OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and written, signed physician orders or other legally recognized practitioner orders were documented in the resident’s facility record for all medications and treatments that the facility was responsible to administer for 2 of 6 sampled residents (#s 2 and 4) who were administered medications and treatments. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 07/2011 with diagnoses including type 2 diabetes. The clinical record, dated 01/27/26 through 05/13/26, was reviewed and noted the following: The facility did not have signed prescriber orders documented in the resident’s record for the medications and treatments they were administering. On 05/19/26 at 2:15 pm, Staff 5 (Resident Service Coordinator) provided a copy of signed physician orders dated 05/19/26. The need to ensure the facility kept written, signed physician orders or other legally recognized practitioner orders in the resident’s facility record for all medications and treatments the facility was responsible for administering was reviewed with Staff 1 (ED) and Staff 4 (Resident Service Director) on 05/20/26 at 2:45 pm. They acknowledged the findings. 2. Resident 2 admitted to the facility in 12/2025 with diagnoses including pain, depression, and “excess fluid.” The resident’s MARs, dated 04/01/26 through 05/19/26, and physician’s orders were reviewed. The following was identified: a. On 03/18/26, Resident 2's physician signed an order for weekly weights. There was no documented evidence the weights were taken weekly between 03/18/26 and 04/21/26. b. On 04/08/26, the resident received signed orders to start Flonase (for allergies), loratadine (for allergies), and nystatin oral suspension (for thrush). There was no documented evidence the medications were transcribed onto Resident 1’s MAR or administered per physician's orders. c. The following medications were not available to staff for administration per documentation of waiting for the delivery: * Acetaminophen (for pain) - five times; and * Duloxetine (for depression) - 12 times. The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 4 (Resident Service Director), and Staff 5 (Resident Service Coordinator) on 05/20/26 at 1:42 pm. They acknowledged the findings.

1a. Resident 4 medications reviewed and orders requested for medication/treatments without physician-signed orders. 1b. Resident 2's weights were reviewed and assessed by the nurse to rule out nutrition risks. 1c. Resident 2 medication administration record reviewed and reconciled to ensure physician orders and medication records match. 1d. Resident 2 medications reviewed to ensure all medications are in-house 2. In-services completed on the following physician orders, and the medication ordering process will be completed by all medication technicians by 6/12/2026. Weights for the past six months reviewed and assessed on all residents will be completed by 6/6/2026. Audit performed on all resident MARS to ensure medications are in-house and medication administration records meet 3. The Nurse, Resident Care Coordinator, or designee will audit medication administration records a minimum of five days a week to ensure orders are followed, and medications are in-house. ED will review audits once a week for the next 60 days. The monthly audit of 20% of the census will be audited moving forward and addressed in Quality Assurance Meetings. 4. Nurse, RCC, and Designee will ensure audits are completed accordingly. The executive director will review audits monthly in quality assurance meetings with the clinical department.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. 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 kept accurate and included resident-specific parameters for PRN medications for 2 of 6 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2025 with diagnoses including nicotine dependence. The resident’s clinical record including the MAR, dated 05/01/26 through 05/18/26, and physician’s orders were reviewed. The following was identified: a. Resident 1's physician discontinued the PRN hydrocod/apap (for pain) on 04/17/26. The medication was still transcribed on the MAR. b. There were blanks with no explanation of why there was no documentation on the administration of a nicotine patch (for nicotine cessation) on 05/03/26 and 05/07/26. c. Resident 1 had three PRN medications prescribed for constipation. There were no resident-specific parameters to direct unlicensed staff on the sequential order to administer the medications. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 4 (Resident Service Director), and Staff 5 (Resident Service Coordinator) on 05/20/26 at 1:42 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 12/2025 with diagnoses including pain and depression. The resident’s MARs, dated 04/01/26 through 05/19/26, and physician’s orders were reviewed. The following was identified: a. There were duplicate entries transcribed on the MARs for the following medications: * Duloxetine (for depression); and * Diclofenac gel (for pain). On 04/26/26, two separate staff members initialed administering duloxetine to Resident 2 at 8:00 am. Staff could not verify if the medication was administered twice on that day or if the administration was incorrectly documented. b. There were multiple staff initials verifying that medications were administered in between dates where other staff documented that the medication had not been delivered by the pharmacy. c. Several dates were blank with no explanation relating to the following medication administration: * Acetaminophen (for pain) on 04/16/26 and 05/06/26 at 12:00 pm; and * Duloxetine on 04/03/26, 04/04/26, and 05/05/26 at 8:00 am. d. Resident 2 had two PRN medications prescribed for constipation. There were no resident specific parameters to direct unlicensed staff on the sequential order on when to administer the PRN medications. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (ED), Staff 4 (Resident Service Director), and Staff 5 (Resident Service Coordinator) on 05/20/26 at 1:42 pm. They acknowledged the findings.

1a. Resident 1’s discontinued prn has been removed from MAR. 1b. Resident 1’s mars removed and holes for past 30 days have been followed up on. 1c. Resident 1’s prns reviewed and assessed to ensure parameters in place. 1d. Resident 2’s mars reviewed and duplicate orders removed. 1e. Resident 2’s mars was reviewed for the past 30 days and missing documentation was assessed. Mars was updated. 2. In-service on medication administration documentation and parameters will be completed by 6/12/2026 with all medication technicians. Nurse, RCC, and Designee will complete a full audit on MARS to ensure PRN parameters are in place and duplicate orders have been removed from the record. 3. Nurse, RCC, and Designee will review orders a minimum of five times a week to ensure orders have been transcribed, have parameters if needed, and ensure duplicates are removed through triple check system. A monthly audit of 20% of the resident census will be audited moving forward and addressed in Quality Assurance. 4. Nurse, RCC, and Designees will ensure audits are completed accordingly. The executive director will review audits monthly in the quality assurance meeting with the nursing department.

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 411-054-0070 (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 ensure an adequate number of direct care staff on the overnight shift to meet the 24-hour scheduled and unscheduled needs of each resident and failed to meet the fire safety evacuation standards as required by the fire authority. Findings include, but are not limited to: The facility’s acuity-based staffing tool was reviewed on 05/20/26 at 9:50 am. The posted staffing plan indicated there were two direct care staff scheduled for each overnight shift. The acuity interview on 05/18/26 indicated multiple residents on the second through fourth floors required the assistance of one care staff for transfers and wheelchair mobility. 1. Staffing schedules showed the facility was without a MT from 2:00 am until 6:00 am on the morning of 05/06/26. On 05/19/26 at 9:50 am, Staff 1(ED) was unable to verify through timecard records that a MT was in the facility on 05/06/26 between 2:00 am and 6:00 am. Additionally, she stated staff were permitted to leave the facility for their unpaid breaks, which could take up to 30 minutes, during which time only one direct care staff was available to address the scheduled or unscheduled needs of the residents on night shift. The facility failed to meet the scheduled and unscheduled needs of each resident during that time. 2. At the time of the survey, 05/18/26 through 05/20/26, the facility was home to 77 residents. The facility consisted of four floors with three exit stairwells on either end and midway between. In an interview on 05/19/26 at 1:50 pm, Staff 8 (CG) stated there were between eight to ten residents on floors two through four who used a wheelchair for ambulation or who had mobility impairments that would necessitate use of an evacuation transfer sheet or stair chair to descend the stairs. The evacuation sheets required two staff, and the stair chair required one to two staff to operate, depending on the size of the resident. Interviews between 05/18/26 and 05/20/26 with direct care staff indicated not all staff were aware of the procedure for evacuating residents who used wheelchairs to ambulate or were unable to negotiate the stairs if there was a need to move them to a different floor of the building or outside. A stair chair or evacuation transfer sheet was available on all floors in Exit Routes Two and Three but Exit Route One only had a stair chair on the second floor and no evacuation devices on the third or fourth floors. Staff 12 (CG) stated she had worked at the facility for two years and had never relocated residents and had not been educated in how to use the stair chair or evacuation sheet to move residents down the stairs. On 05/20/26 at 9:50 am, Staff 1 (ED) reported there hadn’t been a full evacuation of the building to a designated point of safety outside of the building in the last two years. Staff 1 acknowledged the facility was not able to demonstrate that two care staff were enough to meet fire evacuation standards, since evacuation under these circumstances had never practiced. The need to ensure there were an adequate number of direct care staff on the overnight shift to meet the 24-hour scheduled and unscheduled needs of each resident and meet fire safety evacuation requirements was discussed with Staff 1 on 05/19/26 at 11:20 am. She acknowledged the findings.

1. ABST tool and service plan will be reviewed to ensure they reflect each other. Continuing to interview, hire, and train appropriate staff to meet staffing requirements for scheduled and unscheduled needs. 2. Community will continue to hire and train appropriate staff to meet the needs of our residents to meet the needs of the ABST with compliance by 7/31/2026. 3. ED or designee will review ABST and staffing to five days a week to ensure staffing is appropriate. 4. ED or designee will ensure audit and compliance weekly/monthly and as needed.

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 411-054-0090 (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). The findings include, but are not limited to: Fire drill records from 11/2025 to 04/2026 were reviewed and identified the following: 1. Fire drill records lacked one or more of the following required components: * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * The evacuation time period needed; * The number of occupants evacuated; * Alternate exit routes used during fire drills to react to varying potential fire origin points; and * Staff failed to provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. 2. Because the facility failed to document problems encountered with residents who failed to participate in the fire drills and to provide fire evacuation assistance from the building, the facility was unable to verify the ability to meet the applicable evacuation level or document what immediate changes were made to ensure the evacuation standard was met. The need to ensure the facility conducted and documented fire drills in accordance with the OFC was discussed with Staff 1 (ED) on 05/19/26 at 10:12 am. She acknowledged the findings.

1. Fire Drills with required documentation will be performed monthly on alternate shifts. 2. ED/MD reviewed Oregon Fire Codes for drills. 3. ED and a designee will review monthly drills to ensure documentation includes escape routes used, problems encountered, evacuation time periods, and the number of occupants evacuated recorded. 4. ED/MD will ensure that monthly drills meet the required documentation.

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 a written record of residents’ fire and life safety instructions and procedures within 24 hours of admission was kept and residents were 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. The findings include, but are not limited to: Fire and Life Safety records were reviewed on 05/18/26 at 10:53 am and the following was identified: Resident 5 moved into the assisted living in 02/2026. The resident received a handbook upon moving in that included some fire and life safety instruction. However, the handbook lacked instructions for evacuation methods and designated meeting places inside or outside of the building. During an interview on 05/19/26 at 10:20 am, Staff 1 (ED) reported “I will say, I'm aware of this and know we need to do better with this. I know we discuss it quarterly, but we don't do a good job with documenting what we discussed.” The need to ensure a written record of residents’ fire and life safety instructions and procedures within 24 hours of admission was kept and residents were re-instructed, at least annually, was discussed with Staff 1 on 05/19/26 at 10:53 am.

1. Resident 5 has been educated on evacuation routes, and the service plan has been updated. 2. ED or designee will ensure all current residents have received fire and life safety instructions, and service plans reflect this. ED or designee will ensure new residents receive instructions on life and safety fire training within 24 hours of admission. 3. ED or designee will audit 20% of the census monthly to and review in the Quality assurance meeting. 4. ED, MD, and/or designee will ensure audits are completed accordingly.

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: