OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#6) whose MARs and Controlled Substance Disposition Log were reviewed. Findings include, but are not limited to: Resident 6 moved into the facility in 08/2022 with diagnoses including chronic pain syndrome. During the acuity interview on 11/18/25, the resident was identified as receiving hospice services and was administered a narcotic pain medication as needed. The resident's 10/01/25 through 11/19/25 MARs and Controlled Substance Disposition Log were reviewed, and the following was identified: Resident 6 had signed physician orders for oxycodone 10 mg -20 mg to be administered every three to four hours for pain as needed. The documentation showed multiple discrepancies. The Controlled Substance Disposition Log documented the oxycodone was administered on 92 occasions, while the MARs indicated the medication was administered on 85 occasions. There were multiple entries on the MARs which were not reflected on the Controlled Substance Disposition Log, and there were multiple entries on the Log which were not reflected on the MARs. On 11/21/25 at 10:24 am, inconsistencies between the MARs and Controlled Substance Disposition Log were reviewed with Staff 1 (Administrator), Staff 5 (LPN), Staff 10 (Regional Director of Operations), and Staff 11 (RN Consultant). They acknowledged the discrepancies.

OAR 411-054-0055 (1)(e ) systems: tracking control substances. 1. The controlled substance disposition log and MAR's for resident 6 was reviewed and missing entries were corrected as system allowed. 2. Clinical leadership were educated on Saphire Medication audit tools and CQI systems to ensure narcotic logs match to MAR. Education provided and system reviewed on 12/9/2025. 3. Audits will be completed each week per Sapphire policy. Identified discrepancies will be promptly corrected and education provided to person responsible. This audit will be completd for the next 8 weeks and brought to QA meetings for review 4. RCC/DHS/ED or designee.

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

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the use of a supportive device with restraining qualities was thoroughly assessed by an RN, PT, or OT prior to use, failed to instruct caregivers on the correct use of and precautions related to the supportive device, and failed to document use of the device in the resident's service plan for 1 of 3 sampled residents (#1) who used side rails. Findings include, but are not limited to: Resident 1 was re-admitted to the facility in 06/2025 with diagnoses including traumatic subdural hemorrhage and mild cognitive impairment. During room meal delivery on 11/20/25 at 8:37 am, the surveyor observed two quarter length side rails in the up position on the resident's bed. There was no information documented in Resident 1’s service plan, dated 11/18/25, relating to the use of side rails, instructions to caregivers on the correct use of the side rails, and precautions related to the supportive device. There was no documented evidence an assessment of the side rails was completed by an RN, PT, or OT. The lack of an assessment of the resident's side rails was discussed with Staff 1 (Administrator), Staff 5 (LPN), Staff 10 (Regional Director of Operations), and Staff 11 (RN Consultant) on 11/20/25 and 11/21/25. They acknowledged the findings.

