OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation Temporary rule language in effect until 02/05/2027 (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure quarterly evaluations identified the resident’s current status, and was sufficient to form the basis of the resident’s service plan for 2 of 4 sampled residents (#s 1 and 3) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2022 with diagnoses including dementia. The resident’s 07/12/26 through 10/12/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The following was identified: During the acuity interview on 10/12/26 at 10:30 am, Staff 1 (Administrator) and Staff 2 (RCC) identified Resident 1 as being in a relationship with an unsampled resident. The relationship was described as involving physical contact in public spaces and the residents spending time in bed together behind closed doors. During the survey, the residents were observed at times holding hands, speaking with each other, and going in and out of each other’s rooms. There was no documented evidence Resident 1’s evaluation identified his/her preferences and relationship with the unsampled resident. There was no documented evidence Resident 1’s cognition, decision making abilities including ability to consent, and current needs were evaluated related to his/her relationship with the unsampled resident. The need to ensure evaluations identified preferences and relationships and included information reflective of health status and current needs was reviewed with Staff 1, Staff 2 (Vice President of Operations), and Staff 4 (RN) on 10/16/26 at 11:10 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 05/2024 with diagnoses including Alzheimer’s disease and chronic obstructive pulmonary disease. Resident 3 was admitted to hospice on 08/04/26. During the acuity interview on 10/12/26 at 10:30 am, Staff 1 (Administrator) and Staff 3 (RCC) identified Resident 3 as requiring two-person assistance. Interviews and observations from10/12/26 through 10/16/26 identified Resident 3 required two-person assistance with transfers, toileting and other ADLs, and one-to-one assistance with eating. Resident 3’s evaluation did not accurately reflect the assistance required. The significant change of condition evaluation dated 08/06/26 and signed by the RN on 08/26/26 identified one-person assistance with daily routines and transfers. The two-person dependent option was not selected. The evaluation indicated Resident 3 ate independently and received meals in the independent dining room. On 10/16/26 at 12:15 pm, the need to ensure the resident’s evaluation was sufficient to develop the service plan was discussed with Staff 1, Staff 2 (Vice President of Operations), and Staff 4 (RN). No additional information was provided.

1.Resident #1's evaluation was updated to address the resident's relationship, preferences, cognition, decision-making abilities, and ability to consent. Resident #3's evaluation was updated to reflect current needs. ADLs, and one-to-one assistance with eating. Sapphire's Vice President of Clinical Services provided in-person evaluation training to the new DHS on 10/19. 2.The DHS will ensure evaluations accurately reflect residents' current needs, preferences, and abilities. The ED or designated staff member will review completed evaluations for accuracy for the next two months and ensure identified discrepancies are corrected. 3.The ED or designated staff member will review all evaluations completed by the DHS for two months then spot check per Sapphire CQI Monthly thereafter. Evaluations will continue to be completed per OAR. 4.The ED/Designee and DHS are responsible.

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 residents’ service plans were reflective of current care needs and provided clear instruction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including type 2 diabetes and dementia. Resident 2’s clinical record from 07/12/26 through 10/12/26 was reviewed, staff interviews were conducted, and observations of the resident were made. The following was identified: Resident 2’s service plan, dated 09/07/26, lacked clear direction to staff regarding the resident’s need for one-to-one assistance with eating. During lunch observations from 10/12/26 through 10/15/26, Resident 2 sat at a table designated for residents who needed assistance with meals. Resident 2 was observed receiving one-to-one assistance with eating. Multiple staff interviewed between 10/12/26 and 10/15/26 indicated Resident 2 required staff assistance with meals. On 10/16/26 at 12:15 pm, the need to ensure service plans reflected residents’ current needs and provided clear instructions to staff was discussed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN). They acknowledged the findings. Resident 3 was admitted to the facility in 05/2024 with diagnoses including Alzheimer’s disease and chronic obstructive pulmonary disease (COPD). Resident 3 was admitted to hospice on 08/04/26. The resident's 07/12/26 through 10/12/26 clinical record was reviewed, Interviews with staff were conducted, and observations of the resident were made. The following was identified: Resident 3’s service plan, dated 09/03/26, did not reflect the resident’s current needs and lacked clear instructions to staff in the following areas: * Two-person assistance with toileting, transfers, and other ADLs; * One-to-one assistance with eating; * Shower assistance provided by the hospice shower aide twice weekly; * Assistance with bed mobility; and * Staff assistance with wheelchair mobility. On 10/12/26 at 2:40 pm, Resident 3 was observed being transferred from his/her wheelchair to his/her bed by two care staff. Multiple staff interviewed between 10/12/26 and 10/15/26 indicated Resident 3 required two-person assistance with transfers and ADLs. During lunch observations from 10/12/26 through 10/16/26, Resident 3 was observed receiving one-to-one assistance with eating. On 10/16/26 at 12:15 pm, the need to ensure service plans reflected residents’ current needs and provided clear instructions to staff was discussed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN). They acknowledged the findings. Resident 1 was admitted to the facility in 04/2022 with diagnoses including dementia. The resident’s 07/12/26 through 10/12/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The following was identified: During the acuity interview on 10/12/26 at 10:30 am with Staff 1 (Administrator) and Staff 2 (RCC), Resident 1 was identified as being in a relationship with an unsampled resident. The relationship was described as involving physical contact in public spaces and the residents spending time in bed together behind closed doors. During the survey, the residents were observed at times holding hands, speaking with each other, and going in and out of each other’s rooms. The service plan, dated 08/20/26, did not include clear direction to staff regarding Resident 1’s relationship with the unsampled resident. The need to ensure service plans provided clear direction to staff was reviewed with Staff 1, Staff 2 (Vice President of Operations), and Staff 4 (RN) on 10/16/26 at 11:10 am. They acknowledged the findings.

1.Resident #1's service plan was updated to address the resident's relationship and provide staff guidance regarding preferences, privacy, and consent. Resident #2's service plan was updated to specify one-to-one assistance with eating. Resident #3's service plan was updated to reflect two-person assistance with transfers, toileting, and ADLs; one-to-one assistance with eating; hospice shower assistance twice weekly; bed mobility; and wheelchair mobility. 2. All resident Service plans will be audited by The ED or designee for accuracy. Following, The DHS will review and sign off on all service plans to ensure they accurately reflect current resident needs and provide clear staff instructions. The ED will provide additional review and sign-off during quarterly updates and significant changes of condition for the next two months. Thereafter, the admin will spot check for accuracy monthly per Sapphire CQI. 3. After initial monitoring period as noted in #2, ongoing reviews will occur at quarterly updates and following significant changes of condition and be reviewed with resident and responsible party for accuracy. 4. ED/Designee and DHS will be responsible.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, determine, document, and communicate resident specific interventions to staff, and failed to monitor changes of condition with weekly progress noted through resolution for 1 of 1 sampled resident (#3) who had a significant change of condition related to weight loss. Resident 3 continued to lose weight. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2024 with diagnoses including Alzheimer’s disease and chronic obstructive pulmonary disease. The resident was admitted to hospice on 08/04/26. The resident’s 07/12/26 through 10/12/26 clinical record was reviewed, interviews with staff were conducted, and observations of the resident were made. Review of Resident 3’s weight records identified the following: * 08/05/26: 170.6 pounds; * 09/03/26: 160.3 pounds; and * 10/08/26: 147 pounds. Between 08/05/26 and 09/03/26, Resident 3 experienced a 10.3-pound weight loss, or 6.0% of his/her body weight, over 29 days, representing a significant change of condition. On 09/03/26, the RN was notified of the weight loss through the facility’s electronic charting system. There was no documented evidence the facility evaluated the weight loss, updated the service plan, determined interventions, or monitored the weight loss with weekly progress noted through resolution. Resident 3 continued to lose weight between 09/03/26 and 10/08/26, losing an additional 13.3 pounds, or 8.3% of his/her body weight, over 35 days. There was no documented evidence of interventions addressing the continued weight loss. During lunch observations from 10/12/26 through 10/16/26, Resident 3 received one-to-one assistance with eating and was served a mechanical soft diet with thin liquids. The resident ate 75% of his/her lunch meals. Resident 3 was weighed on 10/14/26 during the survey and remained at 147 pounds. During an interview on 10/13/26 at 11:45 am, Staff 5 (Health and Wellness Director/RN) confirmed awareness of Resident 3’s weight loss. Staff 5 was asked to provide documentation addressing the weight loss. No documentation was provided. The facility failed to evaluate Resident 3’s significant weight loss and update the service plan to address the change. The resident continued to lose weight without documented interventions addressing the loss. On 10/16/26 at 12:15 pm, the need to evaluate changes of condition, update the service plan, determine interventions, and monitor, with weekly progress noted through resolution, was discussed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN). No additional information was provided.

1. Resident #3's significant weight loss was assessed by the RN, and change-of-condition documentation was corrected to reflect the weight loss on 10/13/26. Hospice was contacted, and a nutritional supplement order was received on 10/15. The service plan and resident-specific interventions were updated to reflect current nutritional needs, and weekly progress monitoring is in place. Resident was also placed on meal monitoring for consumption tracking. 2. Sapphire's Vice President of clinical did in-person training with new DHS to ensure competency on changes of condition and the requirements of being assessed, documented, communicated to staff, and addressed through appropriate interventions and service plan updates. 3. Change-of-condition documentation will be reviewed weekly for two months by ED/designee. Unresolved changes requiring monitoring will have weekly progress documentation through resolution. Thereafter, documentation will be reviewed Monthly per Sapphire CQI. 4.The EDdesignee and DHS are responsible.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (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:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the RN assessed and documented findings, resident status, and interventions for 1 of 1 sampled resident (#3) who experienced a significant change of condition related to weight loss. Resident 3 experienced ongoing weight loss. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2024 with diagnoses including Alzheimer’s disease and chronic obstructive pulmonary disease. The resident was admitted to hospice on 08/04/26. Between 08/05/26 and 09/03/26, Resident 3 experienced a 10.3-pound weight loss, or 6.0% of his/her body weight, over 29 days, representing a significant change of condition. There was no documented evidence the facility RN had completed a significant change of condition assessment, and the resident continued to lose weight. Refer to C270.

1.Resident #3 received an RN assessment addressing significant weight loss, and the change-of-condition documentation was corrected on 10/16/26. Hospice was contacted, and an order for a nutritional supplement shake was received. Weekly monitoring and interventions are in place, and the service plan will reflect the resident's current needs and RN recommendations. 2.ED and new DHS completed a full review of resident weight reports to identify significant changes and ensure all needed assessments, documentation, provider notifications, and interventions were in place.Weights are now reviewed weekly by DHS in nutrition at risk meeting with oversight and support from Sapphire VP Clinical. 3.Weight reports will be reviewed weekly for the next two months with initiation of weekly nutrition at risk meeting. The ED/designee will provide additional monthly oversight of weight report per Sapphire CQI. 4.The ED/Designee and DHS will be responsible.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to: During the re-licensure survey, conducted 10/12/26 through 10/16/26, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 302 – Tracking Control Substances; * C 303 – Medication and Treatment Orders; * C 305 – Resident Right to Refuse; * C 310 – Medication Administration; and * C 330 – Psychotropic Medications. The need to ensure a safe medication and treatment system was reviewed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN) on 10/16/26 at 11:10 am. They acknowledged the findings.

1. A comprehensive pharmacy review was completed of all MAR and MD orders with discrepencies noted. The ED and DHS addressed and corrected the medication and treatment deficiencies identified under C0302, C0303, C0305, C0310, and C0330, including controlled substance tracking, provider orders, medication refusals, MAR accuracy, and PRN psychotropic medication documentation. Resident-specific corrections are outlined under each corresponding tag. 2.The ED and DHS will review medication administration records during daily morning clinical stand-up to identify missing documentation, missed doses, refusals, and medication discrepancies. Identified concerns will be investigated and corrected, with additional staff education provided, as needed. 3.Medication administration records will be reviewed daily during morning clinical meetings, with additional audits as outlined in the related medication citations. 4.The ED/designee, DHS and RCCs will be responsible.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to maintain an accurate system for tracking controlled substances for 1 of 1 sampled resident (#3) whose MAR and controlled substance disposition logs were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2024 with diagnoses including Alzheimer’s disease and chronic obstructive pulmonary disease (COPD). The resident was admitted to hospice on 08/04/26. Resident 3’s controlled substance disposition log and 09/01/26 through 10/12/26 MARs were reviewed. The following was identified: Resident 3 had signed physician orders for morphine sulfate oral solution, 100 mg/5 ml: * Scheduled: 0.5 ml (10 mg) orally every six hours for pain; and * PRN: 0.5 ml (10 mg) orally every hour as needed for shortness of breath or moderate-to-severe pain. The log pages reviewed contained incorrect order directions. Pages listing the PRN order contained documentation of scheduled doses, and a page listing the scheduled order contained documentation of PRN doses. The log contained the following balance discrepancies: * 09/30/26 at 12:55 pm: 0.5 ml dose was documented, but the balance decreased from 12 ml to 11 ml; and * 10/05/26 at 7:21 pm: 0.5 ml dose was documented, but the balance decreased from 1.5 ml to 0.5 ml. Each entry reflected an additional 0.5 ml decrease not explained on the reviewed log sheet. The recorded balances did not reconcile with the documented doses. On 10/16/26 at 12:15 pm, the need to maintain an accurate system for tracking controlled substances was discussed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN). They acknowledged the findings.

1.Resident #3's morphine controlled substance records were reviewed to address incorrect documentation of scheduled and PRN doses and the balance discrepancies identified on September 30 and October 5, 2026. Discrepancies were investigated, documented, and addressed according to facility policy. Med Techs were educated on proper narc documentation, count and notifications to DHS when discrepencies are identified. 2. All Narcotic medications will be labeled as PRN and Scheduled to ensure they are dispensed separately and Documented Separately. The RCCs will complete weekly medication room and medication cart audits, including controlled substance tracking and documentation per Sapphire CQI. Any deficiencies will immediately be corrected and education provided to MT, as necessary. 3.The DHS will review completed audits for accuracy and ensure identified discrepancies are addressed. The ED or designated staff member will provide additional oversight and training for the next two months and then monthly oversight per Sapphire CQI. 4.The ED/Designee, DHS and RCCs will be responsible.

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 medication and treatment orders were carried out as prescribed and failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2022 with diagnoses including dementia. The resident’s 09/01/26 through 10/12/26 MARs and signed physician orders were reviewed, and interviews with staff were conducted. The following was identified: a. The following PRN medications did not have a current signed physician’s order: * Acetaminophen 325 mg (for pain or fever); and * Refresh tears (for eye dryness). b. The following medications had a signed physician order dated 09/18/26. The medications were not on the MAR and had not been administered as ordered: * Azelastine 0.05% eye drops, one drop into both eyes two times per day for 14 days (for itchy eyes); and * Cetirizine 10 mg once per day for 10 days scheduled, followed by 10 mg daily PRN (for allergies). c. The resident had an order for diclofenac gel (for pain) to be applied to the right shoulder. Between 09/01/26 and 09/21/26, the medication was documented as applied to other areas than prescribed on 11 occasions. The need to ensure medication and treatment orders were carried out as prescribed and to ensure the facility had signed orders for all medications and treatments it was responsible for administering was reviewed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN) on 10/16/26 at 11:10 am. They acknowledged the findings. Resident 2 was admitted to the facility in 06/2022 with diagnoses including type 2 diabetes and dementia. Resident 2 had a signed physician’s order dated 07/16/26 for a continuous glucose monitoring (CGM) sensor. The additional directions instructed staff to apply the sensor to the back of the upper arm or an approved site every ten days and as needed if dislodged or malfunctioning. Progress notes documented sensor placement at the following sites: * 07/16/26: Outer thigh; * 07/27/26: Right upper buttock; * 08/10/26: Left upper buttock; * 09/07/26: Right upper buttock; and * 09/15/26: Left upper buttock. The Diabetic Administration Record, dated 10/05/26, documented the sensor was placed on Resident 2’s right buttock. On 10/14/26 at 11:00 am, during an observation of Resident 2 being transferred to the toilet, the sensor was observed on the resident’s right buttock. The thigh and buttocks were not manufacturer-approved insertion sites for adults. No documented evidence was provided showing a prescribing practitioner authorized placement of the sensor at these alternate sites. On 10/16/26 at 12:15 pm, the need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Vice President of Operations) and Staff 4 (RN). They acknowledged the findings.

1.Resident #1's orders were reviewed to verify signed orders for acetaminophen and Refresh Tears, address the omitted azelastine and cetirizine orders, and ensure diclofenac gel is applied only to the prescribed location. Resident #2's continuous glucose monitoring sensor placement was moved, education provided to delegated staff on FDA approved placement and a placement sheet was provided in med room. 2. A complete audit was conducted for all residents by the Pharmacy to identify any discrepancies and ensure accuracy. Any identified issues by the pharmacy were corrected. New and changed orders will be reviewed daily in clinical stand up and checked per triple check system. 3. The system will be evaluated daily for effectiveness in review in clinical stand up, weekly for the next 4 weeks and monthly per Sapphire CQI thereafter. 4.The ED/designee and DHS will be responsible.

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 or other practitioner when a resident refused to consent to an order for 1 of 2 sampled residents (#1) with documented refusals. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2022 with diagnoses including dementia and chronic obstructive pulmonary disease (COPD). The resident’s 09/01/26 through 10/12/26 MAR and physician orders were reviewed, and interviews with staff were conducted. The following refusals were identified: * Diclofenac gel 1% (for shoulder pain), apply four times per day: refused one time; and * Combivent Respimat Inhaler (for COPD), one puff orally four times per day: refused six times. There was no documented evidence the facility notified the provider when the resident refused to consent to physician’s orders. In an interview on 10/15/26 at 11:00 am, Staff 1 (Administrator) confirmed the facility did not notify the physician when Resident 1 refused to consent to the orders. The need to notify the physician or other practitioner when residents refused to consent to an order was reviewed with Staff 1, Staff 2 (Vice President of Operations), and Staff 4 (RN) on 10/16/26 at 11:10 am. They acknowledged the findings.

1.Resident #1's documented refusal of diclofenac gel and Combivent Respimat inhaler were reviewed and MD was notified of the refusals. MD preferences on refusals were obtained and documented, staff educated on instruction for subsequent refusals. 2.The ED or designated staff member will fax all PCP's to get clarification on refusal notifications to ensure the accuracy on the MAR for staff to notify. DHS/RCCs will review med refusals in morning meeting and ensure proper notifications were made per MD preference. 3.Medication refusals will be reviewed daily during morning clinical meetings. Identified deficiencies will be addressed and corrected and re-education provided, as needed. 4. DHS and RCCs will be responsible

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 an accurate MAR was kept of all medications and treatments the facility administered, including resident-specific parameters for PRN medications, for 3 of 4 sampled residents (#s 1, 2, and 4) whose records were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 06/2024 with diagnoses including vascular dementia, type 2 diabetes, and Parkinson’s disease. Review of Resident 4’s MAR, dated 09/01/26 through 10/12/26, identified the following: The MAR listed two PRN medications for constipation, polyethylene glycol 3350 and Milk of Magnesia 1200 mg/15 ml. There were no resident-specific parameters for the sequential order of use for these medications. On 10/16/26 at 8:50 am, the need to keep an accurate MAR which provided resident-specific parameters and clear instructions for staff was discussed with Staff 1 (Administrator) and Staff 2 (Vice President of Operations). They acknowledged the findings. Resident 1 was admitted to the facility in 04/2022 with diagnoses including dementia. The resident’s MARs, dated 09/01/26 through 10/12/26, and physician’s orders were reviewed. The following was identified: The resident was admitted to the hospital on 09/16/26 and returned to the facility on 09/18/26. On 09/17/26, Staff 8 (RCC) documented administering the following medications to the resident: * Ferosul 325 mg, one tablet every two days (for iron deficiency); * Sertraline 100 mg, two tablets one time per day (for depression and mood); * Calcium 60 with vitamin D3, one tablet daily (for supplement); * Quetiapine 50 mg, one tablet three times per day (for dementia); and * Diclofenac gel 1%, four times per day (for pain management). On 10/12/26 at 11:00 am, Staff 1 (Administrator) confirmed the resident was not in the memory care facility on 09/17/26. The need to ensure the MAR was accurate was reviewed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN) on 10/16/26 at 11:10 am. They acknowledged the findings. Resident 2 was admitted to the facility in 06/2022 with diagnoses including type 2 diabetes and dementia. The resident’s 09/01/26 through 10/12/26 MARs and physician orders were reviewed. The following was identified: Resident 2 had orders for the following PRN medications for cough: * Guaifenesin-dextromethorphan syrup, 100 mg–10 mg/5 ml: Give 5 ml orally every six hours as needed for cough; and * Menthol cough lozenge: Dissolve one lozenge in the mouth every two hours as needed for cough. The medication record lacked resident-specific instructions directing staff when to administer each medication or whether the medications could be used together. No additional instructions were provided. On 10/16/26 at 12:15 pm, the need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN). They acknowledged the findings.

1.Resident #1's MAR was reviewed to investigate medications documented as administered on September 17, 2026, while the resident was OOF. Corrections were documented according to facility policy on 10/15. Resident #2's PRN cough medication orders were clarified with the provider to establish PRN instructions for guaifenesin-dextromethorphan syrup and menthol lozenges. Resident #4's PRN constipation orders were clarified to establish the sequence of use for polyethylene glycol and Milk of Magnesia on 10/15. 2. Pharmacy consultant completed a med review and provided findings for PRN sequencing. Training was completed for clinical staff and MTs. Weekly MT meetings will be held to review med admin system for the next four weeks and monthly thereafter. Training will address accurate MAR documentation, resident-specific PRN instructions, verification of medication administration, and compliance with provider orders and when to notify the DHS of discrepencies identified. 3. MAR documentation will be reviewed daily during morning clinical meetings for the next 4 weeks, then weekly thereafter. 4.The DHS and RCCs will be responsible.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#1) who was prescribed and administered PRN medication to treat behaviors. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2022 with diagnoses including dementia. The resident’s 09/01/26 through 10/12/26 MARs and signed physician orders were reviewed, and interviews with staff were conducted. The following was identified: The resident had an order for quetiapine 25 mg, one tablet to be administered daily as needed for agitation. The medication was administered four times between 09/01/26 and 10/12/26. There was no documented evidence the PRN medication was used only after documented, non-pharmacological interventions had been tried with ineffective results. In an interview on 10/15/26 at 2:05 pm, Staff 1 (Administrator) confirmed non-pharmacological interventions had not been documented as tried with ineffective results prior to administering the medication. The need to document non-drug interventions tried, with ineffective results, prior to administering PRN psychotropic medications was reviewed with Staff 1, Staff 2 (Vice President of Operations), and Staff 4 (RN) on 10/16/26 at 11:10 am. They acknowledged the findings.

1.Resident #1's PRN quetiapine order and four documented administrations was reviewed to address the lack of documented unsuccessful nonpharmacological interventions. The DHS did ensure resident-specific interventions and PRN parameters are documented, and medication technicians received education on their use and documentation. 2. A complete audit of all residents receiving psychotropic medications will be conducted by The ED or designated staff member to ensure PRN psychotropic medication orders used for behaviors contain resident-specific parameters and appropriate nonpharmacological interventions and are required to be documented before administration of medications. 3. New orders will be reviewed daily during morning clinicnal meeting and audited to ensure non-pharm interventions are in place for PRN psycotrophics. 4.The ED/Designee and DHS are responsible.

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 for each care element 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 the care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose ABST data was reviewed. Findings include, but are not limited to: ABST data for Residents 1, 2, 3, and 4 was reviewed. Inaccuracies in care times and care elements for each of these residents were identified through observation and interview. The ABST areas not reflective included, but were not limited to, time spent: * Responding to call lights; * Monitoring behavioral conditions; * Ensuring non-drug interventions for behaviors; * Cueing or re-directing due to cognitive impairment or dementia; * Supervising, cueing, or supporting while eating; and * Transferring in and out of bed or chair. On 10/16/26 at 11:10 am, the need for the ABST to accurately capture care time and care elements that staff were providing to residents was discussed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN). They acknowledged the findings.

1.The ED audited ABST care times for Residents #1, #2, #3, and #4 to ensure they accurately reflect individualized care needs and match service plan. 2.The ED/designated staff member will audit and update ABST minutes for all current residents to reflect each resident's actual scheduled and unscheduled care needs. Care times will be individualized and aligned with current service plans. The ED will audit changes in care to ABST daily during clinical stand up and update. 3.ABST minutes will be reviewed at move-in, quarterly service plan updates, and significant changes of condition, and whenever resident care needs change. 4.The ED or designated staff member will be responsible.

OAR 411-054-0037 (4-7) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete, update, review, and document 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 and corresponding with resident service plan updates, updating 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 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. (a) The posted staffing plan must incorporate: (A) The total ABST care time in minutes per shift, per day. If a proprietary ABST does not have this functionality, at a minimum the ABST total time must be shown in daily minutes as referenced in paragraph (2) of this rule. (B) The unscheduled care needs of residents. (C) The staffing requirements outlined in OAR 411-054- 0070(1). (D) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (E) The 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. (F) The facility’s distinct and 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. Each distinct and segregated area must have a posted staffing plan. (G) The staffing needs required under the Specific Needs Contracts, if applicable. (b) The facility must maintain staffing documentation to show consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (c) The facility must maintain historical posted staffing plans. The posted staffing plan must contain the date(s) it was effective. Records must be kept for a minimum of three years. (6) CONSISTENTLY MEETING NEEDS. The facility must consistently meet the scheduled and unscheduled needs of all residents, 24 hours a day, seven days a week. (7) 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 a 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 numbers as indicated in 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 ABST evaluations were updated no less than quarterly at the same time of service plan update and/or with a significant change of condition for 3 of 4 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: The facility’s ABST was reviewed on 10/12/26 and the following was identified: a. There was no documented evidence Resident 1, 2, and 3’s ABST had been updated quarterly at the same time as the service plan. b. Resident 3 experienced significant changes of condition related to admission to hospice and weight loss. There was no documented evidence the ABST was updated with the significant changes of condition. The need to ensure residents’ ABST evaluations were updated no less than quarterly and with significant changes of condition was reviewed with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 4 (RN) on 10/16/26 at 11:10 am. They acknowledged the findings.

1.ABST audits and updates were completed by ED for the sampled residents, including Residents #1, #2, and #3. Resident #3's ABST was updated to reflect changes associated with hospice admission, weight loss, and increased assistance needs. 2.The ED or designated staff member will audit and update ABST minutes for all current residents to reflect each resident's actual scheduled and unscheduled care needs. Care times will be individualized and aligned with current service plans. Education was provided to admin and designee on when to update ABST to align with services provided. 3.ABST information and will be reviewed and updated per OAR requirements and reviewed daily for COC at morning meeting. 4.The ED/designee will be resposible.

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 include and document all required elements of fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 10/14/26 showed fire drills lacked documentation of the following required elements: * Location of simulated fire origin; * Escape routes used; * Problems encountered and comments relating to residents who resisted or failed to participate; * Evacuation time period needed; and * Number of occupants evacuated. On 10/15/26 at 1:15 pm, the need to include and document all required elements of fire drills in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 7 (Maintenance Director). They acknowledged the findings.

1.Sapphire's Vice President of Operations provided fire and life safety training to the Maintenance Director and ED. Fire drills were conducted on day, swing, and NOC shifts by October 29, 2026. Documentation includes the simulated fire location, escape routes, problems encountered, resident participation concerns, evacuation time, participating staff, and number of occupants evacuated, along with the date and time of each drill. 2.The Maintenance Director will ensure fire drills are conducted and all required information is documented ongoing. The ED or designated staff member will review fire drill records for accuracy and completeness and ensure missing information or deficiencies are addressed during weekly meetings. 3.The ED will review documentation following each drill or training and weekly in one on one meetings for the next 4 weeks and monthly thereafter per Sapphire CQI. 4.The ED/Designee and Maint Director.

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 all interior materials and surfaces and all equipment necessary for the health, safety, and comfort of residents were kept clean and in good repair. Findings include, but are not limited to: The MCC facility was toured on 10/12/26 at 10:00 am. The following areas needed cleaning or repair: * Scratches and gouges on doors and door frames of resident rooms 8, 9, 10, 14, 17, 19, 20, 21, 25, 26, 27, 28, 29, and 30; * Marks and paint chips on plaster walls in multiple areas; * Scrapes and damage to wood handrails throughout the facility; * Marks and deep scratches on wood fixtures and furniture legs in common areas, including piano and bench, furniture in TV room, and dining room chairs; and * Heavy wear and damage on five stuffed vinyl chairs in the game room. On 10/14/26 at 9:35 am, the areas needing cleaning or repair were discussed with Staff 1 (Administrator) and Staff 7 (Maintenance Director). They acknowledged the findings.

1.Damaged doors and frames in resident rooms 8, 9, 10, 14, 17, 19, 20, 21, 25, 26, 27, 28, 29, and 30 will be repaired or replaced. Damaged walls will be patched and painted, and handrails will be sanded, repaired, and repainted. Damaged common-area furniture, including the piano and bench, TV room furniture, and dining room chairs, will be repaired or replaced. The five damaged vinyl chairs in the game room will be removed. Upholstered furniture will receive deep cleaning. 2.The Maintenance Director and ED will conduct weekly environmental walkthroughs to identify damaged surfaces, furniture, and needed repairs. Identified concerns will be documented and addressed. Housekeeping will complete weekly deep cleaning of upholstered chairs and couches. 3.Environmental walkthroughs will occur weekly and be reviewed on weekly one on one. Housekeeping will deep clean upholstered furniture weekly, and identified maintenance concerns will be followed through completion. Full environment concerns will be reviewed monthly thereafter in CQI meeting. 4. The ED/Designee and Maint Director will be responsible.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit. Findings include, but are not limited to: Observations in the facility and interviews with staff on 10/13/26, identified the following: * There were eight double-occupancy rooms (1 through 8) which had no locks on the shared bathroom door; and * There were three shared bathrooms between adjoining resident rooms (12 and 14, 19 and 20, and 26 and 28) which were not lockable on one or both sides. These conditions did not allow residents appropriate privacy for restroom use. On 10/16/26 at 8:50 am, the need to ensure each resident had privacy in his or her own unit was discussed with Staff 1 (Administrator) and Staff 2 (Vice President of Operations). They acknowledged the findings.

1.All resident room and bathroom doors were audited for appropriate locking mechanisms. The audit specifically addressed the shared bathrooms in rooms 1–8 and between rooms 12/14, 19/20, and 26/28. Missing or nonfunctioning locking mechanisms were ordered and installed to provide resident privacy while maintaining required emergency access. 2.The Maintenance Director and ED will incorporate bathroom door locking mechanisms into weekly environmental walkthroughs. Any missing, damaged, or nonfunctioning locks will be documented and corrected promptly. 3. A complete door-lock audit will be conducted, followed by weekly inspections during environmental walkthroughs. 4.The ED/Designee and Maintenance Director are responsible.

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 limited to: Refer to: C362, C363, C420, and C513

Refer to corrective actions under C0362, C0363, C0420, and C0513.

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: C252, C260, C270, C280, C300, C302, C303, C305, C310, and C330.

Refer to corrective actions under C0252, C0260, C0270, C0280, C0300, C0302, C0303, C0305, C0310, and C0330.