OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location to residents and visitors and available for inspection. Findings include, but are not limited to: A tour of the facility, conducted on 06/08/26 at 12:42 pm, identified the facility failed to post in a conspicuous location the following required postings: * Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections; and * Ombudsman poster. The need to ensure all required postings were displayed in an accessible and conspicuous location for the public was discussed with Staff 1 (ED) and Staff 8 (Maintenance) on 06/09/26 at 10:27 am, and Staff 1, Staff 2 (Regional Operations Officer) and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. All required postings have been properly displayed in the community and visable for all residents and visitors. Required postings such as: Ombudsman and LGBTQIA2S+. 2. In-service has been done for all department heads to be aware and mindful of the condition and presence of required postings througout the community. 3. This will be an ongoing routine added to our daily and weekly QA audits to ensure we are consistent and in compliance. Daily community walk-thrus will include specific checks on all required postings. 4. All department heads including but not limited to the Executive Director, Assistant Executive Director and the Maintenance Director will be responsible for maintaining the integrity of all required postings. The Executive Director and/or Assistant Executive Director will be responsible for making sure the required postings are quickly updated in a timely manner as further updates may develop.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs and provided clear direction to staff for 2 of 5 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2025 with diagnoses of chronic kidney disease and an unspecified fracture of the upper end of right humerus. Observations were made of the resident's care on 06/08/26 and 06/09/26, interviews with the resident and facility staff were conducted, and the 02/01/26 service plan was reviewed. Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions regarding the resident’s speech impairment; * Instructions from home health provider for wound care; * Use of TED hose (compression socks for edema); * Instructions for bathing; * Preferred meal service; * Bladder continence status; and * PRN medication orders. In interviews on 06/08/26 at 12:15 pm and 06/09/26 at 11:20 am, Resident 2 stated that s/he did not wear TED hose, required assistance to bathe all areas except his/her face, ate lunch and dinner in his/her room, was not incontinent of bladder and had a home health nurse who treated his/her wounds, all of which were not reflected as such on the resident’s service plan. In interviews on 06/08/26 at 12:15 pm and 06/09/26 at 11:20 am, Resident 2 showed evidence of speech impairment that was not identified on the service plan. Interviews with Staff 16 (CG) and Staff 19 (CG) on 06/09/26 at 9:12 am and 06/10/26 at 2:30 pm respectively, confirmed that the resident could sometimes be difficult to understand and had to be asked to repeat him/herself for clarification. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 06/10/26 at 4:20 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 04/2024 with diagnoses including rib fracture. The resident was subsequently admitted to hospice on 10/26/25 with an admitting diagnosis of multiple sclerosis. Observations were made of the resident's care on 06/09/26 and 06/10/26. Interviews with the resident and facility staff were conducted, and the 03/23/26 service plan was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions for behaviors related to verbal and physical aggression towards residents and staff; * Behavioral problems and effective non-drug interventions; * Number of staff needed to assist with activities of daily living; * Hearing status and instructions to staff for providing care to the resident with significant hearing impairment; * Physician Orders for Life Sustaining Treatment status; * Instructions for what types of skin impairments to report and to whom; * Instructions for perineal and skin care; * Transfers; * How Resident 4 expressed memory loss; and * Incorrect reference to information that the resident was able to utilize the call system independently. Staff 11 (MT/CG) was interviewed on 06/09/26 at 11:33 am and stated “when [Resident 4] gets into aggravated mood, we always have to use two people [to provide care] for safety. [S/he] yells but can also swing.” The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. Resident #2 & #4- service plans have been updated to include missing items noted on the survey document. Remaining resident service plans will be reviewed to assure accuracy for individualized information and current care/service needs. 2. Service plans will be reviewed for accuracy initially, 30 days post move in, quarterly and with a change ofn condition. Routine review of resident care related documentation will be conducted and updates made accordingly to the service plan in between formal reviews/updates. 3. Service plans are reviewed for accuracy 30 days post move in, quarterly and with a significant change of condition. Routine audits of the resident care documentation is daily. 4. The Health and Wellness Director, Assisted Living Director, and Executive Director will be responsible for maintaining compliance with service plan accuracy.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to determine, document and communicate to staff what action or intervention was needed for a resident following a change of condition with weekly progress noted until the condition resolved, for 2 of 4 sampled residents (#s 1 and 5) with documented changes of condition related to wounds. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2024 with diagnoses including adult failure to thrive and aortic valve stenosis. The resident was receiving hospice services. The resident's service plan dated 03/11/26, incident report/investigation, progress notes and temporary service plans dated 03/08/26 to 06/08/26 were reviewed, observations were made, and interviews with staff and the resident were conducted. The following was identified: Resident 1 experienced multiple short-term changes related to skin conditions that lacked documentation of what action or intervention was needed, and weekly documentation on the progress of each wound until resolution: * 03/31/26 - Wound to right buttock and redness to upper inner thighs; * 05/05/26 – “New sores to coccyx;” * 05/09/26 – Skin tear to coccyx; and * 05/26/26 – Bruising to right lower leg. During an interview on 06/09/26 at 09:55 am, Staff 1 (ED) acknowledged the lack of monitoring progress for the changes of condition and reported that the nurse was responsible for weekly skin monitoring and determining actions or interventions as needed. Observation of the skin conditions completed on 6/09/26 at 10:15 am with Staff 4 (Regional RN) revealed the redness to upper inner thighs was resolved, the bruising to the left lower leg remained discolored, and all other wounds were not resolved. The need to ensure short-term changes of condition had monitoring of progress noted at least weekly, and actions or interventions that were determined were documented and communicated to staff, was discussed with Staff 1, Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) at approximately 2:00 pm on 05/10/26. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 04/2026 with diagnoses including diabetes and deep post-operative wound infection. The resident's service plan dated 04/16/26, progress notes and temporary service plans dated 04/18/26 to 06/08/26 were reviewed, observations were made, and interviews with staff were conducted. The following was identified: The following short-term changes of condition related to wounds identified in the progress notes lacked weekly documentation on the progress of each wound until resolution: * 04/18/26 – Right ankle shearing to skin; * 04/18/26 – Surgical wound bottom right foot; and * 04/18/26 – Pressure ulcer right heel. During an interview on 06/09/26 at 09:55 am, Staff 1 (ED) acknowledged the lack of documented monitoring of progress for changes of condition through resolution and reported the nurse was responsible for weekly skin monitoring and determining actions or interventions as needed. The need to ensure all changes of condition were monitored, with progress noted at least weekly to resolution was discussed with Staff 1 and Staff 2 (Regional Director of Operations), and Staff 3 (Chief Operating Officer) on 06/10/26 at approximately 2:00 pm. They acknowledged the findings.

1. Res #1 and #5: residents were assessed and wound logs updated to assure presence of all active skin issues for weekly monitoring. Remaining residents were assessed to assure all active skin issues were present on the wound log for weekly monitoring. 2. Training provided to the new Nurse, ALD and WD on our weekly skin assessment process to assure understanding. Routine observations of the wound log and review of resident related documentation will be conducted to assure skins are known and being updated weekly until resolved. 3. Weekly/daily 4. Nurse, ALD/WD with ED oversight

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure a facility nurse, physical therapist or occupational therapist conducted a thorough assessment of a supportive device with restraining qualities, instructed direct care staff on the correct use and precautions related to the use of the device and documented the use of the device in the resident service plan, for 3 of 3 sampled residents (#s 2, 3 and 5) who used a supportive device with restraining qualities. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2025 with diagnoses of chronic kidney disease and an unspecified fracture of the upper end right humerus. On 06/08/26 at 12:15 pm, bilateral half-length side rails were observed on the resident’s hospital bed. The resident stated they did not restrict his/her movement while in bed and s/he used the rails to assist with transfers in/out of bed. The current service plan, dated 02/01/26, indicated the resident used bed rails for assistance in and out of bed and the device required an assessment by an RN, PT or OT. The assessment of the device that was provided by the facility was dated 06/08/26. In an interview on 06/10/26 at approximately 1:00 pm, Staff 4 (Regional RN) stated the facility had not conducted an assessment of the device prior to 06/08/26 and she wasn’t aware of when the resident received the device. In an interview on 06/09/26, Staff 19 (CG) stated she had not received any instruction on the correct use and precautions related to the use of devices with restraining qualities. The need to ensure a facility nurse, physical therapist or occupational therapist conducted a thorough assessment of a supportive device with restraining qualities and documented the use of the device in the resident service plan was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (Chief Operating Officer) on 06/10/26 at 4:20 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including Parkinson’s disease and stage 5 kidney failure. The resident was receiving dialysis. On 06/09/26 at 1:35 pm, the resident was observed to utilize a bed cane device on one side of his/her bed. The device was stationary and did not raise or lower. It was positioned near the head of the bed, and the resident stated it did not interfere with his/her ability to exit the bed. The resident stated s/he used the device to steady him/herself during transfers. The resident also stated s/he had used the device since moving to the facility. The current service plan, dated 04/12/26, indicated the resident did not use a bed rail or any other device. However, “1/2 rail cane for mobility” was hand-written on the service plan that was provided to the surveyor on 06/09/26. The updated information regarding the device use was not dated. The assessment of the device that was provided by the facility to the surveyor was dated 06/08/26. In an interview on 06/10/26 at 9:45 am, Staff 2 (Regional Director of Operations) confirmed the facility had not conducted an assessment of the device until 06/08/26. The need to ensure a facility nurse, physical therapist or occupational therapist conducted a thorough assessment of a supportive device with restraining qualities and documented the use of the device in the resident service plan was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:30 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 04/2026 with diagnoses including diabetic foot infection. The resident recently had surgery on his/her feet. On 06/09/26 at 10:40 am, the resident was observed to utilize a bed cane device on both sides of his/her bed. The devices were stationary and did not raise or lower. They were positioned near the head of the bed and the resident stated they did not interfere with his/her ability to exit the bed. The resident stated s/he used the devices to hold onto when staff assisted him/her with transfers. The use of the devices was included in the resident’s initial service plan, dated 04/16/26. The assessment of the device that was provided by the facility to the surveyor was dated 06/08/26. In an interview on 06/10/26 at 9:45 am, Staff 2 (Regional Director of Operations) confirmed the facility had not conducted an assessment of the device until 06/08/26. The need to ensure a facility nurse, physical therapist or occupational therapist conducted a thorough assessment of a supportive device with restraining qualities was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:30 pm. They acknowledged the findings.

1. All restraints with supportive devices have been audited and RN assessment completed. Charts/service plans of remaining residents with restraint devices have been reviewed to verify presence of required information and current evals. 2. Training has been provided to the new Nurse, ALD and WD regarding state rules and community policy on the use and oversight of supportive devices to assure understanding. Routine audits of charts/service plans will be conducted for those using devices to assure ongoing compliance. 3. Weekly. 4. The Health and Wellness Director, Assisted Living Director and RN will be responsible for the service plan and ongoing evaluations for supportive devices and report any issues/concerns to maintenance immediately for repair/replacement.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete, update and review the acuity based staffing tool (ABST) evaluation for each resident before a resident moved in and no less than quarterly and corresponding with residents’ service plan updates for 2 of 5 sampled residents (#s 4 and 5) and used the results of the ABST to develop and update the facility’s staffing plan. Findings include, but are not limited to: ABST data was captured on 06/08/26 at 9:30 am just shortly after beginning the survey. 1a. On 06/10/26 at 3:30 pm, Staff 1 (ED) confirmed Resident 5 moved into the facility on 04/28/26. The resident’s ABST evaluation was not created until 05/02/26. b. Resident 4’s most recent service plan was dated 03/23/26. The resident’s ABST evaluation was last reviewed on 12/27/25. 2. The ABST indicated the facility needed the following number of direct care staff to meet the scheduled and unscheduled needs of all the residents in the facility: * Day shift: 4.87 direct care staff; * Swing shift: 4.35 direct care staff; and * Night shift: 1.53 direct care staff. The posted staffing plan, dated 04/18/26, indicated the facility staffed as follows: * Day shift: 4 direct care staff; * Swing shift: 4 direct care staff; and * Night shift: 2 direct care staff. The facility staffing plan did not meet the staffing requirements indicated by the ABST. The need to ensure the ABST was maintained as required and used to develop and update the facility’s posted staffing plan, was reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 06/10/26 at 2:45 pm. They acknowledged the ABST evaluations had not been created or reviewed as required and the staffing plan did not meet the ABST results.

1. ABST has since been fully updated for each resident. Service plans have been reviewed to ensure accuracy and that they match ABST. Additional staff have been hired to fill the schedule to comply with ABST staffing requirements. 2. ABST and service plans will be audited to ensure they match up and are accurate so that appropriate staffing can be scheduled. 3. ABST will be reviewed and updated on a weekly basis and as needed for new residents and/or any change of conditions. 4. ABST and service plan audits will be done by the Assisted Living Director and Health and Wellness Director.

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 conduct and document fire drills according to the Oregon Fire Code (OFC) with all required elements. Findings include, but are not limited to: On 06/10/26, fire drill records from 01/2026 through 06/2026 were reviewed, and the following was identified: a. The facility did not conduct unannounced fire drills at different times of the day, evening and night shifts. b. The facility did not consistently document the following: * Escape route used; * Evacuation time-period needed; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. In an interview on 06/10/26 at 9:32 am, Staff 1 (ED) acknowledged the facility had not performed fire drills on night shift and had not consistently documented the time-period needed for evacuation or escape route used. c. Staff 1 reported the facility had not practiced the evacuation of bedbound residents during its fire drills. Therefore, there was no evidence the facility could meet the evacuation standards for the building. The need to ensure the facility conducted and documented fire drills according to the Oregon Fire Code (OFC) with all required elements was reviewed with Staff 7 (Maintenance) and Staff 8 (Maintenance) on 06/10/26 at 11:10 am, and Staff 1 and Staff 2 (Regional Director of Operations) on 06/10/26 at 4:20 pm. They acknowledged the findings.

1. Fire drills will be done every other month, and Fire Life Safety in-services and education will be done on alternating months. Fire Life and Safety meeting with all staff was done on 6/25, which has put us back on schedule. STAIR-CHAIRs purchased and installed. Staff in-service scheduled for 7/16 on how to safely use stair-chair upon evacuation. 2.All staff will be mandated to attend and participate in all in-services and fire drills to ensure proper training and preparation for if an evacuation is ever needed. Fire Life and Safety Meeting with residents is scheduled for 7/15 at 10a in the movie theater and will be put on a regular schedule as well. Residents will also be reminded of the importance of participating in fire drill and evacuation drills. The Safety Committee team will put on their calendars days and times for upcoming fire drills and training alternating months. Community will follow closely the calendar to ensure quality drills and in-services are happening consistently and according to schedule. Residents will also have an alternating schedule of fire drills and fire safety meetings/in-services. Residents will also have evacuation drills every six months. Residents who refuse to participate will sign waivers and still receive the literature created for the drill and/or in-service. Evacuating bed-bound residents will be practiced using a staff member acting as a bed-bound person, thus providing the staff quality practice with evacuating bed-bound persons. In the event of an evacuation drill, a true bed-bound resident will be evacuated. 3. The Fire Life and Safety binder will be audited and maintained on a monthly basis to ensure compliance. Staff will have fire drills every other month and Fire Life and Safety in-services/meetings on the alternating months. Safety Committee meetings will occur monthly following the All-Staff meetings. Residents will have Fire Life and Safey meetings alternating quarterly with Fire Drills. Evacuation drills for residents/staff will be done every six months. 4. Maintenance and Safety Committee will be responsible for making sure fire drills and education are taking place consistently and according to calendar.

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 thereafter. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) on 06/10/26 at 9:50 am. There was no documented evidence that residents were provided fire and life safety training 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 inside or outside the building in the event of an actual fire. In an interview on 06/08/26 at 12:15 pm, Resident 2 stated s/he had not been provided with fire and life safety training since moving into the facility in 09/2025. The need to provide fire and life safety instruction to residents within 24 hours of admission and re-instructed at least annually was discussed with Staff 1, Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 06/10/26 at 4:20 pm. They acknowledged the findings.

1. Fire Life and Safety meeting for residents will be scheduled fo every 6 months. New residents will receive orientation within 24 hours of admittance to the community that will include instructions on the required fire safety information. 2. All new residents will attend an orientation within the first 24 hours of moving in to ensure comprehension about fire safety, emergency exits, and point of safety. Fire drills and in-services for residents will be put on a calendar to ensure compliance. 3. Fire drills and in-services will be done every 6 months. New residents will receive fire safety instructions within 24 hours of moving in. 4. Assistant Executive Director and Maintenance will be responsible for maintaining schedule, fire drills, and in-services for residents.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and free from unpleasant odors. Findings include, but are not limited to: Observations of the facility between 06/08/26 and 06/10/26 revealed the following: * Odor of urine throughout room 236; and * Odor of urine was apparent throughout the hallway on the second floor near rooms 224, 231, and 235. The area in need of cleaning was shown to and discussed with Staff 2 (Regional Operations Officer) and Staff 3 (Chief Operating Officer) on 06/10/26 at 5:24 pm. They acknowledged the findings.

1. Odors in the hallway and resident's suite have been resolved by carpet extracting, deep cleaning of the suite, and hallway carpet extracting. Suites on the second floor added to weekly QA audits to ensure cleanliness and lack of odors. 2. Daily walk thru of suites 236, 224, 231, and 235 and hallways to ensure cleanliness and odor-free environment. If there are any issues discovered, staff will alert maintenance immediately. 3. Daily suite and hallway audits 4. Executive Director, Assistant Executive Director, Assisted Living Director, Health and Wellness Director and Maintenance will be responsible for ensuring cleanliness and odor free environment.

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured on 06/08/26 at 12:42 pm. Common area windows on the second and third floors opened vertically, and windowsill heights were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls. The lack of a mechanism to prevent accidental falls was discussed with Staff 1 (ED) and Staff 3 (Maintenance) on 06/09/26 at 10:27 am, and Staff 1, Staff 2 (Regional Operations Officer) and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. All windows with sill heights lower than 36 inches and above the first floor have had window locks installed. 2. Maintenance will conduct regular audits of windows and window locks to ensure safety and compliance. 3. Monthly audits of locks and windows. 4. Maintenance will be responsible for audits of windows and window locks and report to Executive Director immediately for replacement and/or repairs.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to post the LGBTQIA2S+ Rights and Protections in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to: Refer to C 152.

1. All required postings have been printed, framed, and displayed in the community and visable to all residents and visitors. Staff will be in-serviced about the purpose of required postings and educated on how they can help maintain integrity of postings. 2. All staff in the community will be aware of required postings and alert maintenance if they discover any issues or absence of postings. 3. Daily audits to make sure postings are visable and in good condition will be added to the environmental QA. 4. Assistant Executive Director and Maintenance will be responsible for ensuring the required postings are visable and in good condition.