OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to investigate and reasonably rule out abuse or suspected abuse and failed to report abuse or suspected abuse to the local Department office for 1 of 3 sampled residents (# 5) whose incidents were reviewed for falls with injury and an injury of unknown cause. Findings include, but are not limited to: Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer’s dementia, anxiety disorder, and osteoarthritis. The resident was receiving hospice services. During the survey the resident was observed to be primarily reclined in a geri-chair, was a two-person transfer, and was dependent on staff for all cares. Interviews with staff, and review of the resident's 05/31/26 through 08/31/25 clinical record were completed. The following was identified: * 06/22/26 - Fall with pain and discoloration to the left side of face and left hip; * 07/14/26 - Bruising to the left hand with swelling; and * 08/07/26 - Fall with right temple laceration and right leg swelling and skin discoloration. Incident reports and investigations were reviewed for the injury of unknown cause and the two falls with injuries, and the following was identified: * The 06/22/26 fall with injury incident report indicated the service plan intervention for non-slip socks was not in place at the time of the fall; * The 07/14/26 injury to the left hand with swelling investigation indicated that “there was no cause ascertainable”; and * The 08/07/26 fall with right temple laceration and right leg bruise/bump incident report indicated the service planned fall mat was not in place at the time of fall. During an interview with Staff 12 (LPN) on 09/01/26 at 10:50 am, he reported he had investigated each incident and thought abuse was reasonably ruled out. None of the three incidents/injuries had been reported to the local Department office. The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local Department office and all injuries of unknown cause were immediately reported to the local SPD office unless an immediate investigation reasonably concluded and documented that the injury was not the result of abuse, was discussed with Staff 2 on 08/31/26, and with Staff 1 (ED) on 09/02/26 at 08:55 am. They acknowledged the findings. The facility was instructed to report the falls with injuries and injuries of unknown cause to the local SPD office on 09/01/26. Documentation of all reporting requested was received from the facility at 8:55 am on 09/02/26.

Reporting & InvestigatingAbuse- Other Action 1. What actions will be taken to correct the rule violations for each example? For Resident #5 and all other residents, documentation of all requested self-reports requested was provided and received by survery team at 8:55am on 9/2/2026 2. How will the system be corrected so that the violation will not happen again? Observation notes, documentation, and incident reports will be reviewed daily by the Health Services Director (HSD), Resident Care Coordinator (RCC), or Executive Director (ED). The review will focus on identifying any potential concerns related to abuse, neglect, resident safety, changes in condition, or patterns of concern requiring further investigation or intervention. When a potential concern is identified, the HSD/ED will ensure that an investigation is initiated and completed in accordance with community policy and regulatory requirements. Findings and follow-up actions will be documented. If abuse or neglect cannot be reasonably ruled out based on the information available, the HSD and/or ED will complete the required self-report to Adult Protective Services (APS) in accordance with applicable reporting requirements. Compliance with this monitoring process will be tracked through a weekly review log, with findings and any required follow-up documented and escalated to the appropriate leadership team as necessary. 3. How often will the area needing correction be evaluated? The area needing correction will be evaluated at least five times per week. The Health Services Director (HSD), Resident Care Coordinator (RCC), and/or Executive Director (ED) will be responsible for completing and documenting the reviews, identifying any concerns requiring follow-up, and ensuring that corrective actions are completed. 4. Who will be responsible for ensuring the corrections are completed and monitored? The HSD and ED will oversee ongoing compliance and monitor the effectiveness of the corrective actions. Any identified concerns will be investigated and addressed promptly. If abuse or neglect cannot be ruled out, the HSD and/or ED will complete the required self-report to Adult Protective Services (APS) in accordance with applicable reporting requirements.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific instructions or interventions were determined, documented, and communicated to staff on all shifts for all short-term changes of condition and/or weekly progress documented until resolution for 5 of 6 sampled residents (#s 1, 2, 3, 4, and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer’s dementia, anxiety, and osteoarthritis. The resident’s 05/31/26 to 08/31/26 clinical record was reviewed, and the following was identified: There was no documented evidence Resident 5 had resident-specific instructions or interventions developed and communicated to staff on all shifts, and/or weekly progress documented until resolution for the following changes of condition: * 06/13/26, 06/19/26, 06/22/26, 07/01/26, 08/04/26, 0807/26, 08/18/26, 08/21/26, and 08/23/26: Injury and non-injury falls; * 07/14/26: Pain and swelling to left thumb; and * 06/14/26, 06/22/26, 07/05/26, and 08/07/26: New medications started, and changes to current medication dosages related to pain and anxiety. Staff 1 (ED) reported on 09/02/26 at 11:30 am that she had recently been notified by Witness 3 (Consultant RN) that the facility was not documenting monitoring progress of changes of condition through resolution. The need to ensure the facility determined actions or interventions for short-term changes of condition, communicated the actions or interventions to staff on each shift, and monitored the condition with weekly progress noted through resolution was reviewed with Staff 1 and Witness 3 on 09/02/26 at 11:30 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2025 with diagnoses including dementia. The resident’s 06/29/26 to 08/31/26 clinical record was reviewed, and the following was identified: There was no documented evidence Resident 1 was monitored, with weekly progress noted through resolution, for the following changes of condition: * 07/06/26, 07/16/26, 07/19/26, 07/23/26, 08/08/26, 08/10/26, 08/23/26, and 08/24/26: Injury and non-injury falls; * 07/06/26: Groin rash; and * 08/02/26: Resident-to-resident altercation. The need to ensure the facility communicated the actions or interventions to staff on each shift and monitored the condition, with weekly progress noted through resolution, was reviewed with Staff 1 (ED) and Witness 3 (Consultant RN) on 09/02/26 at 11:50 am. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 02/2023 with diagnoses including dementia. The resident’s 06/15/26 to 08/28/26 clinical record was reviewed, and the following was identified: There was no documented evidence Resident 2 was monitored, with weekly progress noted through resolution, for the following changes of condition: * 07/15/26: Non-injury fall; * 07/15/26 at 1:10 pm and 1:32 pm, 07/17/26, and 08/02/26: Resident-to-resident altercations; * 07/22/26: New medication lorazepam: * 07/24/26: New medication Fentanyl patch; * 08/08/26: Medication error; * 08/13/26: Discontinue Fentanyl; and * 08/13/26: New medication Methadone. The need to ensure the facility communicated the actions or interventions to staff on each shift and monitored the condition, with weekly progress noted through resolution, was reviewed with Staff 1 (ED) and Witness 3 (Consultant RN) on 09/02/26 at 11:50 am. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 01/2026 with diagnoses including depression. The resident’s 06/08/26 to 08/31/26 clinical record was reviewed, and the following was identified: a. There was no documented evidence Resident 3 was monitored, with weekly progress noted through resolution, for the following changes of condition: * 06/08/26: Return to the facility from the skilled nursing facility and medication changes; * 06/26/26: Resident reported feeling faint; * 07/23/26: New medication Sildenafil (for libido); and * 08/11/26: Depressive episode. b. On 06/10/26 an RN assessment was completed for the resident’s return to the facility following a surgical repair for a hip fracture. The following interventions were identified: * Ensure call light and walker within reach, bed in lowest position, non-skid footwear; * Monitor for inability to bear weight; * Monitor for potential weight loss; and * Encourage slow, deep breaths before standing to reduce dizziness. There was no documented evidence that the facility communicated the actions or interventions to staff on each shift. In an interview on 09/02/26 at 10:55 am, Staff 1 (ED) confirmed the interventions from the RN assessment had not been communicated to staff on all shifts. The need to ensure the facility communicated actions or interventions for short-term changes of condition to staff on each shift and monitored the condition, with weekly progress noted through resolution, was reviewed with Staff 1 and Witness 3 (Consultant RN) on 09/02/26 at 12:25 pm. They acknowledged the findings. 5. Resident 4 was admitted to the facility in 05/2026 with diagnoses including cerebral infarction (stroke) with left hemiplegia. The resident’s 06/01/26 to 08/26/26 clinical record was reviewed, and the following was identified: a. There was no documented evidence Resident 4 was monitored, with weekly progress noted through resolution, for the following changes of condition: * 05/28/26: New move-in; * 06/07/26: Medication changes for blood pressure; * 06/21/26: Non-injury fall; * 08/06/26: Self-administer Vitamin C tablets. b. On 07/12/26 the resident had a non-injury fall. The investigation report identified interventions that included “ensure resident had proper fitting footwear.” There was no documented evidence the facility communicated the actions or interventions to staff on each shift and monitored the resident, with weekly progress noted through resolution. The need to ensure the facility communicated the actions or interventions to staff on each shift for short-term changes of condition and monitored the condition, with weekly progress noted through resolution. was reviewed with Staff 1 (ED) and Witness 3 (Consultant RN) on 09/02/26 at 12:25 pm. They acknowledged the findings.

Change of Condition and Monitoring 1. What actions will be taken to correct the rule violations for each example/resident? Staff, including the Executive Director (ED), Health Services Director (HSD), and Resident Care Coordinator (RCC), will be retrained on the Change of Condition and Temporary Service Plan (TSP) process, including the requirement that resident-specific instructions, interventions, and monitoring needs developed through the TSP process are clearly communicated to all applicable staff. For residents #1 - #5, and any additional residents placed on monitoring, required observations and interventions will continue to be documented in the ALIS system until the identified concern has been resolved and the monitoring is appropriately discontinued. 2. How will the system be corrected so this violation will not happen again? ALIS alert monitoring will be utilized for residents requiring ongoing monitoring. When the identified concern has been resolved and monitoring is no longer necessary, the alert will be formally discontinued in ALIS, with documentation reflecting the resolution and discontinuation of the associated monitoring, instructions, or interventions. The HSD, RCC, and ED will conduct a weekly review of any Change of Conditions, active TSPs and ALIS alerts to ensure that monitoring is current, interventions are being followed, and TSPs and alerts are appropriately updated or closed when no longer indicated. 3. How often will the area needing correction be evaluated? The HSD, RCC, and ED will conduct a weekly review of any Change of Conditions, active TSPs and ALIS alerts to ensure that monitoring is current, interventions are being followed, and TSPs and alerts are appropriately updated or closed when no longer indicated. 4. Who will be responsible for ensuring the corrections are completed and monitored? The Executive Director (ED) and Health Services Director (HSD) will be responsible for ensuring that corrective actions are completed, monitored, and sustained. The RCCs will assist with implementation, communication, documentation, and ongoing monitoring as appropriate.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (#3) who had documented medication refusals. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2026 with diagnoses including depression. The resident's 08/01/26 through 08/31/26 MARs and 07/22/26 signed physician orders revealed that the resident refused to consent to orders for the following medication: * Diclofenac sodium 1% gel (for pain) on 34 occasions. In an interview on 09/02/26 at 12:55 pm, Staff 9 (MT/CG) indicated the refusals were documented on the MAR and acknowledged the physician was not notified when a resident refused a medication, unless they continued to refuse and then would ask the physician if the medication could be discontinued. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED) and Witness 3 (Consultant RN) on 09/02/26 at 12:25 pm. The findings were acknowledged.

Systems- Resident Right to Refuse 1. What actions will be taken to correct the rule violation? Upon identification of a medication refusal, the resident’s Primary Care Provider (PCP) will be contacted promptly to notify them of the refused medication(s). The PCP will also be asked to identify their preferred frequency for notification of future medication refusals for the resident. The resident’s right to refuse medications will be respected, and the refusal and required follow-up will be documented in the ALIS system in accordance with community policy. 2. How will the system be corrected so this violation will not happen again? During clinical stand-up meetings, the Med Pass History Report will be reviewed for medication refusals. The HSD and/or RCC leading the meeting will verify with the medication technician that the appropriate PCP notification has been completed for identified refusals. RCCs will follow up with medication technicians as needed to ensure they understand the resident’s right to refuse medications, the required documentation of a refusal, and the process for notifying the PCP when a medication is refused. 3. How often will the area needing correction be evaluated? The Med Pass History Report will be reviewed daily during clinical oversight to identify medication refusals and verify that required follow-up and PCP notification have occurred. 4. Who will be responsible for ensuring the corrections are completed and monitored? The Health Services Director (HSD) and Executive Director (ED) will be responsible for ensuring that corrective actions are completed and ongoing compliance is monitored. The Resident Care Coordinators (RCCs) will support ongoing follow-up with medication technicians, verify completion of required PCP notifications, and ensure medication technicians receive appropriate training regarding residents’ rights to refuse medications and the required follow-up process.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with restraining qualities were assessed thoroughly by an RN, PT, or OT prior to use for 2 of 2 sampled residents (#s 2 and 5) who had a geri chair (a reclinable padded chair on wheels). Findings include, but are not limited to: Resident 2 was admitted to the facility in 02/2023 and Resident 5 was admitted to the facility in 09/2022; both residents had diagnoses including dementia. Observations of the residents, interviews with staff, and review of the service plans dated 08/06/26, for Resident 2, and 07/23/26, for Resident 5, showed the residents both used geri chairs for extended periods throughout the day. Resident 2 remained in the geri chair during meals, as well. The residents could not get into or out of the geri chairs without staff assistance. Additionally, the residents were unable to recline the chair back or sit up straight and lower the footrests without assistance. Review of the residents’ records showed there was no assessment or evaluation of the geri chairs completed. The devices were not assessed by an RN, PT, or OT prior to initial use and then evaluated at least quarterly to determine safety and appropriateness for the residents. In an interview on 09/02/26 at 10:06 am, Witness 3 (Consultant RN) indicated an assessment of the geri chairs had not been completed prior to survey. She stated hospice ordered and brought in the geri chairs but did not always ensure the facility was notified prior to the device being implemented and a resident placed in the geri chair. She was currently working on the initial assessments but they were not yet completed. The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (ED) and Witness 3 (Consultant RN) on 09/02/26 at 11:50 am. The staff acknowledged the findings.

Restraints and Supportive Devices 1. What actions will be taken to correct the rule violation for each example/resident? An RN assessment will be completed for each identified resident who currently has a restrictive or supportive device. The clinical team will review the resident’s current needs and ensure that the appropriate service plan, TSP, or change-of-condition documentation is completed to address the specific device and the resident’s individual needs. 2. How will the system be corrected so that the violation will not happen again? All restrictive and supportive devices will be identified and documented on a community master tracking document maintained by the HSD. This document will be updated in real time as residents’ care needs, assessments, or service plans change. Prior to the implementation or use of any restrictive or supportive device, an RN assessment must be completed and the appropriate TSP and/or service plan must be in place. The clinical team, consisting of the RCC, HSD, and ED, will coordinate with the RN to ensure the assessment is completed before the device is implemented. Staff will receive in-service education regarding restrictive and supportive devices, including the requirement that a device may not be implemented or used until the required RN assessment and appropriate care-plan/service-plan documentation are completed and staff have been trained on the device and the resident-specific interventions. 3. How often will the area needing correction be evaluated? Restrictive and supportive devices will be reviewed monthly as part of the clinical team meeting. The devices and associated resident-specific interventions will also be reviewed during ongoing clinical stand-up meetings with medication technicians to ensure that current orders, assessments, service plans/TSPs, and staff instructions remain aligned with the resident’s needs. The master tracking document will be maintained and updated in real time whenever a device is initiated, discontinued, or when the resident’s care needs or interventions change. 4. Who will be responsible for ensuring the corrections are completed and monitored? The Executive Director (ED) and Health Services Director (HSD) will be responsible for ensuring that corrective actions are completed and monitored. The RCC will be responsible for ensuring that care staff and medication technicians receive appropriate training and understand that restrictive and supportive devices may not be implemented or used until the required RN assessment and appropriate TSP and/or service-plan documentation are completed for the specific resident and device.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code. Findings include but are not limited to: Six months of fire drill records were reviewed on 09/01/26, and revealed the following: Fire drills lacked documentation of one or more of the following components: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Staff members on duty and participating; and * Number of occupants evacuated. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 09/02/26 at 11:15 am. They acknowledged these findings.

Fire and Life Safety: Safety 1. What actions will be taken to correct the rule violation for each example? The fire drill documentation form has been revised to ensure all required components are consistently documented. The updated form includes sections to document any problems or concerns encountered during the drill, comments regarding residents who resisted or were unable to participate in the drill, staff members who were on duty and participated in the drill, and the total number of residents/occupants evacuated. 2. How will the system be corrected so that this violation will not happen again? The revised fire drill form will be used for all future fire drills to ensure required information is consistently captured. Completed fire drill documentation will be reviewed for compliance. 3. How often will the area needing correction be evaluated? Fire drills will continue to be conducted monthly, in accordance with fire and life safety requirements. 4. Who will be responsible for ensuring the corrections are completed and monitored? The Maintenance Director in coll with community staff will be responsible for ensuring fire drills are conducted as required and that the revised documentation form is completed accurately and in its entirety. The Executive Director (ED) will be responsible for overall oversight and ensuring continued compliance with applicable fire and life safety requirements.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 08/31/26 and 09/01/26 showed the following areas in need of cleaning or repair in Alpine house: * Deep gouges were noted in the laminate flooring in the living room near rooms 11 and 12 and near the piano area. A large piece of the flooring was missing the top layer of the laminate, creating an unsealed surface. Several boards near the dining room were pulling apart, creating a small gap between the boards with dark accumulation in the crevice; * Multiple walls throughout the unit had long black scuffs, paint scrapes, spills, stains, gouges, and/or chips. A corner near the entrance was missing a small piece of plaster and the rubber baseboard near the electrical room was hanging off the wall; * Room 1 had a long streak with a glob of reddish/brown substance on the interior wall; * Rooms 6 and 7 had deep gouges and scrapes across the room doors. Multiple door frames in the unit were chipped and/or gouged, with some splintering noted; *Multiple gouges, chips, and scratches were noted on doors and door frames throughout the facility and on walls in the dining room. The walls in the dining room additionally had some debris and spills on the edges of the decorative framing on the lower sections; * Multiple dining room chairs had dark stains on the fabric backs, debris was noted in the edges of the chairs, and some spills/splatters were noted to arms and chair legs; and * Multiple chairs and a love seat in the common sitting areas had tears and worn or torn vinyl. The fabric layer underneath the vinyl was exposed in small and large sections on seat cushions and backs of furniture. The chair arms and sides had dark spills and stains of varying sizes. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 09/01/26 at 11:10 am. She acknowledged the findings.

Door, walls, Elevators, Odors 1. What actions will be taken to correct the rule violations for each example? The Alpine building will be evaluated for cleanliness and for walls, doors, door frames, baseboards, flooring, and other environmental surfaces that have paint scrapes, chips, gouges, damage, or areas requiring repair. Identified areas will be cleaned, repaired, painted, or replaced as appropriate. Specific corrective actions include: • Repairing the damaged corner area where plaster and rubber baseboard are missing. • Cleaning the walls in Room 1. • Evaluating and repairing gouges and scrapes on the doors in Rooms 6 and 7. • Reviewing all door frames throughout the unit/community and repairing areas that are chipped, gouged, or otherwise damaged. • Evaluating walls throughout the community and repairing or painting areas with chips, gouges, scrapes, or other damage. • Cleaning dining room chairs, including removing stains from fabric surfaces. • Evaluating sitting and lounge chairs throughout the community for tears, worn fabric or vinyl, damaged arms, or other concerns. Items that cannot be adequately repaired will be removed from service and repaired or replaced as appropriate. • Evaluating and cleaning chair surfaces and arms throughout the community. • Reviewing laminate flooring throughout the community and repairing or replacing areas where the top layer is missing, damaged, or where surfaces are not properly sealed. 2. How will the system be corrected so that the violation will not happen again? The community’s Ready for Company Checklist will be utilized as an ongoing environmental monitoring tool. The environmental portion of the checklist will be completed weekly by a member of management to identify cleanliness, maintenance, damage, and other environmental conditions that are below community standards and require attention. When an area requiring correction is identified, the Maintenance Director will coordinate and oversee the appropriate corrective action. Identified items will be tracked and reported by the Maintenance Director during the daily stand-up meeting until the item has been corrected and resolved. 3. How often will the area needing correction be evaluated? The Ready for Company Checklist will be completed weekly by a member of management. Environmental conditions will also be monitored on an ongoing basis through daily operations and maintenance reporting. 4. Who will be responsible for ensuring the corrections are completed and monitored? The Maintenance Director will be responsible for coordinating and completing required repairs and for providing ongoing status updates until identified items are resolved. The Executive Director (ED) will provide overall oversight and ensure that identified environmental and physical plant concerns are addressed and that the community remains in compliance with applicable standards.

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 C231, C420, and C513.

Please refer to C231, C420, and C513

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270, C305, and C340.

Please refer to C270, C305, and C340