OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to: On 05/18/26 at 1:50 pm, Staff 2 (Operations Specialist) informed the surveyor the facility did not have a calendar of scheduled activities for the month of May 2026 as had been requested by the survey team. During the survey from 05/18/26 through 05/20/26, no activities were observed to be offered to residents between 8:30 am and 4:00 pm. The need to ensure the facility provided a daily program of social and recreational activities for the residents was reviewed with Staff 1 (ED) on 05/20/26 at 3:20 pm. She confirmed the facility did not currently have an activities staff, and acknowledged the facility had to develop and implement a daily schedule of activities for the residents.

-Ensure Activity Calendar for Community is posted and provided to residents. -Identify and train team member to oversee activities until new Activity Director is hired. -Re-educate executive Director on the requirement for activites even during times employee turnover. -Exectutive Director to conduct random audits via interview or oberservation for compliance weekly x 3 weeks then monthly x 2 months. -Executive is responsible.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

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 written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 3 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 05/2018 with diagnoses including osteoarthritis, chronic pain, artificial knee joint and hip joints, and anxiety disorder. Review of the resident’s physician orders and 05/01/26 through 05/18/26 MAR indicated the facility did not have written, signed physician orders in the resident’s facility record for the following medications that were administered by the facility: * Hydrocodone-acetaminophen 5-325 mg tablet; 1 tablet every 4-6 hours as needed for pain; * Senna 8.6 mg tablet; 1 tablet BID for constipation; * Acetaminophen (Tylenol) 500 mg, 2 tablets TID for pain; * Morphine sulfate 20 mg/ml solution, 0.25 ml QID for pain; * Morphine sulfate 20 mg/ml solution, 0.25 ml every hour as needed for pain; * Haloperidol 2 mg/ml concentrate, 0.25 ml TID for end of life; and * Haloperidol 2 mg/ml concentrate, 1 ml every 4 hours as needed for anxiety, agitation, hallucinations, insomnia or nausea. The lack of orders was discussed with Staff 4 (Health Services Director/LPN) on 05/18/26 at 12:30 pm. She acknowledged the lack of orders and obtained copies of the orders from the pharmacy later that day. The need to ensure written, signed physician 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 was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Vice President of Clinical Services) and Staff 4 on 05/20/26 at 2:00 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 04/2026 with diagnoses of congestive heart failure and type 2 diabetic peripheral angiopathy with foot ulcers. Review of Resident 2’s 05/01/26 through 05/18/26 MAR and current physician's orders, dated 04/02/26, identified the following medications that lacked written, signed physician’s orders in the resident’s record: *Discontinuation of torsemide 20 mg one tablet by mouth twice daily for congestive heart failure; *Discontinuation of tizanidine one tablet by mouth twice daily as needed for muscle spasms; and *Acetaminophen 500 mg two capsules by mouth three times daily for pain. In an interview on 05/20/26 at approximately 10:00 am, Staff 4 (Health Services Director/LPN) stated she had to contact the pharmacy to have the orders for the aforementioned medications faxed over because they were not in the resident’s record. The need to ensure the facility had written, signed physician orders documented in the resident record for medications being administered to residents was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Vice President of Clinical Services) and Staff 4 on 05/20/26 at approximately 2:30 pm. They acknowledged the findings.

- Signed Physician orders were obtained and placed in resdients record for resident #1 and #2 -HSD audited current residents records for current signed physician orders, addressing concerns identified. -VP of Clinical Services or Designee re-educated HSD on requirement to maintain signed physician oreders in the resident record. -HSD or designee will conduct random audits for signed physician order compliance weekly x 3 weeks then monthly x 2 months. HSD is responisble.

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 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medications that were administered PRN that were given to treat a resident's behavior had written, resident-specific parameters, for 1 of 1 sampled resident (#1) who was prescribed and administered PRN psychotropic medications. Findings include, but are not limited to: Resident 1 moved into the facility in 05/2018 with diagnoses including osteoarthritis, chronic pain, unspecified dementia – severe with mood disturbance and anxiety disorder. Review of the resident’s physician orders and 05/01/26 through 05/18/26 MAR indicated Resident 1 was prescribed and had been administered the following PRN psychotropic medications: * Haloperidol 2 mg/ml concentrate, 1 ml every 4 hours as needed for anxiety, agitation, hallucinations, insomnia or nausea; and * Lorazepam 0.5 mg tablet, 1 tablet every 4 hours as needed for anxiety. On 05/20/26 at 10:50 am, Staff 4 (Health Services Director/LPN) and the surveyor reviewed documentation in the MAR as to why the medications were administered to Resident 1. The MAR indicated staff failed to consistently document the circumstances for which the medication was administered. When staff did document behavior that prompted the administration of either of the medications, it was always due to the resident pushing his/her call light repeatedly and seemingly not wanting to be alone in his/her room. However, the MAR indicated staff administered the haloperidol and lorazepam at different times for the same behavior. Staff 4 stated the lorazepam should be given for symptoms of anxiety and the haloperidol should be given for symptoms of agitation and insomnia. She acknowledged the MAR did not describe specifically how Resident 1 exhibited “anxiety” and “agitation.” The need to ensure that PRN psychotropic medications had written, resident-specific parameters that provided guidance for unlicensed staff as to which medication to administer, was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Vice President of Clinical Services) and Staff 4 on 05/20/26 at 2:00 pm. They acknowledged the findings.

-Resident specific parameters were written for Resident #1 PRN Medications -HSD audited current residents receiving PRN Psychotropic medication, adressing concerns identified. -VP of Clinical Services or Designee re-educated HSD and Med-Techs on requirement that PRN psychotropic medicatyion have resident specific parameters. -VP of Clinical Services or Designee re-educated HSD, RN and ED on SMART meeting specifically new orders for PRN psycotropic medications. -HSD or designee will conduct random audits on PRN psychotropic medications for compliance weekly x 3 weeks then monthly x 2 months. -ED is responisble

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. 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 observation, interview, and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated following a significant change of condition for 1 of 2 sampled residents (#3) who experienced a significant change of condition, and failed to use the results of the ABST to develop and routinely update the facility's posted staffing plan. Findings include, but are not limited to: a. Resident 3’s individual ABST evaluation noted it was last reviewed and updated on 04/03/26. The resident experienced a significant change of condition on 05/03/26. There was no documented evidence the ABST was updated at the time of the significant change of condition, as required. b. On 05/18/26 at 9:32 am, when survey entered the facility, the posted staffing plan titled “Direct Care Staffing Hours” was observed at the reception desk and indicated: * Day Shift: “24”. On 05/18/26, the ABST indicated the following staffing levels were required based on the data entered into the tool: * Day shift – 26.57 hours, or 3.321 direct-care staff. On 05/19/26 at 1:45 pm, Staff 1 (ED) confirmed the facility hours noted on the staffing plan indicated they staffed two Care Partners and one MT on day shift. The facility failed to use the results of the ABST to develop and maintain the posted staffing plan for day shift. The staffing plan only provided 24 hours of direct care time when the ABST indicated 26.47 hours were required. On 05/20/26 at 12:33 pm, the above information, including the posted staffing plan and the staffing level discrepancies between the posted staffing plan and the ABST-generated staffing level when survey entered, was reviewed with Staff 1, Staff 2 (Operations Specialist) and Staff 3 (Vice President of Clinical Services). Staff 3 acknowledged the discrepancies between the posted staffing plan and the ABST-generated staffing levels. The need to ensure residents’ ABST evaluations were reviewed and updated with significant changes of condition, and the results of the ABST were used to develop and routinely update the facility’s posted staffing plan was reviewed with Staff 1, Staff 2, Staff 3 and Staff 4 (Health Services Director/LPN) on 05/20/26 at 3:00 pm. They acknowledged the findings.

-ABST & posted staffing plan was updated to reflect Resident 3 accurately. -HSD or designee reviewed current residents recent significant change of conditions as compared to ABST tool, adressing concers identified. -VP os clinical services or designee re-educated ED and HSD on requirement to update ABST with significant changes of condition and the results of the ABST are used to develop and routinely update the posted staffing plan. -The HSD or ED will do Audits on the ABST tool and posted staffing plan for compliance weekly x 3 weeks then x 2 months. -ED is responsible

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 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly hired direct care staff (#s 10 and 11) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/19/26 at 1:10 pm with Staff 2 (Operations Specialist) and revealed the following: Staff 10 (CG) and Staff 11 (CG), hired 04/08/26 and 04/21/26, respectively, lacked demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; * Conditions which require assessment, treatment, observation, and reporting; * General food safety, serving and sanitation, and * First aid and abdominal thrust training. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2, Staff 3 (Vice President of Clinical Services) and Staff 4 (Health Services Director) on 05/20/26 at 3:00 pm. They acknowledged the findings.

- Staff #10 and Staff #11 completed their within 30 days of hire training required for direct care staff. -ED or designee reviewed trainings required w/in 30 days of hire training for current staff, adressing concerns identified. -Operations specialist re-educated Ed and HSD on the required training direct care staff must complete w/in the first 30 days of hire; training included tracking system education. -ED will conduct random audits for compliance on training required for drect care staff within 30 days of hire weekly x 3 weeks then monthly x 2 months. ED is responisble.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. 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 and life safety instruction was provided to staff on alternating months from fire drills and written fire drill records included all required elements. Findings include, but are not limited to: Six months of fire drill records were requested on 05/18/26 at 9:15 am. In an interview on 05/20/26 at 11:30 am, Staff 2 (Operations Specialist) stated she was unable to locate any documentation regarding fire drills and only located one staff training document from 01/16/26. In an interview on 05/20/26 at 9:45 am, Staff 5 (Maintenance Assistant) stated he had not conducted any fire drills or staff training since he began his employment in January 2026. There was no documented evidence unannounced fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts and that fire and life safety instruction was provided to staff on alternate months of fire drills. The need to ensure that unannounced fire drills were conducted and recorded every other month at different times of the day, evening and night shifts and staff were instructed in fire and life safety procedures on alternating months from fire drills was reviewed with Staff 5 on 05/20/26 at 9:45 am and Staff 1 (ED), Staff 2, Staff 3 (Vice President of Clinical Services) and Staff 4 (Health Services Director/LPN) on 05/20/26 at approximately 2:30 pm. They acknowledged the findings.

- Fire Drill (s) and Fire Safety instruction was provided to the staff on 5/27/2026. - ED or designee trained Maintenance Director on the requirement to ensure fire and life safetly instruction is provided to the staff on alternating month from fire drills and written fire drill records included all required elements. Seasoned Maintenance Director from another community did training with community maintenance director for scheduling requirements and record keeping. - ED will monitor compliance with the Prestige established fire and life safety program through monthly reviews of drill documentation and Safety Committee records for a period of six months. Fire drills will continue to be conducted monthly on a rotating schedule across day, swing, and noc shifts to ensure each shift participates in four drills annually, including two full evacuation drills. Monthly audits will verify that drills are completed as scheduled, and a variety of fire and life safety topics are reviewed through the Safety Committee process. -ED is responsible for ensuring ongoing compliance with these requirements.

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 that residents were instructed about the facility’s fire and life safety procedures per the Oregon Fire Code (OFC) within 24 hours of admission and at least annually. Findings include, but are not limited to: On 05/19/26, the surveyor requested documented evidence fire and life safety training for residents was completed 24 hours after move-in for Resident 2, and additional evidence or re-instruction annually for Resident 1. In an interview on 05/20/26 at 10:15 am, Staff 2 (Operations Specialist) stated she was unable to locate any documentation regarding the residents’ initial or annual fire and life safety procedure instruction. The need to ensure the facility provided instruction to residents about the facility’s fire and life safety procedures per OFC within 24 hours of admission and at least annually was reviewed with Staff 1 (ED), Staff 2, Staff 3 (Vice President of Clinical Services) and Staff 4 (Health Services Director/LPN) on 05/20/26 at approximately 2:30 pm. They acknowledged the findings.

- Existing Residents were provided instruction about facility's fire and life safety procedures. - ED has been re-educated on the resident orientation requirements and the use of the community move-in checklist. Moving forward, new residents will receive the required orientation within 24 hours of admission, with completion documented on the move-in checklist. New admissions will be reviewed during the community's Monday through Friday Stand-Up meetings to ensure orientation requirements have been completed timely. In addition, annual resident instruction will be completed and documented for all residents during the annual assessment process. - ED To ensure both new admission and annual resident instruction requirements are met, the Executive Director will review move-in orientation documentation during daily Stand-Up meetings for all new admissions and will verify completion of annual resident instruction during the annual assessment review process. Compliance will be monitored monthly for six months to ensure both admission and annual instruction requirements are consistently completed and documented. - ED is responsible for overseeing and ensuring compliance with both the admission and annual instruction requirements.

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: