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 ensure effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: In an interview on 08/19/26 at 10:25 am, Staff 1 (Interim ED/Business Office Manager) stated any concerns from residents could be brought to the attention of management by attending Resident Council meeting or by filling out the grievance form. During the entrance conference on 08/17/26 the survey team requested three months of resident council meeting minutes. One documented resident council meeting dated 05/31/26 was provided for review. On 08/20/26 at 11:24 am, Staff 3 (Activity Director) confirmed there were no records of Resident Council meetings conducted for the year prior to 05/31/26. The meeting on 05/31/26 identified the following resident concerns: “ Freezer doesn’t freeze ice…”; “ No reply [room number] on [doctor] appointment on June 1st, upset because there was no reply to message”; “ Nursing sometimes not enough people on the floor”; and “ When is the management going to be here and stay here”. There was no documentation of follow up or resolution. In an interview on 08/20/26 at 12:23 pm, Resident 1, who had recently moved into the facility, was asked who s/he would go to and how s/he would make a grievance. Resident 1 was unaware of whom to contact or whether the facility had a grievance procedure and indicated s/he would go to her/his son. In an interview on 08/18/26 at 2:02 pm, Resident 2 stated, s/he “can’t complain to management because [I am] bed-bound and have to rely on caregivers [to relate any complaint].” A grievance binder located in the secure cabinet behind the receptionist counter contained no documentation on ongoing system for documenting, tracking, following up on and resolving resident complaints and grievances. The need to ensure the facility developed effective methods of responding to and resolving resident complaints was discussed with Staff 1, Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 11:48 am. They acknowledged the findings.

1) The Executive Director will review and address all concerns identified during the last three Resident Council meetings. Each concern will be documented, assigned for follow-up, investigated, and resolved or tracked until resolution. The response provided to the resident(s) will also be documented. The Executive Director will follow up with Resident 1 to explain the grievance process and how to submit a complaint. The Executive Director will address Resident 2's concern regarding being bed-bound and unable to independently report a complaint. Staff will be instructed to accept and document verbal complaints and assist residents who need help communicating or submitting grievances. 2) A standardized Resident Complaint/Grievance Tracking Log containing: Date Received, Resident, Concern, Method Received, Person Assigned, Investigation/Action, Response Date, Resolution/Status, Date Closed will be implemented. Verbal complaints will be documented in the same manner as written complaints. The grievance process will be explained during admission and reinforced through Resident Council and other resident communications. Information will be provided in an accessible manner for residents who need assistance. Resident Council concerns will be documented, assigned for follow-up, and reviewed for resolution. Minutes will reflect concerns raised and applicable follow-up actions or status. All employees, including department managers, will receive education on the revised grievance process. Staff will be instructed not to disregard, delay, or simply pass along a resident complaint without ensuring it is reported and documented. 3) The Executive Director or designee will audit the grievance/complaint tracking log weekly for 90 days to verify that: 1. Complaints are documented. 2. Complaints are assigned appropriately. 3. Investigation and follow-up are documented. 4. The resident or representative receives a response. 5. Resolution or current status is documented. 6. Unresolved complaints are escalated and followed through resolution. Resident Council minutes will be reviewed monthly for 90 days to ensure concerns and follow-up actions are documented. Audit findings will be reported to the Executive Director. Any variance will be corrected promptly, with additional education or corrective action provided as needed. After the initial 90-day monitoring period, grievance monitoring will become part of the facility's ongoing quality assurance process. 4)The Executive Director is responsible for overall implementation of this Plan of Correction. The Health Services Director and Department Managers are responsible for investigating, addressing, and documenting complaints within their respective areas. The Executive Director or designee will monitor the grievance system and ensure unresolved concerns are appropriately escalated and followed through resolution.

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' current care needs, provided clear directions to staff regarding the delivery of services and/or were reviewed and updated following a significant change of condition for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 02/2026 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease and atrial fibrillation. S/he was subsequently admitted to hospice services following a stroke. Observations were made of the resident's care on 08/19/26. Interviews with the resident and facility staff were conducted, and the service plan dated 07/10/26 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: * Pacemaker precautions, instructions for proper maintenance, and how to monitor malfunctions; * Number of staff needed to assist with activities of daily living; * Instructions for staff as to how side rails were to be used, monitored for safety, and to whom to report any malfunctions; * Oxygen equipment precautions, instructions for how to monitor for safety; * Instructions on what types of skin impairments to report and to whom; * Instructions on proper maintenance of air mattress used for pressure ulcer prevention; * Incorrect reference to resident using dentures; * Instructions to staff on providing care to resident with a history of strokes; * Instructions on use of urinary tract antiseptic to prevent urinary tract infection; and * Instructions on specific changes of condition to report to hospice. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 11:48 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2026 with diagnoses including high blood pressure, high cholesterol, and depression. Review of Resident 1’s clinical record showed the service plan, dated 07/27/26, was not reviewed and updated after a significant change of condition related to weight loss was identified on 08/04/26. The service plan did not reflect the resident’s current nutritional needs and preferences, including the foods s/he liked and disliked, or indicate s/he ate all meals in the apartment. Observations of Resident 1 and interviews with staff confirmed the resident ate all meals in his/her apartment. On 08/20/26 at 12:43 pm, the need to ensure service plans were reviewed and updated when a resident experienced a significant change of condition and were reflective of the resident’s current care needs was discussed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED). They acknowledged the findings. 3. Resident 3 moved into the facility in 05/2025 with diagnoses including Type 2 diabetes, dementia, and depression. Resident 3’s clinical record, including the service plan dated 07/13/26, was reviewed, and staff interviews were conducted. The service plan did not provide clear direction to staff regarding the delivery of services in the following areas: * The level of assistance the resident required with toileting and incontinence care; and * Interventions staff were to use when the resident refused incontinence care and showers. In an interview on 08/18/26 at 9:07 am, Staff 16 (Nursing Assistant) reported Resident 3 required full assistance with incontinence care. On 08/20/26 at 12:43 pm, the need to ensure service plans provided clear direction to staff regarding the delivery of services and reflected each resident’s current needs was discussed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED). They acknowledged the findings.

1) Resident #2: The Health Services Director will review the resident’s assessment, medical records, hospice plan of care, physician orders, and current needs. The service plan will be revised to accurately reflect the resident’s needs, preferences, and required interventions. The revised plan will provide clear staff direction, including applicable precautions and monitoring related to the pacemaker, ADL assistance, side rails, oxygen, skin impairment, air mattress, oral/denture status, stroke-related needs, urinary medications/antiseptics, and changes of condition requiring hospice notification. The plan will specify who, what, when, how, and how often services are provided. It will be dated and initialed, made available to staff, and offered to the resident/legal representative. Corresponding ABST care elements will also be reviewed and updated. Resident #1: The Health Services Director will review the significant weight-loss change identified on 08/04/26 and assess the resident’s nutritional needs, preferences, food likes/dislikes, meal location, and intake pattern. The service plan will be revised to reflect current nutritional needs and the resident’s preference to eat meals in the apartment. The updated plan will be dated, initialed, available to staff, offered to the resident/legal representative, and reflected in ABST care elements as applicable. Resident #3: The Health Services Director will review and update the service plan to clearly identify the assistance needed for toileting and incontinence care, including interventions to use when the resident refuses care or showers. The plan will specify who, what, when, how, and how often services are provided. It will be dated and initialed, made available to staff, offered to the resident/legal representative, and reflected in ABST care elements as applicable. 2) The Health Services Director will review current residents’ service plans to ensure they accurately reflect current assessed needs, preferences, significant changes in condition, and required services. The review will verify that plans: • Reflect resident evaluations and quarterly evaluations. • Incorporate applicable Person-Centered Service Plan elements. • Reflect resident preferences, dignity, privacy, choice, individuality, and independence. • Provide clear direction to staff. • Specify who, what, when, how, and how often services are provided. • Are reviewed and updated following significant changes in condition. • Are consistent with ABST care elements. • Contain properly dated and initialed changes. • Have updated copies offered to the resident/legal representative. Any discrepancies will be corrected promptly, including updates to the service plan and ABST care elements as applicable. A Service Plan Review Checklist will be used at admission, the 30-day review, quarterly reviews, and following significant changes in condition. The checklist will be retained as evidence of completion. Before finalizing a service plan, the Health Services Director will compare it with the resident’s assessment, physician orders, hospice plan of care when applicable, and ABST care elements to identify inconsistencies. 3) The Health Services Director will audit resident service plans over the next four weeks. Audits will verify that plans: • Reflect current needs and preferences. • Are updated following significant changes in condition. • Provide clear staff direction. • Specify who, what, when, how, and how often services are provided. • Contain dated and initialed changes. • Are consistent with ABST care elements. • Meet quarterly review requirements. • Have updated copies offered to the resident/legal representative. After the initial four weeks, monthly audits will be completed for three additional months. 4) Executive Director and Health Services Director

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (#3) who received subcutaneous injections by facility unregulated assistive persons (UAPs). Findings include, but are not limited to: Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. During the acuity interview on 08/17/26 at 3:42 pm, Resident 3 was identified to be administered a subcutaneous injection at least daily by a facility UAP. Resident 3's MARs from 08/01/26 through 08/17/26 revealed subcutaneous injections had been given by Staff 7 (Med Aide/Nursing Assistant), Staff 9 (Med Aide/Nursing Assistant), Staff 10 (Med Aide/Nursing Assistant), Staff 11 (Med Aide/Nursing Assistant), Staff 12 (Med Aide/Nursing Assistant), and Staff 17 (Med Aide). Review of the nursing delegation binder revealed the following: * Nursing delegation authorizations for Staff 7 and Staff 12 were out-of-date; * Staff 9, Staff 10, Staff 11, and Staff 17 had no delegation authorization; and * The RN comprehensive assessment to determine Resident’s 3 condition was stable and predictable, one of the criteria for delegation of a nursing procedure, was not documented in the nursing delegation binder. Witness 1 (Consultant RN) assumed nursing oversight at the facility on 08/17/26. During an interview on 08/19/26 at 3:16 pm, she confirmed the lack of documentation in the delegation binder and stated the missing information had been requested from the delegated regional RN. Updated authorizations for Staff 7, 9, 10, 12 and 17 were received by the survey team on 08/19/26 at 3:50 pm; however, none of them had been signed by the applicable UAP. There was no authorization received for Staff 11. In an interview on 08/19/26, at 2:13 pm, Staff 10, who administered insulin to Resident 3, confirmed he had never signed the delegation documents before and was asked to sign them that day (08/19/26). The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was discussed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 11:48 am. They acknowledged the findings.

1) The Consultant RN, Karolyn, assumed nursing oversight on 08/17/2026 and reviewed Resident #3’s subcutaneous injection needs and delegation records. All UAPs administering the delegated injection will have current RN delegation authorization, required RN teaching, and documented competency before performing the procedure. The Consultant RN, Karolyn, reviewed the delegation status of Staff 7, 9, 10, 11, 12, and 17. Staff without current RN authorization will not perform the procedure until delegation is completed and documented. The Consultant RN, Karoly, completed a review of residents receiving nursing procedures through UAP delegation. Missing, expired, incomplete, or unsigned records will be corrected. UAPs without current RN authorization will not perform delegated procedures. 2)The facility will maintain a centralized Delegation Tracking Log that includes: • Resident and delegated procedure; • Authorized UAP; • Delegation date; • RN reassessment/review dates; • Documentation status; and • Date verified by facility leadership. Before a UAP performs a delegated procedure, the Health Services Director will verify that current RN authorization and required documentation are in place. 3) The Health Services Director will audit delegated nursing procedure records over the next four weeks, followed by monthly audits for three months. Audits will verify that RN assessments, delegation authorizations, teaching, competency evaluations, signatures, and follow-up documentation are current and complete. Any deficiencies will be corrected promptly, and additional staff education will be provided as needed. Audit results will be provided to the Executive Director and Health Services Director and maintained as evidence of compliance. 4)The Consultant RN/ Health Services Director are responsible for RN assessment, delegation, teaching, competency evaluation, and follow-up. The Health Services Director is responsible for tracking delegation records, verifying compliance, and ensuring UAPs do not perform delegated procedures without current RN authorization

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 07/2026 with diagnoses including high blood pressure, high cholesterol, and depression. Review of the resident’s clinical record from 07/27/26 to 08/17/26 identified the following: On 07/31/26, Resident 1 was sent to the emergency room due to a fast heart rate and was hospitalized for four days and returned to the facility on 08/04/26 with new diagnoses of congestive heart failure and atrial fibrillation. Resident 1 had discharge instructions containing medication and treatment orders electronically signed by the physician. The discharge instructions included an order to obtain and record Resident 1’s weight daily. The instructions required notification of the resident’s primary care provider for a weight gain of more than three pounds within 24 hours or five pounds within one week. Resident 1’s MAR from 08/01/26 through 08/17/26 contained no documented evidence the daily weight order and notification instructions were carried out as prescribed. On 08/20/26 at 12:43 pm, the need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED). They acknowledged the findings. 2. Resident 2 moved into the facility in 02/2026 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease and atrial fibrillation. S/he was subsequently admitted to hospice services following a stroke. Resident 2's hospice physician orders, dated 05/29/26, and vitals report from 01/17/26 through 08/17/26 were reviewed. Interviews with the resident and facility staff were conducted. The following order was noted: * “Please notify [hospice] of any refusals and/or missed medications.” In an interview with Staff 6 (Nursing Assistant) at 11:26 am on 8/19/26, Staff 6 stated the resident was refusing weights due to not wanting to get out of bed. There was no documented evidence the facility notified the hospice provider during 06/2026 and 07/2026. In an interview on 08/19/26 at 8:21 am, Staff 10 (Med Aide/Nursing assistant) stated typically the facility RN would provide documentation to the hospice provider per orders. The RN was not available for interview because she was no longer employed by the community. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 11:48 am. They acknowledged the findings.

1) Resident 1: The Health Services Director, Kashia, reviewed the hospital discharge orders and clinical record. The order for daily weights and provider notification for a weight gain of more than 3 pounds in 24 hours or 5 pounds in one week was reviewed and implemented. Current orders were reconciled with the hospital discharge orders to ensure medications and treatments were accurately recorded and carried out. Staff responsible for weights were educated on the order and notification requirements. Resident 2: The Health Services Director, Kashia, reviewed the hospice orders, including the requirement to notify hospice of medication refusals or missed medications. Orders were reviewed and updated as needed to ensure they were accurately documented and implemented. Staff were educated on documenting and reporting refusals and missed medications/treatments as required. The Health Services Director will complete an audit of all current residents' practitioner orders, including medications, treatments, monitoring, weights, vital signs, notification requirements, and hospice orders. The audit will verify that: • Orders are present and accurately documented. • Medications and treatments are provided as ordered. • Required monitoring is completed and documented. • Required provider notifications are completed. • Refusals and missed medications/treatments are documented and reported. • Only authorized practitioners make changes to medication or treatment orders. Any discrepancies will be corrected immediately, including obtaining clarification or new orders when needed. 2) Orders will be reconciled with the MAR/TAR and electronic health record upon: • Admission or readmission • Hospital discharge or transfer • Significant change in condition • Receipt of new or changed practitioner orders • Receipt of hospice orders Hospital and external discharge orders will be reviewed promptly upon return to the facility. Orders with specific monitoring or notification requirements will be clearly identified for staff. Facility staff will not independently change medication or treatment orders. Any clarification or change will be obtained from the authorized prescribing practitioner and documented. 3) The Health Services Director will audit new, changed, hospital discharge, and hospice orders over the next four weeks. After four weeks, monthly audits will be completed for three additional months. Audits will verify accurate documentation, implementation, monitoring, required notifications, documentation of refusals/missed medications, and that orders are not changed by unauthorized staff. Any identified discrepancy will be corrected immediately, with additional education or corrective action provided as needed. Audit results will be reviewed by the Executive Director. 4) Health Services Director and Executive Director.

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 residents' MARs included medication reasons for use and provided resident-specific parameters for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 02/2026 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease and atrial fibrillation. S/he was subsequently admitted to hospice services following a stroke. Resident 2's MAR from 08/01/26 through 08/17/26 and physician orders were reviewed and revealed the following: a. The order for continuous flow oxygen lacked a route for administration and a reason for use. b. The following PRN medications lacked resident-specific parameters for use: * Acetaminophen 650mg (for pain or fever); and * Nystatin cream (for infection). The need to ensure MARs were accurate and provided resident-specific parameters was discussed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 11:48 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2026 with diagnoses including high blood pressure, high cholesterol, and depression. Residents 1's 08/01/26 through 08/17/26 MAR was reviewed, and the following was identified: a. There were no resident-specific instructions or parameters for weekly vital signs, including when to notify the physician or nurse. b. The following medications lacked a reason for use: *Aspirin; *Atorvastatin; *Furosemide; *Losartan; *Metoprolol; *Potassium; and *Sertraline. On 08/20/26 at 12:43 pm, the need to ensure an accurate MAR was kept of all medications the facility was administering was discussed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED). They acknowledged the findings. 3. Resident 3 moved into the facility in 05/2025 with diagnoses including type 2 diabetes. Residents 3's 08/01/26 through 08/17/26 MAR was reviewed, and the following was identified: The MAR did not include resident-specific instructions regarding the continuous glucose monitor: * Where to apply the sensor and how to change it; * What staff were to do if the sensor fell off, failed, or did not provide a reading; * What staff were to do if the sensor reading did not correspond with the resident’s symptoms; * Whom staff were to contact if there was a problem with the sensor. On 08/20/26 at 12:43 pm, the need to ensure MARs were accurate was discussed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED). They acknowledged the findings.

1) The HSD, Kashia, reviewed the current provider orders and MARs for Residents #1, #2, and #3 and corrected the identified deficiencies. • Resident #1: MAR updated to include medication reasons for use and resident-specific instructions and parameters for weekly vital signs, including notification requirements. • Resident #2: Oxygen order and MAR corrected to include route and reason for use. Resident-specific PRN parameters for acetaminophen and nystatin were obtained and documented. • Resident #3: CGM instructions were reviewed and added to the MAR, including sensor placement/replacement, troubleshooting, response to inaccurate or missing readings, and appropriate notification. The HSD will verify that all corrections are complete and accurate. The HSD will complete an audit of MARs and medication records for all residents receiving medication administration services. The audit will verify: • Medication reason for use is documented. • PRN medications have resident-specific parameters and instructions. • Required medication instructions and clinical parameters are documented. • Allergies and sensitivities are accurate. • Provider orders and MARs are current and consistent. • Required medication administration documentation is complete. Any discrepancy will be corrected promptly. Clarification will be obtained from the appropriate healthcare provider when needed. 2) The HSD will review medication orders and MARs: • Upon admission and readmission. • When medications are started, discontinued, or changed. • When a resident's condition may affect medication administration. • During scheduled MAR audits. Reviews will verify the following: medication reasons for use and resident-specific PRN parameters and instructions, when applicable. Identified discrepancies will be corrected and addressed with the responsible staff member. 3) The HSD will audit resident MARs over the next four weeks, followed by monthly audits for three additional months. Audits will verify medication reasons for use, PRN parameters, resident-specific instructions, clinical parameters, MAR accuracy, and consistency with provider orders. Results will be documented and reviewed with the Executive Director, Any identified discrepancy will be corrected promptly. Additional education or competency review will be provided when indicated. 4)The Health Services Director, with oversight from the Executive Director.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured care time and care elements staff were providing to residents for 1 of 3 sampled residents (# 2) whose ABST data was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 02/2026 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease and atrial fibrillation. S/he was subsequently admitted to hospice services following a stroke. The resident’s inputs and the service plan dated 07/10/26 were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST calculation did not incorporate expected care time in the following areas: * Time spent on safety checks, fall prevention; * Time spent assisting with communication, assistive devices for hearing, vision, speech; * Time spent monitoring physical conditions or symptoms; * Time spent providing treatments; * Time spent assisting with leisure activities; * Time spent repositioning in bed or chair; and * Time spent transferring in or out of bed or a chair. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 11:48 am. They acknowledged the findings.

1) The HSD, Kashia, reviewed Resident #2’s current service plan dated 07/10/2026, care needs, services provided, and ABST evaluation. The ABST was corrected to accurately reflect the resident’s current care needs and service plan, including applicable care elements for safety/fall prevention, communication assistance, monitoring of conditions, treatments, leisure activities, repositioning, and transfers. The Health Services Director, Kashia, and Executive Director, Jessica, verified that the revised ABST accurately reflects the resident’s current care needs and service plan. 2) The HSD will complete a review of all residents’ ABST evaluations against their current service plans to ensure: • All applicable care elements are identified. • Care time is resident-specific and not based on predetermined averages. • ABST information matches the current service plan. • Changes in condition and care needs are reflected. • Scheduled and unscheduled care needs are considered. • Staffing plans reflect identified resident care needs. Any discrepancies will be corrected promptly, and staffing will be adjusted when resident care-time needs change. The facility will review and update each resident’s ABST: • Prior to move-in; • When there is a significant change in condition; and • At least quarterly with the service plan review. 3) The Health Services Director will audit ABST evaluations over 30 days, followed by weekly audits for 60 days and monthly audits for three months. Audits will verify that: • ABST information matches the current service plan. • Applicable care elements are identified. • Care time is resident-specific. • Changes in resident needs are reflected. • Scheduled and unscheduled care needs are considered. • Staffing plans correspond with current resident needs and ABST information. Discrepancies will be corrected promptly. Audit results will be documented and reviewed. 4)The Executive Director and Health Services Director.

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 ensure the acuity-based staffing tool (ABST) was completed before move-in and reviewed and updated following a significant change of condition for 1 of 3 sampled residents (#1) whose ABST was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2026. Record review identified Resident 1’s initial ABST evaluation, dated 07/28/26, was not completed prior to move-in. Resident 1 experienced a significant change of condition in 08/2026. The ABST was last updated on 07/28/26 and was not reviewed or updated following the significant change of condition. On 08/20/26 at 12:43 pm, the need to ensure resident ABST evaluations were completed prior to move-in and updated and reviewed following a significant change of condition was discussed with Staff 1 (Interim ED/Business Office Manager), Staff 2 (Health Services Director), and Staff 3 (ED). They acknowledged the findings.

1)Resident #1’s record was reviewed by the Health Services Director, Kashia. The resident’s current care needs were assessed, and the ABST was completed/updated as necessary. The ABST was compared with the resident’s service plan and the facility’s staffing plan. Any identified discrepancies were corrected. The Health Services Director will review current resident records to verify that: • An ABST was completed before move-in. • The ABST accurately reflects current care needs. • The ABST was reviewed/updated after a significant change in condition. • The ABST was reviewed at least quarterly with the service plan. • The ABST and service plan are consistent. • ABST results are reflected in the posted staffing plan. • Staffing is sufficient for scheduled and unscheduled care needs. Any identified deficiencies will be corrected promptly. 2) Admissions: The ABST will be completed and reviewed before each resident moves into the facility. The admission checklist will include verification of ABST completion. Significant Change: When a significant change in condition occurs, the Health Services Director will review and update the ABST as needed and reassess the resident’s service plan and staffing needs. Quarterly Review: The ABST will be reviewed at least quarterly with the residents' service plans to ensure they accurately reflect current care needs. 3) For 90 days, the Health Services Director will monitor compliance as follows: • Days 1–30: Audit new admissions, significant changes, and quarterly reviews. • Days 31–60: Continue audit of the above areas. The Executive Director will review results weekly. • Days 61–90: Continue monitoring and address any identified deficiencies. Any variance will be corrected promptly, with additional education provided as needed. At 90 days, facility leadership will review audit results to determine sustained compliance. 4) The Executive Director and Health Services Director.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled direct care staff (#s 8, 13, and 18) completed all required pre-service orientation training and required pre-service dementia training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were requested on 08/18/26 from Staff 1 (Interim ED/Business Office Manager), and the following was identified: a. There was no documented evidence Staff 13 (Med Aide/Nursing assistant), hired 03/25/26, completed the Home and Community-Based Services (HCBS) training prior to beginning job responsibilities. b. There was no documented evidence Staff 18 (Med Aide/Nursing assistant), hired 04/28/26, completed the following required pre-service orientation topics prior to beginning job responsibilities: * Resident rights; * Abuse reporting requirements; * Fire safety and emergency procedures; and * LGBTQIA2S+. c. There was no documented evidence Staff 8 (Med Aide/Nursing assistant), hired 03/09/26, and Staff 18 completed the following pre-service dementia training topics prior to beginning their job responsibilities: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need to ensure all direct care staff completed all required pre-service orientation training and required pre-service dementia training prior to beginning job responsibilities was discussed with Staff 1, Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 12:43 pm. They acknowledged the findings.

1) • Staff #13, hired 03/25/26, completed the required Department-approved HCBS training on 08/18/26. Documentation is maintained in the employee training record. • Staff #18, hired 04/28/26, completed required pre-service orientation, including Residents’ Rights, Abuse and Reporting Requirements, Fire Safety and Emergency Procedures, LGBTQIA2S+ training, and approved dementia training on 08/31/26. Documentation is maintained in the employee training record. • Staff #8, hired 03/09/26, completed the required approved pre-service dementia training on 02/27/26. Documentation is maintained in the employee training record. The facility verified completion of the identified training requirements for Staff #8, #13, and #18. 2) The Executive Director or designee will complete an audit of current employee training records to identify any missing or incomplete pre-service training or documentation. The audit will verify, as applicable: • Required pre-service orientation and position-specific training. • Residents’ Rights and community-based care values. • LGBTQIA2S+ training. • Abuse and reporting requirements. • Fire safety and emergency procedures. • Infectious disease prevention. • Department-approved HCBS training. • Food handler certification, when required. • Approved pre-service dementia training for direct care staff. • Resident-specific orientation and service-plan review before providing personal care services. Any missing training or documentation will be corrected immediately. Employees will not perform duties requiring the missing training until the training is completed and documented. The Executive Director will verify and document completion of all required training before employees perform duties requiring that training. For direct care staff, required dementia training and resident-specific orientation, including review of the resident’s service plan, will be completed before applicable care is provided. Training certificates and required documentation will be maintained in each employee’s training record. 3) An audit of current employee training records will be completed by 10/19/26. Over four months, the Executive Director will review new-hire training records before the employee performs applicable job duties. Reviews will verify: 1. Required training has been completed. 2. Training was completed before applicable duties began. 3. Required documentation is present. 4. Direct care staff completed required dementia training. 5. Required resident-specific orientation was completed before personal care services. 6. The Pre-Service Employee Training Checklist is complete. Audit results will be documented and reviewed by the Executive Director. Any identified deficiency will be corrected immediately, and additional education will be provided as needed. After the four-month monitoring period, the checklist and verification process will remain part of the facility’s standard onboarding process. 4) The Executive Director is responsible for implementation and monitoring of this Plan of Correction. The Health Services Director will assist with verification and maintenance of training records.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct care staff (#s 10 and 18) had demonstrated competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were requested on 08/18/26 from Staff 1 (Interim ED/Business Office Manager), and the following was identified: There was no documented evidence Staff 10 (Med Aide/Nursing assistant), hired 06/23/26, and Staff 18 (Nursing Assistant), hired 04/28/25, had demonstrated competency within 30 days of hire in one or more of the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving, and sanitation; * Other duties as applicable (med pass, treatments); and * First aid and abdominal thrust. The need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1, Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 12:43 pm. They acknowledged the findings.

1) The Executive Director will review the training and competency records for Staff #10 and Staff #18. Any missing training or competency requirements will be completed and documented. Staff will not independently perform assigned duties until competency has been demonstrated and documented. The Executive Director will complete an audit of all current direct-care employee files to verify required training and competency were completed and documented within 30 days of hire. The audit will verify: • Hire date and 30-day due date. • Completion of required training. • Documented competency for assigned duties. • First Aid and abdominal thrust training. • Medication/treatment competency, when applicable. • Timely completion and required signatures/dates. Any missing documentation will be corrected immediately. Staff without documented competency will not independently perform the applicable duty. 2) The facility has implemented a 30-Day New Hire Training and Competency Tracking Tool. At hire, Business Office Manager will enter the employee’s hire date and competency due date. The Executive Director/designee will review the tracker weekly for upcoming and overdue requirements. The employee file will not be considered complete until all required training and competency documentation has been reviewed and filed. Department leaders and qualified/licensed staff will complete competency evaluations based on the employee’s assigned duties. 3) The Executive Director or designee will audit all newly hired direct-care employees weekly for three months to verify required training and competency are completed within 30 days of hire. Audits will verify: 1. Hire date and 30-day due date. 2. Required training completion. 3. Competency for assigned duties. 4. Required signatures and dates. 5. First Aid and abdominal thrust training. 6. Medication/treatment competency, when applicable. 7. No independent performance of duties without documented competency. After three months of successful audits, monitoring will continue monthly for an additional three months. Any variance will be corrected immediately, with additional education or competency evaluation provided as needed. 4) • Executive Director: Overall implementation and monitoring. • Business Office Manager: Training tracker and 30-day deadline monitoring. • Health Services Director: Competency evaluation and documentation within their scope. • Department Leaders: Ensuring required training and competency are completed.

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 unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 08/18/26, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed the following: * Staff were not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, and the number of occupants evacuated. The requirements regarding fire drills were discussed with Staff 1 (Interim ED/Business Office Manager) and Staff 4 (Maintenance Director) on 08/18/26 at 11:14 am, and with Staff 1, Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 11:48 am. They acknowledged the findings.

1) Fire drills that include the evacuation or relocation of residents in accordance with the facility's fire/life-safety plan will be implemented immediately. All staff will be educated regarding their responsibilities during fire drills, including providing appropriate evacuation assistance to residents, following designated evacuation routes, and relocating residents to the designated point of safety. The Maintenance Director will ensure that fire drill documentation accurately reflects the actual drill and includes all required elements including: • Date and time. • Simulated fire origin. • Escape route used. • Problems encountered. • Residents who resisted, refused, or were unable to participate. • Evacuation time. • Staff on duty and participating. • Number of occupants evacuated 2)The Executive Director, Health Services Director, and Maintenance Director will review the facility's fire drill procedures with all staff. Staff education will include resident-specific evacuation needs, staff assignments, evacuation assistance, designated points of safety, use of alternate exit routes, fire alarm activation, and required documentation. The facility will maintain a fire drill schedule to ensure unannounced drills occur every other month at varying times, including day, evening, and night shifts. Alternate evacuation routes and simulated fire-origin locations will be utilized. Fire and life-safety education will be provided to staff during alternate months when a fire drill is not conducted. The facility will review resident evacuation capabilities and staffing assignments as necessary to ensure the applicable evacuation standard can be met. If a drill identifies an inability to meet the applicable evacuation level, the facility will immediately take corrective action. 3)The Executive Director will review fire drill documentation immediately following each drill for three months to verify that the drill was conducted as required and that all required documentation was completed. The Executive Director will also observe fire drills to verify that staff are providing appropriate evacuation or relocation assistance to residents and following established emergency procedures. Any identified deficiency will be corrected immediately, and additional staff education will be provided as necessary. After the initial three-month monitoring period, compliance will continue to be reviewed through the facility's quality assurance and emergency preparedness processes. 4) The Executive Director is responsible for overall compliance. The Health Services Director and Maintenance Director are responsible for assisting with staff education, fire drill implementation, resident evacuation needs, documentation, and monitoring.

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 about fire and life safety procedures within 24 hours of admission in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 08/18/26 at 11:14 am. On 08/18/26 at 11:14 am, Staff 1 (Interim ED/Business Office Manager) and Staff 4 (Maintenance Director) were asked to explain the facility's process for providing residents with instructions on fire and life safety procedures within 24 hours of admission. Staff 4 reported he was responsible for providing fire and life safety training to all residents. However, the facility was unable to produce any documented evidence confirming the training had been given within 24 hours of admission. The need for residents to be instructed about fire and life safety procedures within 24 hours of admission per the OFC was discussed with Staff 1 and Staff 4 on 08/18/26 at 11:14 am, and with Staff 1, Staff 2 (Health Services Director), and Staff 3 (ED) on 08/20/26 at 11:48 am. They acknowledged the findings.

1) The Maintenance Director will review fire and life safety training records for all current residents. For residents who are capable of following the required instruction and whose training cannot be verified, the required training will be provided and documented. Training will include fire and life safety procedures, evacuation procedures and routes, resident responsibilities during drills, the designated meeting/safe location, and actions to take when an emergency alarm is activated. Residents who are unable to follow the instruction due to mental capability will be addressed. The facility will review current resident records to verify completion and documentation of required initial and annual fire and life safety training. Any missing or incomplete documentation will be corrected promptly. 2) Effective immediately, fire and life safety training will be included in the admission/move-in process. The Maintenance Director will ensure that each resident who is capable of following the instruction receives training within 24 hours of admission and at least annually thereafter. Training will be documented on the facility's Resident Fire and Life Safety Training Record, including the date, time, required topics, resident participation, and staff signature. 3) The Executive Director will audit new admissions over the next four weeks, followed by monthly audits for three months, to verify: • Training was completed within 24 hours of admission. • Required training topics were addressed. • Documentation is complete and signed. • Annual re-training is current. • Records are maintained in the designated location. Any variance will be corrected immediately, and additional staff education will be provided as needed. Audit results will be reviewed by the Executive Director and addressed through the facility's quality assurance process when appropriate. 4) The Maintenance Director is responsible for providing, coordinating, and documenting resident fire and life safety training. The Executive Director is responsible for oversight, monitoring, and ongoing compliance.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and access to the ALF’s common-use areas, entrance, and exit ways were smooth and maintained in good repair. Findings include, but are not limited to: On 08/17/26 at 4:00 pm, the enclosed central courtyard was observed. The center portion of the concrete pathway was chipped, cracked, and crumbling, creating an uneven walking surface and a potential tripping hazard for residents. Four exterior doors providing access from the courtyard into the facility had splintered areas and open vertical cracks along the door panels. Areas of the surface finish were missing, exposing bare wood. A walkthrough of the courtyard and review of the findings was discussed with Staff 1 (Interim ED/Business Office Manager) and Staff 4 (Maintenance Director) on 08/19/26 at 12:30pm. They acknowledged the findings.

1) The facility is obtaining contractor bids for repair or replacement of the damaged concrete pathway. A contractor will be selected by September 11, 2026, and repairs will be completed by October 15, 2026, subject to contractor availability. The Maintenance Director will inspect the four exterior courtyard doors and coordinate repair or replacement of damaged areas. Repairs will be completed by September 30, 2026. Until repairs are completed, the Maintenance Director will monitor the affected areas and implement interim safety measures as needed. 2) The Maintenance Director will inspect all exterior pathways, entrances, exits, common-use area access points, and exterior doors for damage or safety concerns. Identified concerns will be documented on the facility maintenance/repair log, prioritized based on resident safety, and corrected promptly. 3)The Maintenance Director will inspect exterior pathways, courtyard areas, entrances, exits, and exterior doors weekly for four weeks and monthly for three months thereafter. Inspection results will be documented and reviewed by the Executive Director. Any concerns will be corrected and documented through the facility maintenance process. 4) Maintenance Director / Executive Director

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Referral for staff training C370

1)Employee #18 has completed the required Department-approved LGBTQIA2S+ training. The Executive Director reviewed the employee's training record and verified completion. 2) The Executive Director reviewed the facility's pre-service orientation process and identified that completion of the required LGBTQIA2S+ training was not verified prior to employee #18 beginning job responsibilities. Effective immediately, the Executive Director will verify that all newly hired employees have completed and have documented all required pre-service orientation, including the Department-approved LGBTQIA2S+ training, prior to beginning job responsibilities. A pre-service orientation checklist will be completed for each newly hired employee and reviewed by the Executive Director prior to the employee's first shift. 3) The Executive Director or designee will audit newly hired employee training records for 90 days to verify that required pre-service orientation and LGBTQIA2S+ training are completed and documented prior to the employee beginning job responsibilities. The Executive Director will compare the employee's training completion date with the employee's start date/first work date. Any identified discrepancy will be corrected immediately, and the employee will not begin job responsibilities until all required training has been completed and documented. Audit results will be documented and maintained for review. 4) Executive Director or designee