OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility’s kitchen on 06/18/25 at 9:45 am revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on, around or underneath the following: * Baseboards and floors throughout the kitchen; * Walls throughout the kitchen; * Ceilings throughout the kitchen, including fire sprinkler heads, vents and light fixtures; * Shelves on prep, serving, and cooking stations; * Water and gas lines throughout the kitchen; * Table legs of prep tables, rolling carts and storage racks in the kitchen and walk-in refrigerator; * Handles, doors/fronts and sides of upright refrigerator units and appliances; * Ice maker interior cartridge; * Drain in soda dispenser; * Interior casing of can opener; * Plate holder wells, interior and exterior walls; * Floors in dry storage room; and * Floors, walls and door of janitor’s closet. b. The following kitchen items required repair or replacement: * Ice maker door had hard water tracks from the frame of the door down the right side of the machine; * Microwave oven had chipped and melted enamel on the interior door and frame; * Spatulas were stained and burned/gouged; * Wall material was cracked along the doorway to the janitor’s closet; * Cutting boards on prep and service lines were scored and stained and uncleanable; * A gap in the ceiling tiles above the stove revealed cardboard filler between the end of the tiles and the wall; and * Multiple plastic food serving containers on the storage rack were broken. c. Poor infection control practices observed, but not limited to: * Kitchen staff failed to perform hand hygiene consistently between dirty and clean tasks; * Beard restraints were not used by staff; * Plated desserts in one of the free-standing refrigerators were not covered; * Silverware on preset tables were not wrapped; * Salad bar refrigerator did not have a thermometer; * Open boxes and an open bag of food were observed in the dry storage room; and * Multiple containers of salad dressing in the dry storage room were dented. A kitchen walkthrough was completed with Staff 1 (ED) and Staff 3 (Regional Kitchen Manager) on 06/18/25 at 1:05 pm. The areas that did not meet the rules were discussed with Staff 1 and Staff 3. They acknowledged the findings.

Kitchen and administrative staff will complete a thorough cleaning of all items listed in this citation. The Executive director will do a walkthrough following this assigned cleaning time. If there are items that still need to be cleaned, the ED will assign those tasks to kitchen staff. The ED and the DSM will review all items that need to be repaired and will put in work orders to have the repairs completed. If an item is beyond repair, a new one will be purchased. An inservice will take place in regard to proper infection control practices. The cooks and servers will follow a AM/PM cleaning task list to ensure that all appliances, storage, and furniture remain clean and in good repair. The DSM will routinely monitor all kitchen employees during their shift for proper infection control practices. If any issues are noted, the DSM will follow-up with prompt retraining. Evaluation will take place weekly during a 1:1 meeting between the executive director and the dining services manager. The executive director and the dining services manager.

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:

1a) The kitchen is to be cleaned in all areas identified in the survey on or before 12/1/2025: -Handwashing sink to remove the brown and black stains -Cleaning of all pipes and drains to remove stains and debris -All walls and ceilings to remove dust and debris -All appliances to remove debris and build up -All shelving both in the walk-in refrigerators and main kitchen -All food storage areas to be cleaned of all food debris including on any cans or storage bins Additionally, all staff will be retrained on proper cleaning procedures and the utilization of a daily cleaning task list to ensure the kitchen remains in good repair and clean at all times moving forward on or before 12/1/2025 1b) Damaged spatulas, can openers and cutting reboards replaced with new equipment. Team will be in-serviced on ensuring all equipment in the kitchen at all times 1c) All kitchen staff will be in-serviced on proper food storage on or before 12/1/2025. All non-properly stored food has been disposed of immediately 1d) Flatware table setting is to be changed where flatware will be covered in a napkin and not exposed to open air 1e) All kitchen staff will be in-serviced on proper temperatue taking of all food, including the salad bar, to ensure food remains at proper and safe temperatures throughout the meal service 2) All staff are to be trained as outlined in the above plan to correct on or before 12/1/2025. Additionally, cleaning task lists are to be reviewed each day by the administrator or designee to ensure the kitchen is in good repair and clean. Once per day, the administrator or designee will also walk the kitchen and food storage to ensure all items are in compliance (cleanliness, repair, condition of equipment, etc.). Table settings are to be corrected as outlined above to comply with the rule. 3) Daily, the above items will be reviewed as outlined in #2. Training will occur once for current team members and then additionally as needed and as new staff are onboarded into the community. 4) The administrator or designee is responsible to ensure all corrections have taken place.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: On 10/17/25, from 10:47 am through 11:20 am, the facility main kitchen was observed, and the following was identified: 1. The following areas needed cleaning: A handwashing sink near the entrance had brown and black stains; The surrounding pipe and wall near juice dispenser area had residue and debris; The wall and baseboard near the entrance as well as the area next to the coffee and juice dispensers had accumulated black matter; The drain under the ice machine had black matter accumulation; The wall and ceiling around the fire alarm had food debris; The fire alarm cover had accumulated dust; The table legs of dishwasher had accumulated food debris; The wall behind dishwasher area had black matter and the caulking around the dishwasher base had accumulated black residue; and The plastic shelving across from the one-door refrigerator had multiple canned food items including coffee with visible food debris and dried food. 2. The following areas needed repair: Spatulas were stained and burned; The commercial can opener had accumulated black matter, and the blade was stained and worn off; Cutting boards were scored and stained rendering an uncleanable surface; and A gap was noted in the ceiling tiles above the stove area. 3. Improper food storage: Inside the walk-in cooler had multiple open items without dates, including cheddar mozzarella, pepper jack, milk, ham, pre-sliced salami and blue cheese; The blue cheese was not fully covered or sealed; A cranberry sauce container was uncovered and undated; Pre-sliced salami was not completely covered or sealed; Cottage cheese was undated and uncovered; Inside the walk-in cooler floor had dried food debris; One-door refrigerator contained multiple bowls of fruit cocktail that were not covered and undated; In the dry storage area, cane sugar bags and gravy mix bags were not dated; and Shredded coconut was uncovered and undated in the dry storage area. 4. Other areas of concern included: One dented can was observed in the dry storage area; Silverware on the preset dining tables was not wrapped or covered; The salad bar in the dining room did not have a thermometer; and A dry mop was stored in the clean silverware area. The areas of concern were observed and discussed with Staff 12 (MCC Director) and Staff 13 (Executive Chef) on 10/17/25 at 1:10 pm. The findings were acknowledged.

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 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 3 staff (#5) who prepared food had active food handler's certificates. Findings include, but are not limited to: On 06/18/25, employee records were requested and reviewed to ensure staff had active food handler's cards. The food handler's card for Staff 5 (Cook) was expired effective 05/31/25. On 06/17/25 at 12:40 pm, Staff 1 (ED) confirmed Staff 5 was currently on shift and preparing food but did not have an active food handler’s card. The need to ensure staff who prepared food had active food handler’s certificates was discussed with Staff 1 on 06/18/25 at 1:43 pm. She acknowledged the findings.

Staff #5 completed the training to renew her food handlers certificate. Upon onboarding, the AED will ensure that all pre-service requirements are completed prior to providing service. The AED and HWD will routinely review the staff training matrix to ensure that all certifications are up to date. The staff training certificate matrix will be reviewed weekly during the 1:1 meeting between the ED and the AED/HWD. Executive director, assistance executive director, and the health and wellness director.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0105 (1) Inspections and Investigations (Amended 12/15/21)(1) The facility must cooperate with Division personnel in inspections, complaint investigations, planning for resident care, application procedures, and other necessary activities. (a) Records must be made available to the Division upon request. Division personnel must have access to all resident and facility records and may conduct private interviews with residents. Failure to comply with this requirement shall result in regulatory action. (b) The State Long Term Care Ombudsman must have access to all resident and facility records that relate to an investigation. Certified Ombudsman volunteers may have access to facility records that relate to an investigation and access to resident records with written permission from the resident or guardian. (c) The State Fire Marshal or authorized representative must be permitted access to the facility and records pertinent to resident evacuation and fire safety.(d) The Oregon Health Authority and appropriate Local Public Health Authority must be permitted access to the facility and records pertinent to investigation of illness or outbreak, as authorized by law. This Rule is not met as evidenced by: Facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

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: 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 observation and interview, the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

1a) The kitchen is to be cleaned in all areas identified in the survey on or before 12/1/2025: -Handwashing sink to remove the brown and black stains -Cleaning of all pipes and drains to remove stains and debris -All walls and ceilings to remove dust and debris -All appliances to remove debris and build up -All shelving both in the walk-in refrigerators and main kitchen -All food storage areas to be cleaned of all food debris including on any cans or storage bins Additionally, all staff will be retrained on proper cleaning procedures and the utilization of a daily cleaning task list to ensure the kitchen remains in good repair and clean at all times moving forward on or before 12/1/2025 1b) Damaged spatulas, can openers and cutting reboards replaced with new equipment. Team will be in-serviced on ensuring all equipment in the kitchen at all times 1c) All kitchen staff will be in-serviced on proper food storage on or before 12/1/2025. All non-properly stored food has been disposed of immediately 1d) Flatware table setting is to be changed where flatware will be covered in a napkin and not exposed to open air 1e) All kitchen staff will be in-serviced on proper temperatue taking of all food, including the salad bar, to ensure food remains at proper and safe temperatures throughout the meal service 2) All staff are to be trained as outlined in the above plan to correct on or before 12/1/2025. Additionally, cleaning task lists are to be reviewed each day by the administrator or designee to ensure the kitchen is in good repair and clean. Once per day, the administrator or designee will also walk the kitchen and food storage to ensure all items are in compliance (cleanliness, repair, condition of equipment, etc.). Table settings are to be corrected as outlined above to comply with the rule. 3) Daily, the above items will be reviewed as outlined in #2. Training will occur once for current team members and then additionally as needed and as new staff are onboarded into the community. 4) The administrator or designee is responsible to ensure all corrections have taken place.

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: