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 investigations of injuries of unknown cause and falls included all required information and reasonably concluded and documented the events were not the result of abuse for 1 of 2 residents (#1) who experienced injuries of unknown cause and falls. Findings include, but are not limited to: Resident 1 moved into the community in 01/2021 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as having a history of falls. Review of the resident’s 05/08/25 change of condition evaluation noted the resident was a high fall risk and listed an intervention to “ensure resident has [four-wheeled walker] when ambulating.” Observation notes, incident reports, and investigations dated 03/13/25 to 06/09/25 were reviewed, and the following was identified: * 05/27/25 – A progress note indicated resident had an unwitnessed fall, with no report of injury at time of incident, and the resident was unable to state what had happened; * 05/27/25 – A progress note indicated resident reported, “some lower back pain”; * 05/28/25 – A progress note indicated, “resident [sic] back was pretty painful for [him/her] this morning…has bruising on lower back [left] side”; * 06/03/25 – A progress note indicated the resident had an unwitnessed “fall without injury,” and the resident was unable to state what had happened; * 06/03/25 – An incident report indicated the resident had a left knee abrasion related to the fall; and * 06/03/25 – A progress note stated, “Though reported as a [non-injury fall] resident did complain of some pain located to [his/her] lower back this shift.” Facility investigations for the falls on 05/27/25 and 06/03/25 were reviewed. The facility did not reasonably conclude and document the incidents were not the result of abuse. There was no documented investigation of the bruise reported on 05/28/25 to determine if it was a result of the resident’s fall on 05/27/25. The need to ensure investigations reasonably ruled out abuse for injuries of unknown cause and incidents of suspected abuse, or were reported to the local SPD office if abuse could not be ruled out, was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided.

1. The facility RN/HSD will receive additional training on investigation documentation to understand how to ensure their documentation can reasonably rule out abuse and neglect. * Incidents for resident #1 indicated in SOD will be reviewed and late reports to APS will be made if unable to rule out abuse and neglect 2. All investigations will include clear detailed documented evidence to rule out abuse and neglect. * All incidents will be reviewed within 24hours to rule out abuse and neglect, including for residents unable to recall what occurred. 3. Incident reports will be reviewed daily during clinical standup to ensure proper investigations are completed and abuse and neglect has been ruled out. 4.The Executive Direcor/Designee and Director of Operations will be responsible to ensure all the investigations have documented evidence to reasonably rule out abuse or neglect ensuring compliance.

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 preferences, provided clear direction to staff, and/or were implemented for 2 of 3 residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the community in 01/2021 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as having a history of falls. The resident’s service plan, dated 05/08/25, and intermediate service plans, dated 03/13/25 to 06/09/25, were reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The service plan was not reflective of Resident 1’s needs and preferences, lacked clear direction to staff, and/or was not implemented in the following areas: * Side rails for mobility; * Fall interventions; * Hospice services; * Use of wheelchair; * Hospital bed; * Ability to use call light; * Meal assistance, including provide one item at a time; * Communication status/needs/assistance; * Assistance with glasses; * Pain, including non-pharmaceutical interventions; * Environmental factors impacting resident’s well-being, including noise; * Alcohol use cessation; * Preferred name; * Preference for open door; and * Daytime and nighttime sleeping and eating routines. The need to ensure the implementation of services and that the service plan was reflective of the resident’s needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided. 2. Resident 3 was admitted to the facility in 10/2022 with diagnoses including glaucoma, hypertension, pain from compression fracture mid-back, and dementia. S/he was subsequently admitted to hospice on 04/11/25. Observations were made of the resident's care on 06/10/25 and 06/11/25, interviews with the resident and facility staff were conducted, and the care plan, dated 04/14/25, was reviewed. Resident 3's care plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions for aspiration precautions and interventions while choking; * How side rails were to be used and monitored for safety; * Instructions on specific changes of condition to report to hospice; * Physician Orders for Life Sustaining Treatment status; * Number of staff needed to assist with activities of daily living; * Number of staff needed to assist with grooming and eating; * History of dehydration; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Instructions on to whom to report skin impairments; * Personality, including how the person copes with change or challenging situations; * Number of staff needed to assist with emergency evacuations; * Instructions on peri and skin care; * Use of barrier cream with toileting changes; and * How a person expresses memory loss. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (AED), and Staff 3 (Health Services Director/RN) on 06/11/25 at 12:45 pm. They acknowledged the findings.

