OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to report incidents of abuse or suspected abuse to the local Seniors and People with Disabilities (SPD) office for 1 of 2 sampled residents (#2) who had incidents that were reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 05/2021 with diagnoses including atrial fibrillation, congestive heart failure and stroke. The resident’s 12/18/24 to 03/17/25 progress notes and incident reports, 02/01/25 to 03/21/25 MARs, and current physician orders were reviewed. The following was identified: The resident had orders for the following medications, all to be administered in the morning: * Eliquis for atrial fibrillation (a heart condition); * Flecainide for atrial fibrillation; * Escitalopram for depression; * Ferrous gluconate for anemia; * Folic acid for supplement; * Magnesium oxide for supplement; * Vitamin C for supplement; and * Calcium carbonate for supplement. A 02/21/25 progress note stated, “[Day shift] MT went to check on Resident and to give [him/her] meds and…was found still laying in…bed and could barely speak…[Resident 2] was taken out to the Hospital.” Review of the 02/21/25 MAR indicated Resident 2’s morning medications had been administered. However, a 02/21/25 incident report indicated the resident’s morning medications were found in the med cart. The incident report indicated the night shift MT had signed the MAR but did not administer the medications due to the resident still being asleep, and did not communicate to the day shift MT or correct the MAR. The above incident constituted possible abuse/neglect, which required immediate reporting to the local SPD office. At 10:32 am on 03/18/25 Staff 1 (Health Services Administrator – AL) stated the incident had not been reported. Survey requested the facility report the incident, and confirmation was received at 1:21 pm on 03/18/25. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office was discussed with Staff 1, Staff 4 (Health Services Quality Coordinator) and Staff 5 (Regional Director of Operations) on 03/20/25. They acknowledged the findings.

1. The APS report for resident #2 was submitted on 03/18/2025. APS visited to speak to staff and request additional documents on 03/19/2025. The resident's service plan was reviewed and updated. Administrator and RN retrained med techs on 04/02/2025 on expectations of dispensing medicines before each shift changeover. This retraining covered the requirements for signing medication when it has been administered, and striking it out when medication has not been administered. Apology offered to the resident and family. 2. Daily review of incident reports to determine whether abuse can be ruled out or not, and use of the screening line if unable to decide. Further teaching guidance will be provided by the RN, RSCs, and the Nurse Assistant to ensure continious improvement and compliance. 3. Daily 4. It is the Administrator's and RN's responsibility to oversee corrections.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: RV1 findings

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a sufficient number of direct care staff to meet the fire safety evacuation standards, based on resident acuity and structural design, during the night shift. Findings include, but are not limited to: a. During the acuity interview at 10:52 am on 03/17/25 the following was reported: * The facility was a three-story ALF with a current census of 75 residents; and * Five residents required a two-person assist to transfer, with four of them requiring a hoyer lift (three residing on the second floor and two residing on the first floor). b. The facility reported on the Acuity-Based Staffing Tool (ABST) Facility Entrance Questionnaire the following: * Two residents were identified as having support for behavioral symptoms; and * Five residents were identified as having support for cognitive impairments. c. The staffing plan posted by the facility was as follows: * Day shift: 6:00 am to 2:30 pm: 4 CGs and 2 MTs; * Swing Shift: 2:00 pm to 10:30 pm: 3 CGs and 2 MTs; and * Overnight (NOC) Shift: 10:00 pm to 6:30 am: 2 CGs and 1 MT. d. During an interview on 03/20/25, Staff 2 (ED) indicated facility procedure during an evacuation on the night shift was to call himself and Staff 1 (Health Services Administrator) to drive or walk to the facility to assist, as well as to use staff from the separately licensed MCC housed in the same building as part of the evacuation plan. He further stated the facility had purchased an “evacuation blanket” for emergencies. The blanket was in the ED’s office, and he stated the facility had not conducted drills using it for residents requiring two-person assistance for transfers. e. Observations of the community, conducted from 03/17/25 to 03/20/25, revealed multiple sampled and unsampled residents used assistive devices (walkers and wheelchairs) for mobility. The night shift staffing plan was insufficient to meet the fire evacuation standards of the Department for multiple sampled and unsampled residents based on their acuity and building structural design. At 11:16 am on 03/20/25, the insufficient night shift staffing for evacuation standards was discussed with Staff 1 and Staff 2. An amended staffing plan to address the insufficient night shift staffing was requested and received by the survey team at 12:25 pm on 03/20/25. The need to have a sufficient number of direct care staff to meet the fire evacuation standards was discussed on 03/20/25 at 1:02 pm with Staff 1, Staff 2, Staff 4 (Health Services Quality Coordinator) and Staff 5 (Regional Director of Operations). They acknowledged the findings.

