C420, C422, C510, and C513.

Refer to C240, C295, C362, C420, C422, C510, C513

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C252, C260, and C303.

Refer to C252, C260, C303.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation areas were no less than six feet in height. Findings include, but are not limited to: The facility was endorsed as a secure MCC for residents with a diagnosis of dementia. The facility consisted of four cottages, and its residents had access to outdoor recreation areas in each cottage. The outdoor recreation areas were toured on 07/27/26 through 07/30/26. The fencing was vinyl which surrounded the perimeters of the secured areas. The fence was measured in multiple spots in the four cottages and had different height measurements based on the location of the fencing. Multiple areas of the vinyl fences, including the vinyl gates, measured below six feet. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height was discussed with Staff 1 (ED) on 07/30/26. He acknowledged the height of the fence was less than six feet in areas.

1. The fence height will be adjusted to ensure that all areas are no less than six feet in height. 2. The Maintenance Director and Executive Director will receive additional training on the Quarterly Building Inspection. 3. The Maintenance Director and Executive Director will review quarterly with the QA - Quarterly Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.