1. Service Plans for residents #1 and #3 will be updated to reflect all required components as indicated in survey findings. 2. Facility will reivew all service plans to ensure proper service plan compliance and all required areas of resident centered service plans. 3. The service plan team will review and sign off on every 30-days, quarterly, and when there is a change of condition. Ongoing review of SP/Evals will be completed during QAPI review process and internal auditing. 4.The RN/HSD, Executive Director/Designee, and Operations Director will be responsible to ensure the needed corrections have been made, and will be monitoring to ensure the needs and directions to meet those needs are clear and resident specific on each service plan.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document weekly progress until the condition resolved for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including glaucoma, hypertension, pain from compression fracture mid-back, and dementia. S/he was subsequently admitted to hospice on 04/11/25. Resident 3's observation notes, dated 03/17/25 through 04/23/25, care plan, dated 04/14/25, additional intermediate service plans, and after-visit summaries from the off-site providers were reviewed. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: * 04/05/25: “…there are open sores now on residents [sic] coccyx that are bleeding…”; * 04/08/25: “…seems like there is a pressure sore on [his/her] right heal [sic].”; * 04/11/25: admitted to hospice and all previously scheduled medications were discontinued; * 04/23/25: “…has breakdown in buttocks right side…”; and * 05/14/25: “…took 1st dose of morphine (for pain)...watch for effectiveness …” The need to ensure the facility had a system to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, to communicate the determined action or intervention to staff, and to document progress until the condition resolved was reviewed with Staff 1 (ED), Staff 2 (AED), and Staff 3 (Health Services Director/RN) on 06/11/25 at 12:45 pm. They acknowledged the findings. 2. Resident 1 moved into the community in 01/2021 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as having a history of falls. The resident’s 03/13/25 to 06/09/25 progress notes, incident reports, outside provider notes, and intermediate service plans were reviewed. a. There was no documented evidence the following short-term changes of condition had actions or interventions determined, documented, and communicated to staff on each shift: * 04/12/25 – Hospice admit; * 04/29/25 – “Edema +1 pitting bilaterally”; * 05/09/25 – Medication change and family no longer bringing alcohol in for the resident; * 06/03/25 – Unwitnessed fall. b. There was no documented evidence the following short-term changes of condition had monitoring with weekly progress noted to resolution: * 04/29/25 – “Edema +1 pitting bilaterally”; * 05/28/25 – Bruise on “lower back left side”; and * 06/03/25 – Left knee abrasion. The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift, with weekly progress noted to resolution for all short-term changes of condition was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided. 3. Resident 2 was admitted to the facility in 06/2023 with diagnoses including schizoaffective disorder and bipolar disorder. Resident 2’s progress notes, dated 03/25/25 through 05/21/25, service plan dated 04/02/25, and intermediate service plans were reviewed. The resident experienced multiple short-term changes without documented monitoring of progress at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas: * 03/25/25 – Fall; * 04/01/25 – Abscess in left armpit and new medication; * 04/03/25 - Positive for MRSA; and * 04/24/25 – New medication. During an interview with Staff 1 (ED) on 06/11/25 at 1:30 pm, she acknowledged the lack of monitoring of progress for changes of condition through resolution and the lack of actions or interventions determined and communicated to staff. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 on 06/11/25. She acknowledged the findings.

1. Service Plans for resident #1,2 & 3 will updated to reflect any interventions and instructions as applicable for above residents if needed. 2.Facility RN/HSD will complete additional COC training via Oregon Care Partners. * Interventions and instructions for each short-term change of conditon will be documented via alert monitoring and intermediate service plan for staff to read and sign. * Additional staff trainings will be provided for COC and how to report, monitor and follow up 3. Resident short-term change of conditions will be monitored and documented daily and reviewed, and weekly thru resolution from facility RN/Designee. *Resident service plans will be updated for all permanent change of conditions as identified during the monitoring time period or as needed. 4.The Med-techs, RN, and ED/Designee and Director of Operations will ensure instructions, corrections are made and monitored daily, weekly and to resolution.

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 residents' MARs included resident-specific parameters and instructions for PRN medications ordered by a legally recognized prescriber and administered by the facility for 2 of 3 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including glaucoma, hypertension, pain from compression fracture mid-back, and dementia. S/he was subsequently admitted to hospice on 04/11/25. Resident 3's MAR from 05/01/25 through 06/11/25 and physician orders were reviewed and revealed the following: a. The following PRN medications lacked instructions for sequential order of use: * Acetaminophen 500mg (for pain or fever); * Acetaminophen 650mg suppository (for pain or fever); * Diclofenac Sodium 1% gel (for pain); and * Morphine Sulfate 20mg/ml (for pain). b. The following PRN medications lacked resident-specific parameters for use: * Haloperidol 2mg/ml (for anxiety, agitation, or hallucinations); and * Lorazepam 0.5mg (for anxiety or agitation). c. The following medications lacked clear, specific instructions: * Bisacodyl 10mg suppository (for bowel care); * Milk of Magnesia 400mg/5ml (for bowel care); * Miralax Powder (for bowel care); and * Fleet enema (for bowel care). The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (AED), and Staff 3 (Health Services Director/RN) on 06/11/25 at 12:45 pm. They acknowledged the findings. 2. Resident 1 moved into the community in 01/2021 with diagnoses including Alzheimer’s disease. The resident’s 05/01/25 to 06/09/25 MAR and current physician orders were reviewed. The resident had signed orders for the following: * Acetaminophen 500 mg caplet, as needed for pain; * Acetaminophen, 650 mg suppository as needed for pain; and * Morphine sulfate 20 mg/ml solution, 0.25 ml by mouth every hour as needed for pain. Review of the MAR indicated staff administered the acetaminophen caplet on 05/27/25, and the morphine on seven occasions between 05/27/25 and 06/03/25. There were no resident-specific parameters to direct unlicensed staff on the sequential order of administration. In an interview at 10:36 am on 06/10/25, Staff 7 (MA) reviewed the resident’s MAR and confirmed the three PRN pain medications lacked instructions for staff. The need to ensure resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided.

1. Residents #1 and #3 MAR will be updated with clear specific parameters and instructions for sequencing on administration of pain medication and bowel medications. Community ED/RN will ensure all non-pharmacological interventions are in place. 2. Facility MAR's will be reviewed and corrected for any missing information including medication parameters. Facility will complete triple check process and assure all medications have required components. Facility will provide ongoing training to medication techs regarding proper medication processes, need for parameters, etc. 3. Facility RN/ED/AED or trained designee will complete weekly MAR audits to ensure compliance with all medications and medication components. 4.Med-techs,RN/HSD, AED, ED/Designee and Director of Operations will be responsible for ensuring compliance.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility’s Acuity-Based Staffing Tool (ABST) did not accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to: A review of ABST documentation, interviews, and observations throughout the survey were completed. The following was identified: * The minutes recorded on the ABST did not match services provided by staff in multiple areas for Residents 1 and 2. The need for the ABST to accurately capture care time and care elements that staff were providing to each resident was discussed with Staff 1 (ED) on 06/11/25. She acknowledged the findings.

1. ABST tool has been updated for Resident #1 & #2 to reflect the correct minutes assigned for resident specific care needs. 2. Facility ABST tool has been reviewed and updated to reflect correct minutes assigned for scheduled and unscheduled resident care needs. 3. The facility ABST tool will be reviewed and updated at 30-day, quarterly, and anytime a change of condition occurs per resident. 4.Executive Director/Designee and Director of Operations will be responsible to ensure the corrections and continued updating, and monitoring of facility ABST tool for compliance.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drills records from 12/2024 to 06/2025 were reviewed. a. The records lacked documented evidence of completing fire drills on alternating months from fire and life safety training. b. Fire drills completed lacked the following documentation: * Time of fire drill; * Problems encountered, comments related to residents who resisted or failed to participate; * Evacuation time period needed; and * Number of occupants evacuated. The need to ensure fire drills were conducted in accordance with OFC was discussed with Staff 1 (ED) at 10:40 am on 06/11/25. She acknowledged the findings, and no further information was provided.

1. A extra fire drill will be completed to make up for the missing drill in April 2025. Facility will continue to alternate Fire life safety training and Fire drills every other month ensuring compliance is documeted in FireLife Safety Binder. 2.Fire Drill forms will be filled out immeadiatley after fire drill ensuring the following documentation is identified on the form; time of drill, residents who failed to participate, evacuation time period needed, and number of evacuated residents. *Fire Safety will be gone over with residents during their quarterly service plan update meeting. Facility to ensure instructions are printed on quarterly service plan prior to residents signature. 3. Executive Director along with Director of Operations will review monthly during site visits and correct any areas as needed. 4. The Executive Director/Designee and Director of Operations will be responsible to ensure corrections are completed and monitored for compliance.