OAR 411-054-0060 restraints and supportive devices. 1. Resident #1 side rail evaluation and assessment was completed on 11/20/2025. Side rails were added to the care plan with instructions to the staff for use and precautions. 2. A room to room review of all devices and equipment for potential need for evaluations and assessment was completed on 12/1/2025. All evaluations and assessments were reviewed to ensure completion and reflective care plans. Staff will be in-serviced on reporting of new assistive devices on 12/17/2025. Clinical leadership team was educated on Sapphire audit tools and policy to capture assistive devices on 12/1/2025. 3. A room to room review for any new devices will be done monthly and changes will be added to care plans and assessments completed as needed. This audit will be brought to monthly QA for review. 4. DHS/ED or designee.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 11/19/25 at 9:45 am. The following areas were observed to need cleaning and/or repair: Hallway One: * There were dust and dead bugs in the common area windowsill; * There was debris smeared on the wall in common area; * Cobwebs were observed on the skylight located between Units 5 and 8, and a layer of dust build-up was observed on the skylight vent; * A layer of dust build-up was observed on the vent in the skylight located between Units 3, 4, 9, and 10. Small Dining Room: * Wood doors in the hallway located to the right of the dining room were scuffed; * The public restroom had a missing light bulb above the sink, a patched area to the right of the toilet had not been painted, and there was debris smeared on the wall; and * There were dead bugs and dust in the windowsills. Large Dining Room: * Shelving around the fireplace was observed to have circular stains in the wood, was scuffed with rough edges, and a wooden shelf was not properly secured by the support brackets; * The cabinet to the right of the kitchen door had food splatters and debris down the front; * A red microwave was sticky to the touch, the glass plate inside of the unit was not the correct size, and the inside had rusted areas and was in disrepair; and * There were dead bugs and dust in the windowsills. Small Corridor Between the Dining Rooms and Halls Two and Three: * There were scuffs on the wood doors. Hall Two: * There was an approximately five inch rectangular-shaped missing area of the wall located at the head of the bed in Unit 15; * Gouges and splintering were observed on the wooden dresser in Unit 15; * The curtain covering an alcove where briefs were being stored located in Hall Two had white matter on the outside; * There were dead bugs and debris located inside the large, circular light fixtures; and * A layer of dust build-up was observed on the vent in the skylight located between Units 12 and 19. Hall Three: * There were dead bugs and debris located inside the large, circular light fixtures; * The baseboard to the right of unit 24’s walk-in shower was coming off of the wall and there was black matter built-up where the baseboard continued under the shelving; * There was wood was coming off of the frame around unit 24’s closet; * Unit 24 had wood-like laminate flooring. There were raised areas and areas that were rough to the touch in what appeared to be “wood knots” located outside of the unit’s restroom and to the left of the resident’s bed; * A layer of dust build-up was observed on the vent in the skylight located between Units 25, 26, 29, and 30; and * The handrail located to the left of Unit 27 was in disrepair. Crater Lake Lounge: * The upholstered chairs had areas in need of cleaning; * There were staples sticking out of the windowsills, circular stains, and debris observed; * The circular light fixture located above the fireplace was cracked and had blue tape on the outside of the glass; * There were areas of smeared debris in the public restroom located to the left of Unit 31; and * Stains were observed on the wooden shelving that was located around the fireplace. Hall Four: * There were dead bugs and debris located inside the large, circular light fixtures; * A layer of dust build-up was observed on the vent in the skylight located between Units 33, 34, 38, and 39; and * A large picture frame and empty bookshelf was being stored in the residents’ telephone room, and there was dried paint and a sticky substance observed on the countertop. Hall Five: * There were dead bugs and debris located inside the large, circular light fixtures. Patios Located in the Back of the Building: * There were brooms, a gardening hoe, a large table umbrella, a bucket holding dirt and leaves, a large dead plant, and chairs stored near the resident use doors. On 11/21/25 at approximately 11:30 am, the above areas were toured with Staff 1 (Administrator), Staff 9 (Maintenance Director), and Staff 10 (Regional Director of Operations), who acknowledged the findings. However, during the tour, Staff 10 verified the facility was in the process of rectifying many interior environment issues. She verified the initial walk-through occurred on 10/28/25 and an additional one was completed again on 11/08/25. Lists of improvements with expected due dates, ranging from 11/28/25 through 01/05/26, were provided to survey prior to exit.

OAR 411-054-0300 (4)(d-i) General building: Doors walls, cleanable. 1. Hallway one: window sills, walls, skylights and vents were cleaned of bugs, dirt and debris by maintenance 12/10/25. Large dining room: shelving around fireplace will all be cleaned, sanded and resealed. Cabinet was cleaned of splatters and debris. The microwave was removed from dining room on 11/24/2025 and replaced with new microwave. The window sills were cleaned of bugs and dust 12/10/25. Small corridor: scuffs to wood doors will be sanded and sealed by maintenance. Hallway two: Unit 15 wall and dresser will be repaired. The curtain covering the alcove was replaced on 12/8/2025. The light fixtures and vents were cleaned of debris 12/10/25. Hallway three: Debris in light fixtures was cleaned. The baseboard to the right of Unit 24 will be replaced and cleaned of build up. The wood around 24's closet will be secured to wall. The laminate in Unit 24 will be scheduled to be replaced. Vent and skylight will be cleaned of dust. The handrail to left of Unit 27 will be repaired. Crater lake lounge: Upholstered chairs will be cleaned. Staples will be removed from walls. Shelving will be cleaned of stains. Hallway four: bugs, debris and dust were cleaned from light fixtures and skylights 12/10/25. Bookshelf to be removed and countertop cleaned. Hallway five: Debris was cleaned from light fixtures. Patios: Cleaning items, debris and unneeded items will be removed and stored properly. 2. A facility walk through was completed on 10/28/25 and 11/8/25 identifying repairs needed to facility. A facility walkthrough will occur monthly by maintenance including a room walk through with a plan for corrections. Window sills, light fixtures, vents and shelving will be added to weekly cleaning duties to be completed by housekeeping and inspected by maintenance on a monthly basis. 3. Facility walkthrough will be completed once a week for the next 8 weeks to ensure areas areas are cleaned and being maintained. All areas needing repair will be added to master list with completion date attached. This list will be brought to QA monthly. 4. Maintenance director/ ED or designee.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: