OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to develop and implement an effective method for responding to and resolving resident complaints. Findings include, but are not limited to: Upon survey entry on 06/01/26, resident council and food committee notes for the past three months were requested. The resident council notes from meetings dated 02/02/26, 03/04/26, and 04/06/26, included multiple resident concerns/complaints including but not limited to: * Missing clothes; * Housekeeping concerns; * Request for new dining tables/chairs; * Activities suggestions: * Food suggestions and concerns related to temperature and how items are prepared; and * Desire for increased reception hours. There was no documented evidence the facility followed up on, responded to, or resolved concerns brought forward by residents. An interview with Resident 2 took place on 06/02/26 at 1:00 pm and it was discussed how the facility responded to resident concerns and complaints. Resident 2 regularly attended monthly resident council meetings where concerns were brought forward. Resident 2 stated facility management did not provide follow-up or responses to concerns discussed. On 06/03/26 at 11:30 pm, Resident 3 was interviewed regarding how the facility addressed resident concerns. Resident 3 stated residents brought questions, concerns, and complaints forward during resident council meetings. Resident 3 stated facility management did not provide follow-up or responses to residents regarding the concerns discussed during the meetings. An interview with Staff 4 (Office Manager) on 06/03/26 at 1:40 pm revealed facility management would discuss resident council notes the morning following the resident council meeting. Staff 4 stated she would go “table to table” and have conversations with residents following their meeting. Staff 4 confirmed no documented evidence was available to confirm resolution of the resident concerns/complaints. The need to implement effective methods of responding to and resolving resident complaints was discussed with Staff 1 (Director of Operations) and Staff 2 (Regional Support RN) on 06/03/26 at 3:20 pm. They acknowledged the findings.

- Concerns / complaints from resident council meeting notes on 2/2/26, 3/4/26 and 4/6/26 and 6/1/26, have been reviewed. - Resident Council Meeting being held July 6th will follow up from concerns/complaints in prior meetings and provide residents with opportunity to discuss resolution as well as share any new/current concerns. - The grievance process will be reviewed with residents. - ED or Designee and Activity Director were re-educated on the grievance process. - The grievance process was reviewed during all staff meeting. - ED or Designee will conduct random audits via documentation review or resident interview on grievance process effectiveness weekly x 3 weeks then monthly x 2 months. - ED is responsible

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 and recorded according to Oregon Fire Code (OFC), and that fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: During the relicensure survey, 06/01/26 through 06/03/26, the survey team identified the following concerns: Review of the facility’s fire drills from 12/01/2025 to 06/01/26 revealed the following: * Fire drills were not conducted on alternating months with fire life safety training; and * Drills were not conducted on alternating shifts to include all three shifts. In an interview on 06/02/24 at 2:24 pm, Staff 5 (Maintenance) confirmed that neither fire drills nor fire life safety training for staff had been conducted on alternate months. The need to ensure the facility conducted and recorded fire drills according to the Oregon Fire Code and provided fire and life safety training to staff on alternating months from fire drills was discussed with Staff 1 (Director of Operations) and Staff 2 (Regional Support (RN) on 06/03/26 at 3:20 pm. They acknowledged the findings.

- Fire Drill(s) and Fire and Life safety Instruction was provided to staff on 6/25/26 - ED or Designee trained Maintenance Director on the requirement to ensure fire and life safety instruction is provided to staff on alternating month from fire drills and written fire drill records include all required elements. ED or Designee will audit fire and life safety instruction & fire drills for compliance monthly x 6 months and continue to monitor utilizing all staff to provide FLS education. ED is responsible

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 in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 5 (Maintenance) on 06/02/26 at 2:24 pm. There was no documented evidence that residents were provided fire training within 24 hours of admission and again at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. The need to ensure residents were provided fire training within 24 hours of admission and again at least annually related to general fire and life safety procedures was discussed with Staff 1 (Director of Operations) and Staff 2 (Regional Support RN) on 06/03/26 at 3:20 pm. They acknowledged the findings.

- Existing Residents were provided instruction about facility’s fire and life safety procedures. - Operations Specialist re-educated Maintenance Director on the requirement to provide instruction to residents within 24 hours of move in and at least annually thereafter. - Ed or Designee will audit new admissions for fire life safety procedure education compliance daily during Stand-Up meetings to ensure orientation requirements are completed in a timely manner. - ED is responsible.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain all interior surfaces in good repair. Findings include, but are not limited to: During the environmental tour on 06/01/26 at 2:30 pm, resident dining room furniture was observed in disrepair. Multiple resident dining tables had damaged edges, including chipping and peeling around the perimeter of the tabletops and corners. Resident dining chairs had flattened cushioning, chipped and splintered chair legs, and worn armrests. On 06/03/26 at 5:00 pm, the areas in need of repair were reviewed with Staff 1 (Director of Operations) and Staff 2 (Regional Support RN). They acknowledged the findings.

- Dining Room Tables were reviewed for damaged edges, chipping, peeling around the perimeter and corners - areas identified were repaired by Maintenance Director through sanding and staining. - Dining Chairs were reviewed for flattened cushioning, chipped and splintered chair legs - areas identified were repaired by Maintenance Director through upholstery work, sanding and staining. - ED or Designee re-educated Maintenance Director on the importance of keeping Dining room furniture in good repair. - ED or Designee will conduct random audits on dining room furniture surfaces weekly x 3 weeks then monthly x 2 months - ED is responsible.