OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, at least one other staff person who was familiar with or who was going to provide services to the resident and a licensed nurse if the resident needed, or was receiving nursing services for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: Residents 1, 2 and 4’s current service plans were reviewed during the survey. The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. In an interview on 07/21/26 at 5:30 pm, Staff 1 (ED) confirmed there was no documented evidence of a service planning team. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 5 (Regional VP) on 07/22/26 at 8:30 am. The findings were acknowledged.

1. Actions to correct the rule violation for each example/resident: The RCC, RN, and Executive Director (ED) will review Residents 1, 2, and 4. Each service plan will be reconvened with the resident, legal representative when applicable, person of choice, ED/designee, staff familiar with the resident, and RN when nursing services apply. Invitations, attendance, resident preferences, participation or documented attempts, decisions, and signatures will be recorded. Current service plans will be reviewed for the same gap and corrected when identified. 2. System correction to prevent recurrence: A Service Planning Team checklist and due-date tracker will be required for admission, quarterly review, and significant change. A service plan will not be closed until required invitations, participation, preferences, RN involvement when indicated, signatures, and distribution are verified. Staff responsible for service planning will be trained, and the ED will validate completion through QAPI. Weekly audits of this system will be completed. 3. Evaluation frequency: Weekly audits will be completed and then run through QAPI on a weekly basis. 4. Staff responsible for completion and monitoring: ED and/or designee responsible.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#1) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 1 moved into the facility in 10/2028 and had diagnoses which included pain and was currently receiving hospice services. Resident 1 had an order for morphine sulfate PRN (as needed) every hour for pain or shortness of breath. Resident 1's Controlled Substance Disposition Logs and MARs, reviewed from 06/01/26 through 07/20/26, revealed three occasions (06/27/26, 07/01/26 and 07/04/26) when staff signed on the drug disposition log that the PRN morphine was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 3 (RCC) and Staff 5 (Regional VP) during interviews on 07/22/26. They reviewed the documentation and acknowledged the discrepancies.

1. Actions to correct the rule violation for each example/resident: The RN and RCC will reconcile Resident 1's Controlled Substance Disposition Logs, MAR entries, and remaining count, including 06/27/26, 07/01/26, and 07/04/26. Discrepancies will be investigated and reported to leadership, the practitioner or hospice, and other required parties when indicated. Current controlled substances will receive a 100% reconciliation. Medication staff will be retrained and competency validated. 2. System correction to prevent recurrence: The facility will use an RN- or pharmacist-approved controlled-substance process. Two authorized staff will verify shift counts; administration will be documented on the MAR and disposition log at the time given; and the MAR, log, and count will be reconciled each shift. A variance will be reported immediately and remain open until investigated, resolved, and signed by the RN or RCC. Disposal records will also be verified. Weekly audits of this system will be completed. 3. Evaluation frequency: Weekly audits will be completed and then run through QAPI on a weekly basis. 4. Staff responsible for completion and monitoring: ED and/or designee responsible.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

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 interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible for administering for 2 of 4 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 08/2021 with diagnoses including edema and hypertension. The resident’s clinical record was reviewed during the survey and the following was identified: There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the medications and treatments the facility was responsible to administer. During an interview on 07/21/26 at approximately 3:45 pm, Staff 1 (ED) reported she had contacted Resident 3’s prescriber for signed physician orders. No signed physician orders were provided during the survey. On 07/22/26 at approximately 9:10 am, the need to ensure resident records had signed physician or other legally recognized practitioner orders for all medications and treatments being provided was discussed with Staff 5 (Regional VP). She acknowledged the findings. ?2. Resident 2 was admitted to the facility in 07/2019 with diagnoses which included hypertension, diabetes, depression, and heart disease. The resident’s clinical record was reviewed from 04/01/26 through 07/20/26, and the following was identified: Resident 2 had a Nurse Practitioner order, dated 06/29/26, for the following: “Recommend diabetic diet, protein shakes, and diabetic snacks.” There was no evidence in the record that the recommendations from the practitioner were implemented. During an interview with Staff 14 (Dining Services Manager) on 07/21/26 at 3:00 pm, he stated the resident was not on a special diet. Staff 3 (RCC) was interviewed on 07/22/26 at 7:50 am. During the interview, she reviewed the orders. She was unsure if the recommendations had been implemented. The need to ensure orders were followed was reviewed with Staff 5 (Regional VP) on 07/22/26 at 8:30 am. She acknowledged the findings.

1. Actions to correct the rule violation for each example/resident: The RN and RCC will obtain and file current signed practitioner orders for Resident 3 and reconcile the orders with the MAR/TAR and service plan. Resident 2's 06/29/26 recommendation for a diabetic diet, protein shakes, and diabetic snacks will be clarified with the practitioner and implemented in the dietary roster, meal instructions, and service plan. Current residents will receive an order reconciliation to identify and correct missing, unsigned, or unimplemented orders. 2. System correction to prevent recurrence: An order-tracking log will follow each new or changed order from receipt through practitioner signature, transcription, pharmacy or dietary communication, service-plan update, staff instruction, and implementation. The RN or RCC will verify completion before the order is closed. Dietary and medication/treatment orders will be cross-checked against the same current source. Staff will be trained not to implement an undocumented change. Weekly audits of this system will be completed. 3. Evaluation frequency: Weekly audits will be completed and then run through QAPI on a weekly basis. 4. Staff responsible for completion and monitoring: ED and/or designee responsible.

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:

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/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#2) who had documented medication and treatment refusals. Findings include, but are not limited to: Resident 2 was admitted in 07/2019 with diagnoses which included hypertension, diabetes, depression, and heart disease. Resident 2's MARs were reviewed from 07/01/26 through 07/20/26. Staff documented Resident 2 refused the following medications and treatments on numerous occasions: * Aspirin EC (for heart disease) 81 mg one tablet daily; * Atorvastatin (for hyperlipidemia) 40 mg one tablet at bedtime; * Farxiga (for diabetes) 10 mg one tablet daily; * Levothyroxine (for thyroid disorder) 50 mcg one tablet every other day; * Levothyroxine (for thyroid disorder) 75 mcg one tablet every other day; * Losartan (for high blood pressure) 25 mg one tablet daily; * Melatonin (for insomnia) 5 mg two tablets at bedtime; * Memantine (for dementia) 5mg one tablet daily; * Metformin ER (for diabetes) 750 mg one tablet daily; * Metoprolol SUCC ER (for high blood pressure) 25 mg one tablet daily; * Novolog insulin (for diabetes) 6 units twice a day; * Nystatin cream (antifungal) twice daily; * Potassium (hypokalemia) 40 MEQ/15Ml 3.75 ml daily; * Secura (protectant cream) to buttocks three times a day; * Tramadol (for pain) 50 mg one tablet daily; * Trazadone (for insomnia) 50 mg one tablet at bedtime; * Venlafaxine (for depression) 150 mg one capsule daily; * Vitamin B-12 (supplement) 1000 mcg one tablet daily; and * Vitamin D-3 (supplement) 25 mcg one tablet daily. There was no documented evidence the facility consistently notified Resident 2's physician/practitioner of the refusals. Staff 3 (RCC) was interviewed on 07/22/26 at 7:50 am. During the interview, she reviewed the MAR and was unsure if staff had notified the resident’s provider of the refusals. The need to ensure the physician/practitioner was notified when a resident refused to consent to orders was discussed with Staff 5 (Regional VP) on 07/22/26 at 8:30 am. She acknowledged the findings.

1. Actions to correct the rule violation for each example/resident: The RN will notify Resident 2's practitioner of the documented medication and treatment refusals and request resident-specific instructions for initial and subsequent refusals. The RN and RCC will assess causes of refusal, document attempted approaches, update the service plan, and follow practitioner direction. Current MAR/TAR records will be reviewed for other refusals requiring notification and follow-up. 2. System correction to prevent recurrence: Medication staff will document each refusal in the MAR/TAR and progress note and immediately notify the RN or RCC. Practitioner notification parameters will be placed in the medication instructions and reviewed during shift report. Weekly audits of this system will be completed. 3. Evaluation frequency: Weekly audits will be completed and then run through QAPI on a weekly basis. 4. Staff responsible for completion and monitoring: ED and/or designee responsible.

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 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate, including resident-specific parameters and instructions for medications, for 3 of 4 sampled residents (#s 1, 2, and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 10/2028 and had diagnoses which included pain and was currently receiving hospice services. Residents 1's MARs, reviewed from 07/01/26 through 07/20/26, revealed the following: a. Lack of resident-specific instructions for multiple PRN pain medications, including sequence of administration. b. Staff were instructed to apply nystatin ointment (for yeast infection) twice a day to “affected area.” The MAR lacked specific application instructions. During interviews with Staff 13 (MT) on 07/22/26 at 7:45 am, and with Staff 4 (RCC) at 7:50 am, they reviewed the MAR and gave different descriptions of what “affected area” the ointment was being applied to. c. The resident had an order for PRN morphine every hour as needed for pain, with the dose to be given in varied amounts based on a pain scale. Review of the MAR indicated staff had administered the PRN morphine but had not consistently documented pain scale results and dose of morphine given. In an interview with Staff 13 (MT) and Staff 4 (RCC) on 07/22/26 at 7:45 am and 7:50 am, respectively, they reviewed the MAR and acknowledged staff were not consistently documenting the pain scale results nor amount of PRN morphine administered. The need to ensure an accurate MAR was discussed with Staff 5 (Regional VP) on 07/22/26 at 8:30 am. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2019 with diagnoses which included hypertension, diabetes, depression, and heart disease. Residents 2's MARs, reviewed from 07/01/26 through 07/20/26, revealed the following: * Lack of clear parameters for hypotension and when blood pressure medications should be held; * Staff were instructed to obtain the resident’s blood pressure and pulse twice a day. The MAR had multiple blanks where no blood pressure or pulse was documented; and * The MAR indicated that catheter care was to be provided twice a day. Between 07/01/26 and 07/20/26, MTs documented one time that the care was provided. In an interview on 07/22/26 at 7:50 am, Staff 4 (RCC) reviewed the MAR and explained that caregivers provided the care, not the MTs. She acknowledged the catheter care instructions should be removed from the MAR. The need to ensure an accurate MAR was discussed with Staff 5 (Regional VP) on 07/22/26 at 8:30 am. She acknowledged the findings. She stated the MAR would be reviewed and updated to ensure it was accurate. 3. Resident 4 moved into the facility in 12/2023 with diagnoses including dementia and hypertension. Resident 4's 07/01/26 through 07/20/26 MAR and physician orders were reviewed and revealed the following PRN medications lacked instructions for sequential order of use: * Acetaminophen 500mg (pain); and * Oxycodone 5mg (moderate-severe pain). On 07/22/26 at approximately 9:10 am, the need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 5 (Regional VP). She acknowledged the findings.

1. Actions to correct the rule violation for each example/resident: The RN and RCC will correct the affected MARs. Resident 1: clarify PRN pain-medication sequence, nystatin application site, morphine pain-scale parameters, and dose documentation. Resident 2: obtain blood-pressure hold parameters, correct missing blood-pressure/pulse documentation, and remove catheter care from the medication MAR when assigned to caregivers. Resident 4: clarify the sequence for PRN acetaminophen and oxycodone. Medication staff will be retrained and competency validated. 2. System correction to prevent recurrence: The RN will reconcile orders and MAR/TAR setup before each monthly cycle. A MAR checklist will verify medication name, reason, dose, route, time, allergies, application site, vital-sign or pain-scale requirements, PRN sequence, hold/call parameters, and staff initials. The RCC will review daily exceptions and blanks. Caregiver tasks will be maintained in the correct care-documentation system rather than the medication MAR. Weekly audits of this system will be completed. 3. Evaluation frequency: Weekly audits will be completed and then run through QAPI on a weekly basis. 4. Staff responsible for completion and monitoring: ED and/or designee responsible.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled direct care staff (#s 8, 9, and 10) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 07/21/26. There was no documented evidence Staff 8 (CG), hired 05/12/26, Staff 9 (MT), hired 05/12/26, and Staff 10 (CG), hired 05/08/26, had demonstrated competency in the following areas: * Providing assistance with ADLs. The need to ensure newly hired direct care staff had demonstrated satisfactory performance in all required areas within 30 days of hire was reviewed with Staff 1 (ED) on 07/21/26, and Staff 5 (Regional VP) on 07/22/26 at 8:30 am. The findings were acknowledged.

1. Actions to correct the rule violation for each example/resident: Staff 8, Staff 9, and Staff 10 will complete, and document observed competency for assistance with activities of daily living. Until competency is validated, they will receive direct supervision and will not independently perform an unvalidated duty. The ED and RCC will review current direct-care employee files to identify and correct other missing 30-day competencies. This will be complete by 9/20/2026 2. System correction to prevent recurrence: A new-hire training and competency matrix will list hire date, assigned duties, required competencies, due dates, trainer, supervision status, and completion evidence. The scheduler will not assign an employee independently to an unvalidated duty. The Business Office/HR designee and RCC will review the matrix before the 30th day and obtain signed observation records from a qualified trainer. Weekly audits of this system will be completed. 3. Evaluation frequency: Weekly audits will be completed and then run through QAPI on a weekly basis. 4. Staff responsible for completion and monitoring: ED and/or designee responsible.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire ? Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. 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 provide and document fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to: On 07/20/26, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided showed there was no documented evidence the facility provided fire and life safety training on alternating months for staff as required. The need to provide fire and life safety instruction to staff on alternate months of fire drills was discussed with Staff 1 (ED) on 07/21/26 and reviewed with Staff 5 (Regional VP) on 07/22/26. The findings were acknowledged.

1. Actions to correct the rule violation for each example/resident: The Maintenance Director and ED will provide and document the missing fire and life-safety instruction and review the prior six months of records for missed alternate-month instruction. Any identified gap will receive corrective training. Attendance, content, date, trainer, shift, and follow-up will be documented and retained for Department review. 2. System correction to prevent recurrence: A 12-month calendar will alternate unannounced fire drills with fire and life-safety instruction and rotate day, evening, and night shifts. Standard forms will document required drill and training elements. The Maintenance Director will maintain the calendar, and the ED will review and sign each record within three business days. Missed or incomplete activities will be rescheduled promptly and reviewed in QAPI. Weekly audits of this system will be completed. 3. Evaluation frequency: Weekly audits will be completed and then run through QAPI on a weekly basis. 4. Staff responsible for completion and monitoring: ED and/or designee responsible.

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 411-054-0300 (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 the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 07/20/26 and 07/21/26 showed the following areas in need of cleaning or repair: 1. Interior: * Multiple ceiling tiles on the first floor were observed with holes and dark stains; * Room 214 had multiple dark stains in the living room and bedroom; and * The first-floor all-user restroom door frame was damaged and partially removed. 2. Exterior: * Exterior windows and siding had cobwebs throughout the perimeter of the building; * Plants and vegetation were visible in gutters throughout the perimeter of the building; * Exterior vinyl siding near the staff break room was damaged; and * Litter and refuse was present throughout the facility grounds. On 07/20/26 at approximately 2:45 pm, the areas in need of cleaning and repair were discussed with Staff 1 (ED) and Staff 4 (Maintenance Director). They acknowledged the findings.

1. Actions to correct the rule violation for each example/resident: The Maintenance Director, Housekeeping, and ED will correct the cited areas: replace or repair damaged and stained first-floor ceiling tiles; clean and repair the stains in Room 214; repair the first-floor all-user restroom door frame; remove exterior cobwebs, gutter vegetation, litter, and refuse; and repair the damaged siding near the staff break room. Each correction will be documented with a work order and completion verification. 2. System correction to prevent recurrence: Documented interior and exterior environmental rounds will identify cleanliness, ceiling, wall, door, siding, gutter, grounds, and repair concerns. Each finding will receive an owner, priority, due date, interim safety action when needed, and work order. A work order will not be closed until the Maintenance Director or ED verifies the correction. Repeat findings will receive root-cause review and revised preventive maintenance or cleaning frequency. Weekly audits of this system will be completed. 3. Evaluation frequency: Weekly audits will be completed and then run through QAPI on a weekly basis. 4. Staff responsible for completion and monitoring: ED and/or designee responsible.

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: