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 interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and meet the fire safety evacuation standards as required by the fire authority or the Department. Findings include, but are not limited to: During the Acuity Based Staffing Tool (ABST) review with Staff 2 (Health and Wellness Manager) on 02/18/26 at 10:30 am, the following was identified: * The facility was a two-story assisted living community with a current census of 83 residents; * One resident on the first floor (Resident 5) required the assistance of two direct care staff for transfers; * Three residents required staff support for behavioral symptoms; and * Four residents required staff support for cognitive impairments. The facility’s posted staffing plan indicated 1 MT and 1 CG were scheduled on night shifts. Review of the facility’s staffing schedule for 02/01/26 through 02/07/26 confirmed 1 MT and 1 CG were staffed on each night shift. Resident 5’s service plan and staff interviews on 02/17/26 and 02/18/26 confirmed the need for two direct care staff for all transfers. The need to ensure a minimum of two direct care staff were scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs and to meet fire safety evacuation standards was reviewed with Staff 1 (General Manager), Staff 2, and Staff 3 (Health and Wellness Nurse) on 02/19/26 at 11:20 am. They acknowledged the findings.

OAR 411-054-0070(1)(b) requires the facility to have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. OAR 411-054-0070(1)(c) requires staffing to be sufficient to meet the fire safety evacuation standards as required by the fire authority or the Department. 1. How the Facility Corrected the Deficient Practice: Effective 02/19/26, the facility increased NOC shift staffing by one (1) additional direct care staff member seven (7) days per week. Night shift staffing now includes: • One (1) Medication Technician; and • Two (2) Caregivers This ensures: •A minimum of two qualified direct care staff are available at all times to safely assist residents requiring two-person transfers, including Resident 5; •Adequate staffing to meet scheduled and unscheduled resident needs; and compliance with fire safety evacuation standards in accordance with OAR 411-054-0070(1)(c). 2. How the Facility Will Ensure the Practice Does Not Recur? The facility will utilize the Acuity Based Staffing Tool (ABST) to determine and maintain sufficient staffing levels on an ongoing basis w/ any changes to a residents service plan, change of conditions, and with quarterly assessments. 3. Monitoring System: • The Administrator and Health & Wellness Manager (HWM) will review the ABST at their weekly meetings and continued monitoring will be conducted by HWM to ensure compliance with OAR 411-054-0070(1)(b) and (c). Any identified staffing variance will be corrected immediately through schedule modification or supplemental staffing. Documentation of reviews will be maintained for survey review. 4. Date of Compliance The facility achieved compliance on 02/19/26 and will maintain ongoing compliance through the monitoring systems described above.

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 use the results of an Acuity Based Staffing Tool (ABST) to develop and routinely update the facility’s posted staffing plan to outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. Findings include, but are not limited to: During the ABST review with Staff 2 (Health and Wellness Manager) on 02/18/26 at 10:30 am, the following was identified: The facility’s proprietary ABST indicated 13.2 staff were required to meet the daily scheduled care needs of the residents. Staff 2 confirmed the tool did not account for the unscheduled needs of residents. The facility scheduled 12.5 staff per day, per the posted staffing plan. The facility failed to meet or exceed the ABST-generated staffing plan to meet the scheduled and unscheduled needs of the residents. This was confirmed by review of the facility’s daily schedule from 02/01/26 through 02/07/26. The need to use the ABST to develop and routinely update the facility’s posted staffing plan to outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility was reviewed with Staff 1 (General Manager), Staff 2, and Staff 3 (Health and Wellness Nurse) on 02/19/26 at 11:20 am. They acknowledged the findings.

OAR 411-054-0037 (4)-(6) Acuity Based Staffing Tool (ABST) – Updates & Staffing Plan: 1. How the Facility Corrected the Deficient Practice: The facility has updated the staffing plan to reflect staffing numbers generated by the Acuity Based Staffing Tool (ABST) and to account for unscheduled care needs. ABST now indicates 13.2 staff are required to meet the daily scheduled care needs. Effective 02/19/2026, the facility implemented the following corrective actions: Increased NOC shift staffing to include three (3) direct care staff, increasing total daily staffing from 12.5 to 13.5 staff per 24-hour period. HWM updated and re-posted the staffing plan to reflect current staffing levels and to account for both scheduled and unscheduled care needs. Reviewed and recalculated the ABST to ensure inclusion of unscheduled care needs. Administrator and HWM initiated recruitment efforts to hire additional direct care staff to maintain staffing levels at or above ABST requirements. All current residents’ ABST evaluations were reviewed to ensure accuracy and inclusion of scheduled and unscheduled care needs. The staffing plan was compared against the updated ABST totals to ensure alignment. The Health and Wellness Director and Administrator are responsible for monitoring and ensuring the Acuity Based Staffing Tool (ABST) is completed accurately and reflects each resident’s scheduled and unscheduled care needs and staff accordingly based on ABST. 2. Systemic Changes to Prevent Recurrence - the facility has implemented the following system changes: a. ABST Review Process: ABST will be completed prior to move-in, upon significant change of condition and at least quarterly in conjunction with service plan updates. Health and Wellness Manager (HWM) will conduct regular audits of ABST staffing and General Manager (GM) will complete secondary monitoring to ensure ongoing compliance. b. Staffing Plan Alignment: Facilities posted staffing plan will be reviewed regularly and immediately following any ABST change impacting staffing totals. Staffing plan will reflect total ABST care time and account for unscheduled care needs, account for paid and unpaid meal breaks, ensure staffing meets or exceeds ABST totals 24 hours/day, 7 days/week, and meet requirements of OAR 411-054-0070(1). Any identified variance will be corrected immediately through overtime, agency staffing, or incentive pay. 3. The Health and Wellness Director and Administrator are responsible for monitoring and ensuring the Acuity Based Staffing Tool (ABST) is completed accurately and reflects each resident’s scheduled and unscheduled care needs. 4. Date of Compliance: Substantial compliance was achieved on 02/19/2026 when staffing was increased and the staffing plan was updated to align with ABST requirements including unscheduled resident needs.

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 (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 ensure fire drills were conducted according to the Oregon Fire Code (OFC), with all required elements documented, and failed to ensure fire and life safety instruction was provided to staff on alternating months from the drills. Findings include, but are not limited to: Six months of facility fire drill and fire and life safety records, from 08/2025 through 01/2026, were reviewed with Staff 4 (Plant Operations Supervisor) on 02/18/26 at 12:15 pm and revealed the following: * There was no documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills; * There was no documented evidence unannounced fire drills were conducted at different times of the day, evening, and night shifts; * Documentation of the 08/15/25, 10/25/26, and 12/16/25 drills lacked information regarding staff who were on duty and participated in the drills; and * Documentation of the 08/15/25 and 12/16/25 drills lacked information related to problems encountered and comments related to residents who resisted or failed to participate in the drills. The need to ensure unannounced fire drills were conducted at different times of the day, evening, and night shifts, fire drill records included all required elements, and staff were instructed in fire and life safety procedures on alternating months from fire drills was reviewed with Staff 1 (General Manager), Staff 2 (Health and Wellness Manager), and Staff 3 (Health and Wellness Nurse) on 02/19/26 at 12:25 pm. They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Training for Staff (a) 1. How the Facility Corrected the Deficient Practice: A fire drill will be conducted in March during the NOC shift to ensure shift variation. Documentation will include date, time, shift, fire origin, exit route, staff participation, evacuation time, and identified issues. 2. Identification of Others at Risk: Fire drill records for the previous 12 months were reviewed on 2/19/26. Any identified gaps were corrected by scheduling additional drills. 3. Systemic Changes: A 12-month drill schedule is implemented to alternate day, evening, and night shifts. The Fire Safety Policy was reviewed on 3/4/26 to include varying times and complete documentation. A standardized drill form was implemented. 4. Monitoring: The General Manager and Plant Operations Supervisor will review fire drill documentation and review findings monthly during their regular scheduled meetings. Any missed variation will result in an immediate make-up drill. Date of Compliance: 3/29/26 (b) 1. How the Facility Corrected the Deficient Practice: All staff will complete Fire and Life Safety training on 03/19/2026. Training will include emergency procedures, evacuation procedures, and disaster response. Staff unable to attend will complete make-up training within 7 days. 2. Systemic Changes to Prevent Recurrence: Beginning 03/19/2026, Fire and Life Safety training will be provided every month during the Fire Drill. New hires will complete training during orientation prior to independent assignment. The General Manager will review the tracking tool already implemented through TELS to ensure ongoing compliance. 3. Monitoring: The General Manager will regularly review TELS where a tracking tools is already used to ensure compliance. Any lapse will result in immediate retraining and corrective review. Date of Compliance: 03/19/2026

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:

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 ensure residents were re-instructed on 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 at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drill and fire and life safety records from 08/2025 through 01/2026 were reviewed with Staff 4 (Plant Operations Supervisor) on 02/18/26 at 12:15 pm. During the review of the fire drill records, Staff 3 reported the facility does not have a written record for annual re-instruction of general fire safety procedures. The need to re-instruct residents on general fire safety procedures at least annually, per the OFC requirements, was discussed with Staff 1 (General Manager), Staff 2 (Health and Wellness Manager), and Staff 3(Health and Wellness Nurse) on 02/19/26 at 12:25 pm. They acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents 1. How the Facility Corrected the Deficient Practice: All current residents will receive Fire and Life Safety retraining on 03/11/2026. Training will include emergency procedures, evacuation routes, alarm response, and individual evacuation needs. 2. Systemic Changes to Prevent Recurrence: Beginning 03/11/2026, resident Fire and Life Safety retraining will be conducted annually in addition to the new resident training done at time of move in. The training schedule has been added to the community calendar. Completion will be documented in each resident record. 4. Monitoring: The General Manager will review resident training documentation semiannually to ensure compliance. Any missed training will be completed within 7 days of identification. Date of Compliance: 03/11/202

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 two resident-occupied floors. During an interview with Staff 4 (Plant Operations Supervisor) at 11:02 am on 02/18/26, 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. Staff 4 stated there was no documented evidence the facility conducted a drill of the plan at least twice a year. In an interview with Staff 1 (Administrator) on the same day at 1:18 pm, Staff 1 confirmed 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, Staff 2 (Health and Wellness Manager), and Staff 3 (Health and Wellness Nurse) on 02/19/26 at 12:25 pm. They acknowledged the findings, and no further information was provided.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning 1. How the Facility Corrected the Deficient Practice: Upon identification of the deficiency, the facility will conduct an emergency preparedness drill to ensure compliance with the requirement of at least two documented fire drills per year. Documentation will be completed to include all required elements (date, time, shift, simulated fire origin, exit route, staff participation, evacuation time, and identified issues). All residents are protected as the facility is currently conducting and documenting fire drills in accordance with requirements. 2. Identification of Residents at Risk All residents have the potential to be affected by this practice. Emergency Preparedness Drills will train staff and residents on how to react in case of an emergency. 3. Systemic Changes • 2 Emergency Preparedness Drills will be implemented to ensure a minimum of two drills per year. • A tracking log is already implemented through TELS. • The General Manager is responsible for ensuring drills are conducted and documented as scheduled. • Staff were re-educated on Emergency Preparedness Drills and documentation requirements on 3/19/26. 4. Monitoring The General Manager will review emergency preparedness drill compliance to ensure at least two drills are conducted and documented annually. Findings will be reviewed in Safety committee meetings. Any missed drill will result in immediate scheduling and completion. 5. Compliance Date The facility alleges compliance as of 3/29/26.

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:

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 furniture was clean and in good repair. Findings include, but are not limited to: The facility environment was toured on 02/17/26 at 9:20 am. Multiple chairs in the exercise room were found with tears in the vinyl on the seat platforms, exposing cloth fabric underneath and rendering the chairs uncleanable. The need to ensure facility furniture was kept clean and in good repair was discussed with Staff 1 (General Manager), Staff 2 (Health and Wellness Manager), and Staff 3 (Health and Wellness Nurse) on 02/19/26 at 12:25 pm. They acknowledged the findings.

OAR 411-054-0300 (4) (d-i) General Building: Doors-Walls, Cleanable 1. How the Facility Corrected the Deficient Practice: Replacement chairs have been ordered on 3/3/26. Upon arrival, damaged chairs will be removed from service and discarded. Expected delivery date: 3/12/26. 2. Systemic Changes to Prevent Recurrence: The General Manager and Plant Operations Manager will conduct monthly environmental safety inspections of common areas, including the exercise room, to identify worn or unsafe furnishings. Findings will be documented and corrected promptly. 4. Monitoring: The General Manager will review monthly inspection logs for 6 months to ensure ongoing compliance. Any identified hazards will be addressed immediately. Date of Compliance: 3/12/26

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: