Print Inspection: RL010130

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 ensure the prescriber was notified when a resident refused to consent to an order for 2 of 2 sampled residents (#s 1 and 2) who had medication and treatment refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 05/2024 with diagnoses including dementia, asthma, and anxiety. The resident’s 02/01/26 through 03/17/26 MAR and current physician orders were reviewed and showed the resident refused the following prescribed orders: * Famotidine, for reflux disease, on three occasions; * Escitalopram, for anxiety, on one occasion; * Propranolol, for anxiety, on two occasions; * Ventolin inhalation aerosol solution, for cough and wheezing, on one occasion; * Melatonin, for sleep, on one occasion; * Terazosin, for enlarged prostate, on one occasion; * Breyna inhalation aerosol, for asthma, on two occasions; * Montelukast sodium, for asthma, on one occasion; * Lactobacillus rhamnosus, for immune support, on one occasion; and * Acetaminophen, for pain, on four occasions. In an interview at 1:08 pm on 03/18/26, Staff 2 (RN/Interim Resident Care Manager) confirmed the prescriber had not been notified of the above refusals. The need to ensure the prescriber was notified when the resident refused to consent to an order was discussed with Staff 1 (Administrator) and Staff 2 at 10:20 am on 03/19/26. They acknowledged the findings. Example #2: 2. Resident 2 was admitted to the facility in 01/2026 with diagnoses including dementia. ? The resident’s 02/01/26 through 03/17/26 MAR and current physician orders were reviewed and showed the resident refused a prescribed lidocaine patch on three occasions. In an interview at 1:08 pm on 03/18/26, Staff 2 (RN/Interim Resident Care Manager) confirmed the prescriber had not been notified of the above refusals. The need to ensure the prescriber was notified when the resident refused to consent to an order was discussed with Staff 1 (Administrator) and Staff 2 at 10:20 am on 03/19/26. They acknowledged the findings.

1. All residents identified with medication or treatment refusals (Residents #1 and #2) were immediately reviewed. The prescribers for both residents were notified of all documented refusals, and new provider guidance was obtained where clinically indicated. The MARs and clinical records were updated to reflect notification and follow-up actions. A 100% audit of all current residents was conducted to identify any additional unreported refusals within the last 30 days. Any identified refusals were immediately communicated to the prescriber and documented in the clinical record. 2. The facility has implemented a standardized Medication/Treatment Refusal Notification Protocol, including: - Mandatory documentation of all refusals in the MAR/TAR at the time of occurrence - Nurse review triggers for high-risk or repeated refusals - Required prescriber notification within 24 hours - Refusal Tracking Log reviewed daily - Integration into daily clinical meetings PointClickCare documentation expectations were standardized, and a nurse acknowledgment workflow was implemented. 3. The facility will implement the following steps: - Daily review of refusal log - Weekly audit of 10% of MARs/TARs - Monthly QAPI review of trends and compliance 4. The following team members will be responsible: - Resident Care Manager (RCM) - daily oversight - Director of Nursing Services (DNS) - weekly audit - Health Services Administrator (HSA) - monthly QAPI

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:

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 in accordance with Oregon Fire Code and failed to ensure fire and life safety training was provided to staff on alternate months from fire drills. Findings, include, but are not limited to: Fire drill records from 09/2025 to 03/2026 were reviewed with Staff 3 (Director of Facility Services) and Staff 4 (Renovations and Compliance Lead) at 1:52 pm on 03/18/26. The following was identified: 1. Fire drill documentation lacked the following: * Escape route used; * Number of occupants evacuated; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. 2. There was no documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. Staff 4 confirmed in the above interview that residents were not participating in fire drills, and the facility was not providing fire and life safety instruction to staff on alternate months from fire drills. The need to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months from fire drills was discussed with Staff 1 (Administrator) and Staff 2 (RN/Interim Resident Care Manager) at 10:20 am on 03/19/26. They acknowledged the findings.

1. All fire drill documentation from the previous 6 months was reviewed and corrected where possible. A full fire drill was conducted with resident participation and complete documentation. Fire and life safety training was provided to all staff. 2.The facility implemented a Fire Drill and Life Safety Compliance Program including: - Standardized documentation templates - Scheduled drills every other month across shifts - Alternating monthly staff training - Resident participation incorporated appropriately - Oversight checklist for each drill 3.The facility will implement the following steps: - After each drill documentation review - Monthly leadership review - Quarterly QAPI review 4. Director of Facility Services - Compliance Lead - primary oversight of fire drills - Director of Facility Services - monthly review - Health Services Administrator - monthly QAPI

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: