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 interview and observation, it was determined the facility failed to ensure the dining room was clean in accordance with Food and Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 05/04/26, between the lunch and dinner meal services, multiple dining tables were observed with soiled tablecloths. They were not replaced before the next meal service. In an interview on 05/05/26 at 9:50 am, Staff 14 (Dietary Aide) stated the tablecloths were supposed to be changed after each meal service and in between if soiled. In an interview on 05/05/26 at 11:15 am, Resident 3 stated, “I kind of have a problem with the tablecloths. I don’t think they change them that often. The other day I pulled off [debris].” On 05/05/26 and 05/06/26, the facility continued to leave soiled tablecloths on the dining tables. The need to ensure linens were laundered or replaced between operations if they became wet, sticky, or visibly soiled was discussed with Staff 1 (ED) on 05/06/26 at 10:45 am. She acknowledged the findings.

C0240 1. From this date forward Community will ensure that all table linens are replaced between each meal service. All visibly soiled linens, including wet or sticky linens will be laundered or replaced during meals as directed. 2. Dining room will be inspected prior to meal service to ensure clean linens are on all tables per company policy. Tables will be inspected during meal service to ensure that soiled linens are timely addressed and removed as needed. Inservice conducted on 5/18/2027 to addess proper management of linens. Routine audits will occur to ensure system is in place. 3. Daily & weekly 4. Dining Services Director, Executive Director or Designee

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:

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused consent to an order, for 1 of 1 sampled resident (#2) with repeated treatment refusals. Findings include, but are not limited to: Resident 2 was admitted to the facility in 09/2025 with diagnoses including atrial fibrillation and amnesia. The resident had an order for the facility to “Buddy tape left middle finger to left ring finger.” Between 04/01/26 and 05/04/26, the MAR indicated the resident refused to allow the facility to perform the treatment on 32 of 34 days. There was no documented evidence the facility notified the physician or other practitioner of the refusals. In an interview on 05/06/26 at 11:10 am, Resident 2 reported and showed the surveyor his/her left ring finger was bent in a closed position. The resident stated the facility was not taping his/her fingers anymore and added it hurt to try to straighten the finger. In an interview on 05/06/26 at 12:00 pm, Staff 9 (MT) confirmed the facility asked the resident every day to tape the fingers as ordered and the resident declined. She acknowledged the facility had not notified the physician of the refusals. The need to notify the physician or other practitioner of the refusals was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 05/06/26 at 1:15 pm. They acknowledged the facility had not notified the physician as required.

C305 1. From this date forward, physician or practitioner will be notified every time a resident refuses consent to an order, per regulations, unless otherwise stated from the provider. Resident #2’s physician or practitioner will be notified of Resident #2 refusing to buddy tape left middle finger to left ring finger between the dates of 4/1/26 and 5/4/26. Resident #2 will be evaluated for pain and coordination of care with provider will occur for plan of care. All future plans of care will be added to MAR and service plan as indicated and staff will continue to document additional resident refusals of orders. 2. Fax template was created for staff to complete and fax to the physician or practitioner when a resident refuses an order. Verification that the physician or practitioner was notified will be reviewed during third checks process with order verification and when completing MAR audits. 3. Weekly & Monthly 4. Wellness Director, Resident Care Coordinator or Designee

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused consent to an order, for 3 of 3 sampled residents (#s 2, 8 and 10) with medication and treatment refusals. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2025 with diagnoses including atrial fibrillation and amnesia. The resident had an order for the facility to “Buddy tape left middle finger to left ring finger.” Between 07/05/26 and 07/13/26, the MAR indicated the resident refused to allow the facility to perform the treatment on seven of nine days. There was no documented evidence the facility notified the physician or other practitioner of the refusals. In an interview on 07/13/26 at 03:00 pm, Staff 1 (ED) confirmed the facility asked the resident every day to tape the fingers as ordered and the resident declined. She acknowledged the facility had not notified the physician each time the resident had refused administration of the treatment. The need to notify the physician or other practitioner of the refusals was reviewed with Staff 1 on 07/13/26 at 4:00 pm. She acknowledged the findings. 2. Resident 8 was admitted to the facility in 02/2021 with diagnoses including hypertension and depression. The resident had an order for the facility to administer polyethylene glycol powder daily for constipation. Between 07/05/26 and 07/13/26, the MAR indicated the resident refused the medication on six of nine days. There was no documented evidence the facility notified the physician or other practitioner of the refusals. In an interview on 07/13/26 at 03:00 pm, Staff 1 (ED) acknowledged the facility had not notified the physician each time the resident had refused administration of the medication. The need to notify the physician or other practitioner of the refusals was reviewed with Staff 1 on 07/13/26 at 4:00 pm. She acknowledged the findings. 3. Resident 10 was admitted to the facility in 04/2021 with diagnoses including irritable bowel syndrome, atrial fibrillation, and chronic obstructive pulmonary disease. The resident had an order for the facility to administer the following medications: * Ani-itch lotion four times daily for chronic itching; and * Guaifenesin every four hours while awake for cough. Between 07/05/26 and 07/13/26, the MAR indicated the resident refused the medications multiple times. There was no documented evidence the facility notified the physician or other practitioner of the refusals. In an interview on 07/13/26 at 04:00 pm, Staff 1 (ED) acknowledged the facility had not notified the physician each time the resident had refused administration of the medications. The need to notify the physician or other practitioner of the refusals was reviewed with Staff 1 on 07/13/26 at 4:00 pm. She acknowledged the findings.

C0305 1.) Resident 2-Resident's record was reviewed. The ordering provider was notified of the documented repeated refusals related to "Buddy taping" the left middle finger 7 of the 9 times between the dates of 7/5/26 and 7/13/26. The notification will be document in resident record and include additional or changes to provider orders. Resident 8- Resident's record was reviewed. The ordering provider was notified regarding the identified 6 refusals of polyethylene glycol as ordered for constipation from the dates between 7/5/26 and 7/13/26. The notification will be documented in the resident record and include additional or changes to provider orders. Resident 10- Resident's record was reviewed. The ordering provider was notified regarding multiple refusals during the dates of 7/5/26 and 7/13/26 of the anti-itch lotion 4 times daily for chronic itching & Guaifenesin every 4hrs for cough while awake. Documentation of the notification was entered and reflected in resident record and includes additional or changes to provider orders. 2.) From this day forward, ordering providers will be notified every time a medication or treatment is refused, unless otherwise ordered by the ordering provider. Documentation of refusal and notification of refusals will be retained in resident record. Inservice for medication staff held on 7/21/26. 3.) Electronic MAR will be reviewed during clinical meeting 2-3 times a week for medication/treatment refusal, provider notification of refusal, and follow documentation in resident record. Management will review system Monthly to ensure in place. 4.) Wellness Director, Associate Wellness Director, Executive Director and/or designee

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medications that were administered PRN that were given to treat a resident's behavior had written, resident-specific parameters and were used only after documented, non-pharmacological interventions have been tried with ineffective results, for 1 of 1 sampled resident (#2) who was prescribed and administered a PRN psychotropic medication. Findings include, but are not limited to: Resident 2 was admitted to the facility in 09/2025 with diagnoses including atrial fibrillation and amnesia. a. Resident 2 had an order for: “Lorazepam 0.5 mg tablet - 1 tablet by mouth daily as needed.” The MAR lacked resident-specific parameters for why and when the medication should be used. b. The resident was administered the lorazepam on five occasions between 04/01/26 and 05/04/26. There was no documented evidence the facility attempted non-pharmacological interventions with ineffective results prior to administering the medication. The need to ensure the MAR included resident-specific parameters and the facility documented non-pharmacological interventions had been tried with ineffective results prior to administering the medication, was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 05/06/26 at 1:15 pm. They acknowledged the lack of parameters and documentation regarding attempts to provide non-pharmacological interventions.

C330 1. Resident #2’s MAR will be updated to reflect diagnosis for why they are taking Lorazepam and symptoms to monitor for when to offer this PRN medication. Resident Specific non-pharmacological interventions will be listed on the MAR and staff will need to indicate which non-pharmacological interventions were ineffective prior to administering medication. From this date forward, staff will document attempts to provide non-pharmacological interventions. 2. All PRN psychotropic medication orders will be processed and reviewed through the three-check system to ensure that the MAR has parameters for why and when to administer the medication and has resident-specific non-pharmacological interventions. The MAR will be set up so documentation reflects what interventions were ineffective prior to administering the medication. Inservice was held 5/20/2026 to review the need to document non-pharmacological interventions prior to administering PRN psychotropic medications. 3. Weekly 4. Wellness Director, Resident Care Coordinator or Designee

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to review and update the Acuity Based Staffing Tool (ABST) evaluation for each resident corresponding with service plan updates, for 4 of 5 sampled residents (#s 1, 2, 4 and 6) whose ABST evaluations were reviewed. Findings include, but are not limited to: The date when the ABST evaluation for each sampled resident was last edited was reviewed on 05/04/26. The dates were compared to the date each sampled resident’s service plan was last reviewed. The following was identified: * Resident 1’s ABST was edited eight days after the service plan review; * Resident 2’s ABST was edited 15 days after the service plan review; * Resident 4’s ABST was not edited after the most recent service plan review on 03/26/26; and * Resident 6’s ABST was edited 16 days after the service plan review. The facility did not update the sampled residents’ ABST evaluations corresponding with their service plan updates, as required. The need to ensure timely updates of the ABST evaluations was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/LPN) on 05/06/26 at 1:15 pm. Staff 1 acknowledged the findings.

C363 1. Resident #4’s ABST will be updated to reflect the most recent service plan completed. Any subsequent changes to Resident # 1, 2, or 6 will ensure that their ABST corresponds with their service plan and updates are made per regulations. 2. All resident’s ABST evaluations were reviewed to ensure that they corresponded with the service plan and reviewed by ODHS. From this date forward, all ABST evaluations will correspond with their service plan update as required. When service plans are updated, ABST will be reviewed upon printing and prior to circulating service plan. 3. Move In, 30-day, 90-day, Change in Condition, and weekly monitoring 4. Wellness Director, Executive Director, Resident Care Coordinator, Designee

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. 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 conduct fire drills according to the Oregon Fire Code (OFC) with all required elements. Findings include, but are not limited to: On 05/05/26, fire drill records from 01/2026 through 04/2026 were reviewed and revealed a lack of consistent documentation of the following required elements: * Location of simulated fire; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * Staff members on duty and participating; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. The need to ensure the facility conducted fire drills according to the Oregon Fire Code (OFC) with all required elements, was reviewed with Staff 1 (ED) on 05/05/26 at 3:15 pm, and 05/07/26 at 11:20 am. She acknowledged the findings. No further information was provided.

C420 1. From this date forward, all fire drills will have documentation of the following elements: Location of simulated fire; escape route used; problems encountered, comments relating to resident who resisted or failed to participate in the drills; evacuation time period needed; staff members on duty and participating; number of occupants evacuated; and evidence alternate routes were used during fire drills. All Fire drills will be conducted according to the Oregon Fire Code with all required elements documented. This includes ensuring that correct documentation form is available and contains all the required elements. 2. Fire drills will be scheduled and planned. All documentation for the fire drill will be reviewed prior to and after to ensure accurate forms available and completed in their entirety after the drill. All Fire drill documentation will be reviewed by at least the person conducting the drill and on other manager. 3. Monthly review 4. Plant Operations Director, Executive Director or Designee

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 general fire and life safety requirements were met for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose fire and life safety records were reviewed. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following were identified: * Lack of documentation that fire and life safety training was provided to Resident 3 within 24 hours of move-in; and * Documentation that annual fire and life safety training was provided to Residents 1, 2, 4, 5 and 6, including all required training topics. The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually was discussed with Staff 1 (ED) on 05/05/26 at 3:15 pm, and 05/07/26 at 11:20 am. She acknowledged the findings. No further information was provided.

C422 1. Resident #3 is historical for move-in fire and life safety training. Resident’s #1, #2, #3, #4, #5, and #6, will have required annual fire and lift safety training provided prior to date of compliance. All training will be documented. 2. From this point forward, Fire and Life training will be included in the move-in packet for all new move-ins and will be reviewed upon move-in day. Resident fire and life safety training will be included with fire drill schedule and reviewed to ensure residents are not missed. If a resident is out of facility during their scheduled fire and life safety training, they will be reassigned to complete training timely. 3. Move-In & Quarterly reviews 4. Plant OPS Director, Executive Director & Deisgnee

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 (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) 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 interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C305.

Refer to C305.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must 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 its interior surfaces were clean and in good repair. Findings include, but are not limited to: The facility was toured with Staff 1 (ED) on 05/06/26 at 10:45 am. The following was noted: * Scuffs, chipped paint and gouges were noted on doors, door frames, walls, corner pillars, furniture and handrails throughout the community, making some surfaces uncleanable. * There was debris/dust/dirt noted on baseboards, window blinds, furniture, windowsills, railings, exercise equipment, exterior windows and ceiling ventilation screens throughout the community. * The carpet in front of the “Coca Cola Room” was soiled. The need to ensure the facility’s interior surfaces were clean and in good repair was reviewed with Staff 1 on 05/06/26 at 10:45 am. She acknowledged the findings.

C613 1. All identified interior services in need of cleaning and repair will be corrected. This includes painting, sanding or resurfacing scuffs, chipped pain and gouges on doors, door frames, walls, corner pillars, furniture, and handrails throughout the community. Furniture that is unable to be repaired will be removed. The debris/dust/dirt noted on baseboards, window blinds, furniture, windowsills, railings, exercise equipment, exterior windows and ceiling ventilation screens throughout the community will be cleaned. The carpet in front of the Coca Cola room will be cleaned. 2. Common Area cleaning checklist will be implemented. TELs program is in place for staff to report items needing repair or cleaning. Inservice to be held with housekeeping and maintenance staff to address expectations of clean and in good repair. All staff In-service conducted 5/20/2026 to discuss expectations of clean and in good repaid, identification of items needing correction and submitting items on TELs. 3. Daily & Weekly reviews 4. Plant OPS Director, Executive Director & Designee.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches, and were above the first floor. Findings include, but are not limited to: The community was toured with Staff 1 (ED) on 05/06/26 at 10:45 am. Second floor resident unit windowsills were observed to be lower than 36 inches and lacked a system which limited how much the windows could open to prevent accidental falls. The need to ensure operable windows were designed to prevent accidental falls was discussed with Staff 1 on 05/06/26 at 10:45 am. She acknowledged the findings.

C615 1. All operable windows with sill height lower than 36 inches will have lock system installed to limit how much the window opens to prevent accidental falls. 2. Lock system will remain in place. All new or replaced windows will be installed with same system. System will be reviewed prior to move-in and ongoing for compliance. All defective locks will immediately be reported to management and placed in TELs. Inservice was conducted on 5/18/2026 to discuss expectations of windows on second floor with sill height lower than 36 inches. 3. Move-In & Quarterly reviews 4. Plant Ops Director, Executive Director, Designee

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by:

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on interview and observation, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility. Findings include, but are not limited to: A tour of the community on 05/04/26 at 2:25 pm and 05/06/26 at 9:00 am, identified that four of the five exit doors did not have a working alarm or other acceptable system to alert staff when residents left the building. During an interview on 05/06/26 at approximately 10:15 am, Staff 5 (Maintenance Director) acknowledged the alarm on one door was disconnected and three of the four other exit doors did not have alarms. The need to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (ED) on 05/06/26 at 10:45 am. She acknowledged the findings.

C655 1. Alarms have been placed and connected on all exit doors to ensure staff are aware when a resident has left the building. 2. An all-staff in-service was conducted on 5/20/26 to address reasons for door alarms, how to report and what to do if the alarms are not functioning. Task to check door alarms will be added to MAR for med techs to verify alarm is functioning. 3. Weekly, Quarterly 4. Plant Ops Director & Executive Director,

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: