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 fire drills per Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drill and fire and life safety records from 02/2026 through 08/2026 were reviewed on 08/18/26. The following was identified: The facility’s fire drill records lacked documented evidence the following required components were addressed: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time needed; and * Number of occupants evacuated. The need to ensure fire drills were conducted per OFC and included a written record of all required components of the fire drill was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 08/18/26 at 2:10 pm. They acknowledged the findings.

C420- FIRE DRILLS 1- During survey it was determined the facility failed to conduct fire drills per Oregon Fire Code. The facility’s fire drill records lacked documented evidence, the following required components were addressed Problems encountered and comments relating to residents, who resisted or failed to participate in the drills; * Evacuation time needed; and * Number of occupants evacuated. 1. Fire drill will be completed on 9/12/26 to include any problems encountered, concerns related to residents participating/refusals, evacuation time and number of occupants evacuated. 2. Administrator will participate in fire drills to ensure drills are completed thoroughly 3. Fire drills will be monitored every other month 4. Executive Director, Administrator and Maintenance will be responsible to see that the corrections are completed and monitored

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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 were made of hard, smooth material and maintained in good repair, measures were taken to prevent the entry of rodents, flies, mosquitoes, and other insects, locked storage for all poisons, chemicals, rodenticides, and other toxic materials, and grounds were kept orderly and free of refuse with all maintenance equipment stored. Findings include, but are not limited to: The facility grounds were inspected on 08/17/26. The following was identified: * Drop-offs were observed in the secured courtyard by the North and East common area library exit doors; * There were window screens observed in disrepair, and one window lacked a screen; * Chemicals were observed in an unlocked cupboard under the sink in East kitchenette; * There were chemicals that were not locked up, and gardening tools were not properly stored on the patio located outside of the Activity Room; * Cobwebs were observed outside the secured courtyard doors; * Brown matter was observed on downspouts and gutters throughout the secured courtyard; and * Disposable cups, broken ground lighting, cigarette butts, cotton swabs, and other litter was observed in the secured courtyard. The need to ensure a system was developed to ensure all exterior pathways were made of hard, smooth material and maintained in good repair, measures were taken to prevent the entry of rodents, flies, mosquitoes, and other insects, locked storage for all poisons, chemicals, rodenticides, and other toxic materials, and grounds were kept orderly and free of refuse with all maintenance equipment stored was reviewed with Staff 1 (Administrator), Staff 4 (Maintenance Director), and Staff 5 (Regional RN) on 08/18/26 at 2:10 pm. They acknowledged the findings.

C510- General Building Exterior: During survey it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material and maintained in good repair, measures were taken to prevent the entry of rodents, flies, mosquitoes, and other insects, locked storage for all poisons, chemicals, rodenticides, and other toxic materials, and grounds were kept orderly and free of refuse with all maintenance equipment stored. 1- Drop off areas were filled, screens were replaced/repaired, all tools and chemicals were removed from courtyard, all garbage/litter inclduing cigarette butts were removed/cleaned, broken lighting fixtures corrected, cobwebs removed, and brown matter on gutters cleaned 2- ED to walk outside of the property 2x a week and will address any areas of concern. 3- Plant op team will complete weekly garbage pick ups and walk throughs to monitor areas of concern, building will be pressure washed 2x a year. 4- Administrator, Plant Operations team or designee is responsible to see that corrections are completed and monitored.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C420 and C510.

Refer to C420 and C510

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

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height and outdoor furniture was of sufficient weight, stability, and design to prevent resident injury or aid in elopement. Findings include, but are not limited to: The secured courtyard of the memory care community was toured on 08/17/26 at 9:20 am, and the following was identified: a. There were areas in the older wooden fencing, located between the black vinyl and the newly constructed wooden fencing, that measured five feet, seven inches. b. Multiple pieces of outdoor furniture, including dining room chairs, two folding chairs, and a small table, were observed in the courtyard to which residents had free access. The furniture was easily movable and not of sufficient weight to prevent injury or elopement. The need to ensure the fencing measured at least six feet and the furniture was of sufficient weight to not aid in injury or elopement was discussed with Staff 1 (Administrator), Staff 4 (Maintenance Director), and Staff 5 (Regional RN) during a tour of the facility’s secured courtyard on 08/17/26 at 1:40 pm. They acknowledged the findings.

Z173- Secure Outdoor Rec Area; During survey, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height and outdoor furniture was of sufficient weight, stability, and design to prevent resident injury or aid in elopement 1- all furniture that did not meet the weight requirement was removed and dirt was removed from fenced area that did not measure 6ft. 2- Administrator will complete walk throughs to ensure no furniture is outside that is insufficient weight. 3- Walk throughs will take place daily. 4- Administrator or designee is responsible to see that corrections are completed and monitored.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: