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 accurate for 4 of 6 sampled residents (#s 2, 5, 6, and 7) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 08/2025 with diagnoses including dementia with agitation. The resident’s 05/01/26 through 06/01/26 MARs and current physician orders were reviewed, and the following was identified: * Four of six standing bowel care orders were not listed on the resident’s MAR; and * On 05/22/26, 05/23/25, and 05/29/26 the evening shift MT noted the resident’s quetiapine (for dementia with severe agitation) was “not available,” although the resident was administered the medication on the morning shift each day of the month and on the evening shift on 05/24/26 through 05/28/26. In an interview on 06/03/26 at 9:23 am, Staff 10 (MT) stated she was unsure why the medication would be unavailable on those dates. Staff 4 (LPN), on 06/03/26 at 9:38 am, indicated she would have expected the MT to speak with day shift MTs about the medication that was unavailable or to re-order it from the pharmacy. The need to ensure the MAR was accurate was discussed with Staff 1 (Administrator) on 06/03/26 at 12:00 pm. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2025 with diagnoses including bed confinement status and Alzheimer’s disease. Resident 2's MARs from 05/01/26 through 06/01/26 and physician orders were reviewed. a. The following PRN medications lacked instructions for sequential order of use: * Morphine 20mg/ml (for pain, difficulty breathing); and * Lorazepam 0.5mg (for anxiety, difficulty breathing, or end of life); b. The following PRN medications lacked resident-specific parameters for use: * Lorazepam 0.5mg (for anxiety, difficulty breathing, or end of life); * Haloperidol actate 2mg/ml (for hallucinations, agitation, nausea, vomiting); and * Risperidone 0.25mg (for behavioral disorders associated with dementia). The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator) and Staff 2 (Director of Nursing/RN) on 06/03/26 at 1:22 pm. They acknowledged the findings. 3. Resident 7 was admitted to the facility in 05/2025 with diagnoses including acute kidney failure, pancreatitis, and diabetes mellitus Type II. The resident’s 05/01/26 through 06/01/26 MARs and current physician orders were reviewed, and the following was identified: The following PRN medications lacked clear instructions for sequential order of use: · Milk of magnesia (for constipation); · Dulcolax suppository 10 mg bisacodyl (for constipation); · Polyethylene glycol 3350 Oral Packet (for constipation); · Polyethylene glycol 3350 powder bulk (for constipation); · Imodium AD tablet 2 mg give 2 tablets (for diarrhea); and · Imodium AD tablet 2mg give 1 tablet (for diarrhea). b. The following PRN medications lacked reason for use and resident-specific parameters: • Lactulose Oral Solution 10/15ml give 30 ml (synthetic sugar). The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 2 (Director of Nursing/RN) on 06/02/23 at 4:15 pm, and with Staff 1 (Administrator) on 06/03/26 at 12:30 pm. They acknowledged the findings. 4. Resident 6 moved into the facility in 09/2025 with diagnoses including diabetes mellitus. The resident’s MAR dated 05/01/26 to 05/30/26, and physician’s orders dated 04/09/26, were reviewed, and the following was noted: *Orders for clobetasol propionate external liquid 0.05% (a topical steroid used to treat severe skin conditions) as needed, lacked a reason for use. *Orders to place mineral oil in the ears for three days if wax required softening before irrigation lacked instructions on the dosage to be used. In an interview on 06/02/26 at 11:10 am with Staff 8 (RCC), she confirmed the electronic MAR system lacked a reason for use and dosage for the PRN medications. The need to ensure residents' MARs were accurate and included resident-specific instructions for administration of PRN medications was discussed on 06/03/26 at approximately 12:45 pm with Staff 1(Administrator) and Staff 2 (Director of Nursing/RN). They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? The Director of Nursing will complete a 100% audit of all current bowel care orders and PRN medication orders to ensure orders are accurate and complete. The audit will verify that duplicate orders are discontinued, standing bowel care orders are reinstated after SNF stays when applicable, and all PRN orders include a clear reason for use, dose, frequency, sequence of use when applicable, and resident-specific administration parameters. Prescribing practitioners will be contacted immediately for clarification of incomplete orders. Medication records will be updated after clarified orders are received. Medication Technicians will receive education regarding when medication refills must be requested and the required process when medications are not received or when prescribers/pharmacies do not respond to refill requests. 2. How will the system be corrected so this violation will not happen again? The facility will revise the medication order review process to require nursing review of all new and revised PRN medication orders prior to activation on the MAR. PRN medication orders must include clinical indication, resident-specific parameters, dose, frequency, and sequence of use when more than one PRN medication is available for the same condition. The facility will also revise the medication refill process to require Medication Technicians to mark medication cards seven days before the medication is expected to run out and document the refill request date. Any medication not received three days before running out will be escalated to the charge nurse, Resident Care Manager, or Director of Nursing for urgent follow-up with the pharmacy or prescribing practitioner. 3. How often will the area needing correction be evaluated? The Director of Nursing or designee will audit 100% of new PRN medication orders weekly and complete weekly medication cart audits to verify medications are reordered, received, and available for administration. Audits will continue weekly for eight weeks, then monthly through the QAPI process. Any deficiencies identified will be corrected immediately, with additional staff coaching or education provided as needed. 4. Who will be responsible to see that the corrections are completed/monitored? Director of Nursing or designee.

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 411-054-0090 (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 instructed on fire and life safety procedures within 24 hours of admission for 1 of 1 sampled resident (#1), and to ensure all residents were re-instructed at least annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed on 06/02/26 and 06/03/25, and the following was identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission for Resident (#1); and * There was no documented evidence of fire and life safety training provided to residents at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 (Administrator) on 06/03/26 at 9:30 am. She reported there had been no resident instruction on fire and life safety within 24 hours of admission or annually.

All current residents will have documented fire and life safety education regarding emergency procedures, evacuation routes, designated meeting locations, and staff responsibilities during an emergency. Resident records will be reviewed to ensure documentation of resident fire safety education is complete. Any missing documentation will be completed immediately. 2. How will the system be corrected so this violation will not happen again? Fire and life safety education will incorporated into the admission process and annual resident review. A standardized documentation form will be implemented to ensure completion and verification of resident education. The admission checklist will require completion of resident fire safety education before the admission process is finalized. 3. How often will the area needing correction be evaluated? Weekly for eight weeks, then monthly through the Quality Assurance Performance Improvement (QAPI) program. 4. Who will be responsible? Administrator or designee.

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:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide individual privacy in their own unit for multiple unsampled residents. Findings include, but are not limited to: During the survey of 06/01/26 through 06/03/26, units 60, 62, 69, and 70 on the Garden View MCC were observed to have two residents sharing each unit and bathroom. The bathrooms had a curtain instead of a door and did not have a way to lock for privacy. In a tour with Staff 1 (Administrator) on 06/03/26 at 10:00 am, it was confirmed the shared units did not have a lockable bathroom door. Staff 1 acknowledged the inability to lock bathroom doors in a shared unit with two residents limited their privacy. The need to ensure residents were provided with individual privacy in their own unit was discussed with Staff 1 on 06/03/26 at 12:30 pm. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Upon identification of the deficiency, lockable bathroom door hardware was installed on the two occupied shared resident bathrooms in the Gardenview Memory Care neighborhood. Installation of lockable door hardware for the remaining two shared resident bathrooms has been scheduled and will be completed prior to the facility's alleged compliance date. All shared resident bathrooms will provide residents with the ability to secure privacy while using the bathroom. 2. How will the system be corrected so this violation will not happen again? The facility has revised its environmental compliance rounds to include verification that resident bathroom doors in shared accommodations meet Oregon regulatory requirements for privacy. Facility leadership will review all future renovation and maintenance projects to ensure resident privacy requirements are maintained and any deficiencies are corrected promptly. 3. How often will the area needing correction be evaluated? The Administrator or designee will verify completion of the remaining door installations and will include resident privacy features as part of the monthly environmental and life safety rounds. Findings will be reviewed through the facility's Quality Assurance Performance Improvement (QAPI) program. 4. Who will be responsible to see that the corrections are completed/monitored? Administrator and Facilities Director (or designee).

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include but are not limited to: Refer to C422.

See C422 All current residents will have documented fire and life safety education regarding emergency procedures, evacuation routes, designated meeting locations, and staff responsibilities during an emergency. Resident records will be reviewed to ensure documentation of resident fire safety education is complete. Any missing documentation will be completed immediately. 2. How will the system be corrected so this violation will not happen again? Fire and life safety education will incorporated into the admission process and annual resident review. A standardized documentation form will be implemented to ensure completion and verification of resident education. The admission checklist will require completion of resident fire safety education before the admission process is finalized. 3. How often will the area needing correction be evaluated? Weekly for eight weeks, then monthly through the Quality Assurance Performance Improvement (QAPI) program. 4. Who will be responsible? Administrator or designee.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all non-direct care staff completed pre-service dementia training for 1 of 1 staff (#15) whose pre-service training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 06/02/26, and the following was identified: Staff 15 (Wait Staff) was hired on 03/09/26. There was no documented evidence Staff 15 completed pre-service dementia training. On 06/02/26 at approximately 2:00 pm, Staff 1 (Administrator) indicated that non-direct care staff were not required to complete pre-service dementia training. On 06/03/26 at 12:00 pm, the need for all non-direct care staff to complete the required pre-service dementia training because the MCC and the RCF were under the same license was discussed with Staff 1. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Upon identification of the deficiency, Human Resources conducted a comprehensive audit of all Memory Care and healthcare staff training records. The audit confirmed that applicable staff had completed or were in compliance with the required dementia education; however, the required preservice dementia course had not been assigned to all staff as required. Human Resources immediately assigned the preservice dementia course to all applicable staff and verified that all required dementia training assignments were complete and documented. 2. How will the system be corrected so this violation will not happen again? The facility revised its onboarding and training assignment process to ensure all staff required to receive dementia training are assigned the preservice dementia course at hire and prior to working independently with Memory Care residents. Human Resources will utilize a standardized onboarding checklist and monthly training report to verify all required dementia education has been assigned and completed within regulatory timeframes. Any discrepancies identified will be corrected immediately. 3. How often will the area needing correction be evaluated? Human Resources will audit dementia training assignments monthly for six months and report findings to the Administrator and Director of Nursing through the Quality Assurance Performance Improvement (QAPI) program. Corrective action will be implemented immediately if any missing assignments are identified. 4. Who will be responsible to see that the corrections are completed/monitored? Human Resources Director, in collaboration with the Director of Nursing.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include but are not limited to: Refer to C310.

See C310 1. What actions will be taken to correct the rule violation for each example/resident? The Director of Nursing will complete a 100% audit of all current bowel care orders and PRN medication orders to ensure orders are accurate and complete. The audit will verify that duplicate orders are discontinued, standing bowel care orders are reinstated after SNF stays when applicable, and all PRN orders include a clear reason for use, dose, frequency, sequence of use when applicable, and resident-specific administration parameters. Prescribing practitioners will be contacted immediately for clarification of incomplete orders. Medication records will be updated after clarified orders are received. Medication Technicians will receive education regarding when medication refills must be requested and the required process when medications are not received or when prescribers/pharmacies do not respond to refill requests. 2. How will the system be corrected so this violation will not happen again? The facility will revise the medication order review process to require nursing review of all new and revised PRN medication orders prior to activation on the MAR. PRN medication orders must include clinical indication, resident-specific parameters, dose, frequency, and sequence of use when more than one PRN medication is available for the same condition. The facility will also revise the medication refill process to require Medication Technicians to mark medication cards seven days before the medication is expected to run out and document the refill request date. Any medication not received three days before running out will be escalated to the charge nurse, Resident Care Manager, or Director of Nursing for urgent follow-up with the pharmacy or prescribing practitioner. 3. How often will the area needing correction be evaluated? The Director of Nursing or designee will audit 100% of new PRN medication orders weekly and complete weekly medication cart audits to verify medications are reordered, received, and available for administration. Audits will continue weekly for eight weeks, then monthly through the QAPI process. Any deficiencies identified will be corrected immediately, with additional staff coaching or education provided as needed. 4. Who will be responsible to see that the corrections are completed/monitored? Director of Nursing or designee.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: