Print Inspection: RL014818

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to: The RCF was a single level home of 10 residents. Eight of 10 residents were reported to have cognitive impairments or a dementia diagnosis. At the time of the survey, the facility did not have specific activity staff and had universal workers (direct care staff) who were expected to provide a daily program of social and recreational activities. The activity calendar posted showed the following activities were scheduled for 10/13/26: * Beanbag toss at 9:00 am; and * Community postcard writing at 2:00 pm. The activity calendar posted showed the following activity was scheduled for 10/14/26: * Movement with scarves at 9:00 am. Observations during the survey, from 10/12/26 to 10/14/26, identified the above activities did not occur. Many of the residents stayed in their rooms throughout the survey. During an interview with Staff 1 (Administrator) on 10/13/26 at approximately 3:00 pm, he confirmed the RCF didn’t have an activity program. Staff 1 reported the facility had hired someone specific to run the activity program; however, the individual would not start until the week of 10/19/26. The need to ensure the RCF had a daily program of social and recreational activities that was based on individual and group interests, physical, mental, and psychosocial needs and created opportunities for active participation in their community was discussed with Staff 1 and Staff 2 (RN) on 10/13/26 at 3:00 pm. They acknowledged the findings.

A part-time and a full-time activity staff have been hired and will begin the week of 10/19/26 with training, developing and implementing a full acitivty program. In addition, all current and future residents will complete a life story, biography and activity preference survey to gather resident preferences to assist in development and implementation of the activities program. If the acitivity staff is out on sick leave or other approved time off, other community staff and administration will cover their open shifts and ensure the activities program is completed during those shifts. The activities program will be reviewed weekly upon initial development and implementation, then monthly. The activities staff will complete daily documentation for all group and individual activities. This will be completed by the activities coordinator.

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 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 04/14/26 through 09/10/26 were requested and reviewed with Staff 1 (Administrator) on 10/13/26 at 8:45 am. During the review of the fire drill records, the following was identified: Resident 2 moved into the RCF in 07/2026 and was not provided fire and life safety instruction within 24 hours of admission. On 10/13/26 at 8:45 am, Staff 1 confirmed the facility did not have a system in place to instruct new residents on general fire safety procedures within 24 hours of admission, and the facility would need to implement a system for annual re-instruction on general safety procedures. 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 and Staff 2 (RN) on 10/13/26 at 8:45 am. They acknowledged the findings.

A resident fire education and responsibility form has been created and all current residents have been educated and responsabilities have been discussed with them and responsible parties. Any new admission will have the education and responsabilities reviewed and discussed with them within 24 hours of admission and the form will be placed within their hard charts for quick access and review. The system will reviewed quarterly with the residents quarterly evaluation to ensure timely review, accurate education. This system will be monitored quarterly by the RCC.