Print Inspection: RL013509

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, 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 and were maintained in good repair, failed to ensure all toxic materials were kept in locked storage, and failed to ensure RCF grounds were kept orderly and free of litter and refuse, with garbage stored in covered refuse containers. Findings include, but are not limited to: The facility consisted of two stand-alone buildings, Rainier and Helens, which housed residents. Each building had a sidewalk which circled the building and led to resident common areas and resident rooms. The sidewalk around Helens led to a walking path which connected resident rooms and the smoking area on the ground floor to the front entrance of the building. The following was observed: a. The following areas had sections of concrete which were not smooth and in good repair: * Main-floor entrance from the parking lot to Helens; * Main-floor entrance from the parking lot to Rainier; and * Pathway under tree-cover which connected the front entrance of Helens and the parking lot to the smoking area. b. The following toxic materials were not kept in locked storage: * Two large red biohazard bins, containing biohazard waste storage, located in the resident use common area on the basement floor of Helens; and * Five propane tanks, 14 five-gallon gasoline tanks, and eight two-gallon gasoline tanks were stored outside Rainier on dried grass. An unsampled resident was observed smoking less than 15 feet from the toxic materials. c. Cigarette butts were observed on the ground outside both Rainier and Helens. d. Uncovered containers with garbage were noted in multiple areas inside and outside Rainier and Helens. The need to ensure all exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways were made of hard, smooth material and maintained in good repair, there was locked storage for all toxic materials, RCF grounds were kept orderly and free of litter and refuse, and garbage was stored in covered refuse containers, was reviewed with Staff 1 (Community Administrator) and Staff 2 (Director of Operations) on 08/05/26 at 11:40 am. They acknowledged the findings.

C510 OAR 411-054-0200 (3) General Building Exterior #1. Immediate actions to correct the rule violation include: a. The facility received a quote on 8/21/26 & 8/24/26 for the concrete correction in the following areas; the corrections are estimated to be completed by 11/1/26. The administrator will request an extension for violation. *Main floor entrance from the parking lot to Helens. *Main floor entrance from the parking lot to Rainier. *Pathway under tree-cover which connected the front entrance of Helens and the parking lot to the smoking area. This area has been barricaded off to alleviate entrance until correction is completed. b. The following toxic materials that were not kept in a located storage have been relocated. *The two large red biohazard bins containing biohazard waste storage have been relocated to the locked closet on the second floor of both Helens & Rainier. *Five propane tanks that are in the locked breathable bin have been moved at a minimum of 50 feet away from Rainier on dirt. The 14 five-gallon & 8 two-gallon gasoline cans have been moved to the locked maintenance storage shed. c. The cigarette butts that were observed on the ground outside both Helens & Rainier were immediately picked up. d. All garbage containers have been replaced with containers that have lids. #2. The system will be corrected so this violation will not happen again by: a. The Administrator & Maintenance team will conduct walk-throughs of all pathways on a monthly basis to ensure compliance. This task has been added to the TELS maintenance program. b. Education will be provided to the Administrator, Maintenance team and RCC related to proper storage of toxic materials. c. The residents and staff will be re-educated on the smoking policy. The Administrator or designee will conduct an exterior walk through of both Helens & Rainier once daily and pick up any cigarette debris. d. The Administrator or designee will conduct an interior and exterior walk through of both Helens & Rainier on a weekly basis to ensure all garbage containers have lids. This task has been added to the TELS maintenance program. #3. The area needing correction will be evaluated by: the Administrator, Maintenance Director and / or RCC will conduct walk-throughs of inside and outside of the community daily, weekly, monthly and will discuss concerns with IDT during daily stand up clinic meetings, as well as during quality improvement meetings. #4. The Facility Administrator, Maintenance Director and / or designee will ensure the corrections are completed and monitored.

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 clean and maintained in good repair. Findings include, but are not limited to: The facility consisted of two stand-alone buildings, Helens and Rainier. Helens was toured on 08/04/26 at 9:30 am, and the following was observed: a. Basement and stairwells: * Laundry room had multiple areas of missing flooring and a hole in the wall; * Carpeting had extensive stains; and * Unused items were stored in the common use area including a toilet seat rise and a hospital bed frame and mattress. b. Second floor: * Build-up of debris and dark discoloration of the baseboards and flooring, near the stairwell and adjacent resident rooms; * Build-up of debris along the track for the stairwell gate; * Stains and debris along walls; * Broken cabinet door under stove; * Ceiling fan with build-up of debris in sitting area; * Stained armchair; * Exposed pipes and uncleanable surface under both sinks in the kitchenette; and * Flooring near dining area had gouges. Rainier was toured at 9:45 am on 08/05/26 and the following was observed: a. Basement and stairwells: * Carpeting had extensive stains; * Stained loveseat; and * Piece of furniture with glass panel hanging off. b. First floor: * Gouged surfaces of chair bases around the common use table; and * Scuffing and stains along walls. c. Second Floor: * Multiple handrails and the top of the gate had unfinished surfaces; * A broken outlet cover near room 2F; * Approximately 24-inch-long crack along the top of the wall in the hallway near the stairwell; * Missing baseboards along the dining floor at the top of the stairwell; * Gouges in the wall near room 2C; * Two cabinet doors hanging off hinges in the kitchenette; * Outlet near exit door had a missing cover and spiderwebs; and * Exposed piping and uncleanable surface under sinks. The need to ensure the interior and exterior of the building was clean and maintained in good repair was reviewed during a tour of the environment with Staff 1 (Community Administrator) and Staff 2 (Director of Operations) on 08/05/26 at 11:40 am. They acknowledged the findings.

C513 OAR 411-054-0200 Doors, Walls, Elevators, Odors #1. Immediate actions to correct the rule violation include: Helens a. Basement and stairwells *The laundry room had multiple areas of missing flooring and a hole in the wall. This has been repaired. *Carpeting has extensive stains. This carpeting is being replaced with laminate flooring on 10/1/26. *Unused items were stored in the common use area, including a toilet seat riser and a hospital bed frame and mattress. The Administrator immediately relocated the unused items to a storage facility room located in Ashland House. b. Second floor; *Build-up of debris and dark discoloration of the baseboards and flooring, near the stairwell and adjacent resident rooms. These areas were immediately cleaned. *Build-up of debris along the track for the stairwell gate. This area was immediately cleaned. *Stains and debris along walls have been cleaned. *Broken cabinet door under stove. The cabinet door has been repaired. *Ceiling fans with build-up of debris in the sitting area were immediately cleaned. *Stained armchair, this was immediately taken to the dumpster. *Exposed pipes and uncleanable surface under both sinks in the kitchenette. This will be corrected by 10/5/26. *The floor near the dining area had gouges. The gouges have been repaired and repainted. Rainer a. Basement and Stairwells *Carpeting has extensive stains. This carpeting is being replaced with laminate flooring on 10/1/26. *A stained love set and piece of furniture with a glass panel hanging off were immediately taken to the dumpster. b. First Floor: *Gouged surfaces of chair bases around the common use table, the chair bases will be sanded and refinished. *Scuffing and stains along walls. The walls have been cleaned and repainted. c. Second Floor * Multiple handrails and the top of the gate had unfinished surfaces. These handrails and gate will be sanded and refinished by 10/5/26. * A broken outlet cover near room 2F has been replaced. * Approximately 24-inch long cracks along the top of the wall in the hallways near the stairway will be corrected by 10/5/26. * Missing baseboards along the dining floor at the top of the stairwell. * Gouges in the wall near room 2C. The wall has been cleaned and repainted. * Missing baseboards along the dining floor at the top of the stairwell will be replaced by 10/5/26. * Two cabinet doors hanging off hinges in the kitchenette have been repaired. * The outlet near the exit door has a missing cover and spiderwebs. The outlet cover has been replaced and the spiderwebs removed. * Exposed piping and uncleanable surface under sinks will be corrected by 10/5/26 #2. The system will be corrected so this violation will not happen again: The Administrator, and Maintenance Director will complete internal and external walk-throughs of the community weekly and monthly findings will be documented into TEL’s assignments to be completed. #3.The area needing correction will be evaluated by: Building walk-throughs will be completed at least weekly and TEL’s maintenance orders will be reviewed daily. #4. The Facility Administrator, Maintenance Director and / or designee will ensure the corrections are completed and monitored.