1. A mock fire safety evacuation scenario was demonstrated by the ED, RSCs, Administrator, and Regional Quality Coordinator on 03/18/2025. The team used a stopwatch to estimate evacuation time from the furthest point of the AL building. 1 additional caregiver was added to the staffing plan on 03/18/2025. The facility worked in collaboration with an outside agency and assigned NOC agency staff to ensure adequate staffing levels were met. 2. 5 new NOC shift staff hired as of 04/02/2025. The weekly schedule was updated and the facility's recruitment process reviewed. Additional ads for NOC shift have been posted and RSCs and Administrator are continously working on robust recruitment processed to ensure the staffing schedule is in accordance with ABST requirements. 3. Weekly 4. It is the Administrator's responsibility to oversee staffing compliance.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. 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 ensure the posted staffing plan and Acuity-Based Staffing Tool (ABST) met the staffing requirements outlined in OAR 411-054-0070(1). Refer to C 360.

1. On 03/20/2025 RSCs and Administrator reviewed the ABST staffing tool for all residents and ensured current service plans match ABST requirements. 2. Scheduled weekly meetings with RSCs to complete an overall ABST review and to ensure compliance. ABST to be updated for each resident at the initial, quaterly, and siginificant change in condition evaluation. AL health services is using a staffing schedule that highlights recruitment needs against ABST requirements. 3. Initial, quaterly and significant change of condition. 4. It is the RSCs responsibility to review ABST and it is the Administrator's responsibility to ensure overall ABST compliance.

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 (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 instruct residents within 24 hours of admission and re-instruct, 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, and to keep a written record of the training, including the content and residents attending. Findings include, but are not limited to: Documentation of fire and life safety training to residents was requested at 12:40 pm on 03/18/25. During an interview at the same time, Staff 2 (ED) stated the facility had been discussing fire and life safety topics during Resident Council Meetings but not instructing each resident within 24 hours of move-in and annually thereafter. The need to ensure residents were instructed in fire and life safety within the specified timeframes, and to keep a written record of the training was discussed with Staff 1 (Health Services Administrator – AL), Staff 4 (Health Services Quality Coordinator) and Staff 5 (Regional Director of Operations) on 03/20/25. They acknowledged the findings, and no further information was provided.

1. Audit of life safety training performed. All residents in need of training have been trained. 2. All residents will be trained on fire procedures within 24 hours of move-in. Resident evaluation forms have been updated to include initial 24-hour and at least annual training. A new move-in checklist will be used for guidance on new move-in process. 3. Monthly review of fire and life safety training within the AL health services team to ensure resident training is in compliance with OARs. 4. It is the RSCs' responsibility to conduct the initial training with each resident and at least annually. It is the administrator's responsibility to oversee the fire and life safety training compliance.

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 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. Findings include, but are not limited to: The facility was a licensed ALF with three resident-occupied floors. During the acuity interview at 10:52 am on 03/17/25, the resident census was identified at 75, with five residents requiring the assistance of two staff for transfers (three on the second floor and two on the first floor). Review of six months of fire drill records indicated residents participated as follows: * 09/27/24 – Four residents during day shift with a total evacuation time of 11 minutes, 20 seconds; * 12/19/24 – Five residents during evening shift with a total evacuation time of 14 minutes; and * 02/27/25 – No residents evacuated during night shift fire drill. During an interview at 2:55 pm on 03/18/25, Staff 7 (MT) stated he had not practiced evacuating residents requiring two-person transfer assistance. During an interview at 1:34 pm on 03/18/25, Staff 6 (MT) stated she had not practiced evacuating residents requiring two-person transfer assistance. Documentation of the facility’s emergency preparedness plan including evidence that a drill of the plan was conducted at least twice a year was requested at 9:30 am on 03/20/25 and was received at 9:36 am. There was no documented evidence the facility conducted a drill of the plan at least twice a year. Staff 2 (ED) confirmed at the same time that the facility was not conducting a drill of the plan at least twice a year. The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required was discussed with Staff 1 (Health Services Administrator – AL), Staff 4 (Health Services Quality Coordinator) and Staff 5 (Regional Director of Operations) on 03/20/25. They acknowledged the findings, and no further information was provided.

1. The Director of Plant Operations, the ED, and the Administrator have reviewed the evacuation process on 04/02/2025 to ensure compliance with the OFC. Binder in place for every single emergency hazard identified in this OAR. 2. The first annual evacuation (tabletalk) will be held on 4/17/25 at 10:30 AM. The second annual evacuation (physical) will take place on 9/18/25. Annual review of emergency preparedness plan scheduled for 12/21/25. 3. At least twice a year. 4. It is the Director of Plant Operations, the ED's, and the Administrator's responsibility to ensure on-going compliance with Emergency and Disaster Planning.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by: