OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity in a homelike environment. Findings include, but are not limited to: Observations made during the survey revealed all meal service to resident rooms included plastic containers, paper cups, and plastic silverware. During an observation and interview on 05/22/25 at 12:50 pm, Staff 7 (Staffing Coordinator) was using a cart to deliver meal trays to resident rooms. The eating utensils mentioned above were observed for all the meals, and Staff 7 stated this was the typical process. On 05/23/25, the need to ensure services were delivered in a manner which protected residents’ dignity and provided a homelike environment was discussed with Staff 1 (Administrator). She acknowledged the findings.

What actions will be taken to correct the rule violation? - Facility will provide the option to the residents upon move in and during quarterly service plan reviews to have meals delivered to their apartment on dishes and with silverware or in “to go” containers, with plastic silverware. How will the system be corrected so this violation will not happen again? - 100% audit of all residents service plan to ensure their preference is listed under the nutrition section. - Administrator or designee has in-serviced the caregivers and dietary teams. How often will the area needing correction be evaluated? - Dietary manager or designee will audit “to go” meal trays weekly x 4 weeks, then monthly x 90 days to ensure ongoing compliance. Who on your staff will be responsible to see that the corrections are completed/monitored? - Dietary Manager or designee, results will be reviewed at the Quarterly Meeting. Date facility alleges compliance. - 7/22/2025

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

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 ensure injuries of unknown cause were reported to the local Seniors & People with Disabilities (SPD) office unless an immediate investigation could reasonably conclude and document the physical injury was not the result of abuse for 2 of 2 sampled residents (#s 2 and 6), and to ensure the administrator reviewed all investigations. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 02/2023 with diagnoses including generalized anxiety disorder and spinal stenosis. The resident’s 02/18/25 through 05/20/25 progress notes, Fall/Post-Fall Reports, and Skin Event forms were reviewed, and staff were interviewed. The following was identified: * In a progress note dated 03/09/25, staff indicated, “Resident has multiple small bruises on [his/her] arms but [sic] says that [s/he] does not know where they came from . . .” There was no documented evidence the injury of unknown cause was reported to the local SPD office if an immediate investigation could not reasonably conclude and document the bruises were not a result of abuse. The need to ensure all injuries of unknown cause were immediately reported to the local SPD office if an immediate investigation could not reasonably conclude and document the physical injury was not a result of abuse was discussed with Staff 1 (Administrator) on 05/23/25 at 3:10 pm. She acknowledged the findings. Staff 1 was asked to report the injury of unknown cause to the local SPD office, and confirmation of the report was provided to the survey team prior to exit. 2. Resident 2 was admitted to the facility in 06/2022, with diagnoses including diabetes (Type II), Parkinson’s disease, and hypertension. Review of the resident's progress notes, incident investigations, and physician communications from 02/20/25 through 05/21/25 revealed the following: * 04/19/25 - A progress note from a MT described Resident 2’s left wrist being “red and extremely swollen.” The following day, another progress note documented, “new dark purple bruising to the left wrist,” and “the resident was unsure of how [s/he] bruised the area.” The incident report regarding the injury failed to rule out abuse or neglect, and Staff 1 (Administrator) confirmed the incident had not been reported to the local SPD office. On 05/23/25, the need to investigate each resident incident to rule out abuse and neglect and report to the local SPD office, as required, was discussed with Staff 1. She acknowledged the findings. Staff 1 was asked to report the incident to the local SPD office, and confirmation of the report was provided to the survey team prior to exit. 3. Incident investigations were reviewed for Residents 2 and 6. There was no documented evidence the administrator had reviewed the investigations conducted by other staff for either residents’ incident investigations. In an interview on 05/23/25, Staff 1 (Administrator) confirmed she had not been reviewing investigations of abuse or suspected abuse which were conducted by other staff. On 05/23/25, the need for the administrator to review all investigations was discussed with Staff 1. She acknowledged the findings.

What actions will be taken to correct the rule violation? - Administrator filed APS self-reports on 5.23.2025 for resident #6 related to unknown bruising which was noted on 3.9.2025 and resident #2 related to left wrist “red and extremely swollen” noted on 4.19.2025. How will the system be corrected so this violation will not happen again? - Administrator will review and sign every event assessment, which describes “injury of unknown origin” and/or if abuse or neglect have not been ruled out, a FRI will be sent over to APS by Administrator or designee. How often will the area needing correction be evaluated? - Administrator will audit daily x 1 week, then weekly x 4 weeks to ensure ongoing compliance. Who on your staff will be responsible to see that the corrections are completed/monitored? - Administrator or designee. Date facility alleges compliance. - 7/22/2025

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:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 1 of 6 sampled residents (#4) whose service plans were reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in 05/2024 with diagnoses including chronic kidney disease. The resident's current service plan, dated 04/15/25, was reviewed, observations were made, and interviews with staff were conducted between 05/22/25 and 05/23/25. Resident 4's service plan was not reflective and/or did not provide clear instruction to staff in the following areas: * Preference for female caregivers; * Sleeping on the couch instead of in the bed; * Reluctance to accept care, including interventions to minimize refusals; * Level of assistance needed with ADLs; * Frequency of toileting assistance; * Persistent diarrhea; and * Alcohol use. The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 05/23/25. She acknowledged the findings.

What actions will be taken to correct the rule violation? - Resident Services Coordinator has updated the following areas for resident #4. o Preference for female caregivers o Preference to sleep on the couch instead of in the bed o Reluctance to accept care, including interventions to minimize refusals o Level of assistance needed with ADL’s o Frequency of toileting assistance o Persistent Diarrhea o Alcohol consumption How will the system be corrected so this violation will not happen again? - HSD and RSC to in-service all staff regarding residents’ care needs and how to document and communicate changes, to ensure service plans are reflective. - Admin in-serviced, IDT team on SP review process and during quarterly SP meetings and PRN, for comprehensive updates to resident SP. How often will the area needing correction be evaluated? - Admin or designee to audit weekly x 4 weeks and then monthly for 90 days to ensure ongoing compliance. Who on your staff will be responsible to see that the corrections are completed/monitored? - ADMIN, RSC and HSD. Date facility alleges compliance. - 7/22/2025

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. 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 MARs were accurate and included resident-specific parameters and staff instruction for 1 of 5 sampled residents (# 3) whose medications were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2024, with diagnoses including hypertension, hypothyroidism, and dementia. Review of Resident 3’s MAR, dated 05/01/25 through 05/21/25, revealed the following: 1. The MAR lacked reasons for use of the following medications: * Amlodipine 5 mg (for hypertension); * Aspirin 81 mg (for heart health); * Atorvastatin 10 mg (for high cholesterol); * Baclofen 10 mg (muscle relaxant); * Chlorella 200 mg (food supplement); * Donepezil 10 mg (for dementia); * Levothyroxine 50 mcg (for hypothyroidism); * Ocuvite adult 50+ (multivitamin); * Oxybutynin ER 10 mg (for overactive bladder); and * Vitamin D3 (calcium supplement). 2. The MAR lacked clear parameters for the sequential order of use for the following two PRN pain medications: * Acetaminophen 325 mg: “take 2 tablets (650 mg) by mouth every 4 hours as needed for complaint of pain or temperature over 100.1 F”; and * Hydrocodone/APAP 5-325 mg: “1 tablet by mouth every 4 hours as needed for pain.” On 05/23/25, the need to keep an accurate MAR, including reasons for use of all medications and clear instructions for unlicensed staff regarding PRN administrations, was discussed with Staff 1 (Administrator). She acknowledged the findings.

What actions will be taken to correct the rule violation? 1. HSD has audited and ensured resident #3’s MAR has reasons for use of the following medications a. Amlodipine 5 mg (for hypertension) b. Aspirin 81 mg (for heart health c. Atorvastatin 10 mg (for high cholesterol) d. Baclofen 10 mg (muscle relaxant) e. Chlorella 200 mg (food supplement) f. Donepezil 10 mg (for dementia) g. Levothyroxine 50 mcg (for hypothyroidism) h. Ocuvite adult 50+ (multivitamin) i. Oxybutynin ER 10 mg (for overactive bladder) j. Vitamin D3 (Calcium Supplement. 2. HSD has audited and ensured resident #3’s MAR has clear parameters for the sequential order of use for the two following PRN medications. a. Acetaminophen 325 mg b. Hydrocodone/APAP 5-325 mg How will the system be corrected so this violation will not happen again? - 100% audit of all residents MAR’s has been completed for both reasons for use and clear parameters. - HSD or designee has in-services all Med Techs and RSC in regards to the need for MAR’s to have reason for use and clear parameters. How often will the area needing correction be evaluated? - HSD or designee will audit all residents MAR’s daily x 1 week, then weekly for 60 days. Who on your staff will be responsible to see that the corrections are completed/monitored? - HSD or designee Date facility alleges compliance. - 7/22/2025

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 411-054-0090 (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 documentation that fire drills included all required components and failed to consistently provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety records for the prior six months were reviewed on 05/21/25. a. The three fire drills conducted lacked the following required components: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time needed; and * Number of occupants evacuated. b. In an interview on 05/22/25 Staff 1 (Administrator) reported that prior to April the facility was not documenting Fire and Life Safety training for staff. The need to involve residents in unannounced fire drills every other month, include all required components in fire drill documentation, and provide fire and life safety instruction to staff on alternate months from fire drills, was discussed with Staff 1 on 05/23/25. She acknowledged the findings.

What actions will be taken to correct the rule violation? 1. Plant Operations Manager has audited the Fire and Life Safety Document to ensure the document contains the following information. a. Problems encountered, comments relating to residents who resisted or failed to participate in the drills. b. Evacuation time needed c. Number of occupants evacuated. 2. Plant Operations Manager has included on our monthly all staff agenda a Fire and Life Safety topic to review every other month. How will the system be corrected so this violation will not happen again? - Administrator will audit Fire and Life Safety Training. How often will the area needing correction be evaluated? - Administrator or designee will audit fire drills and Fire and Life Safety Training monthly x 3 months. Who on your staff will be responsible to see that the corrections are completed/monitored? - Administrator or designee Date facility alleges compliance. - 7/22/2025

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: