OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, adequate staffing to meet fire safety and evacuation standards on night shift, and a minimum of two care staff available whenever a resident required the assistance of two or more staff for scheduled and unscheduled needs for 1 of 1 sampled resident (#6) and four unsampled residents. It was determined staffing levels on the night shift posed a threat of harm to residents, in the event of an evacuation. Findings include, but are not limited to: The facility was licensed as an ALF with two floors. During the acuity interview on 09/15/25, the consensus was confirmed at 46 residents, with five residents identified as needing two-person assistance for transfers and/or ADL cares. The facility’s posted staffing plan and staffing schedule from 09/08/25 through 09/14/25 were reviewed. The following was identified: The posted staffing plan for the facility was as follows: * Day shift: 3 CG, 2 MT; * Swing shift: 3 CG, 2 MT; and * Night shift: 1 CG, 1 MT. Interviews with staff on 09/18/25 identified Resident 6 as requiring three to four staff to perform ADL cares, repositioning, and transfers. The resident was receiving hospice services and was described as “bed-ridden,” reportedly having not been out of bed for over a week. Interview statements obtained between 2:05 pm and 2:35 pm on 09/18/25 included the following: * Staff 11 (CG) stated, “Three people are needed to perform changes and repositioning in bed. Two people would not be able to get [him/her] out of bed.”; * Staff 13 (MT/CG) stated, “The only way we could get [him/her] out in an emergency would be a blanket lift, with one person on each corner.”; and * Staff 17 (MT/CG) stated, “[S/he] always requires three to four staff to reposition or change [him/her]. It would take more to get [him/her] out of the building.” With the number of residents requiring two-person transfers and/or care, in addition to Resident 6 who required the assistance of three to four staff for transfers, the facility failed to have staff sufficient in number to meet the scheduled and unscheduled needs of the residents on the overnight shift, as well as to meet fire safety and evacuation standards, when only two direct care staff were scheduled. It was determined the current staffing levels on night shift were inadequate and posed a threat to the safety and well-being of the resident. On 09/19/25 at 10:05 am, the survey team spoke with Staff 1 (ED) about the safety concerns around staffing issues on the overnight shift. A written plan to increase staff on the overnight shift was requested. On 09/19/25 at 11:43 am, Staff 1 presented the survey team with a proposed plan of correction to increase staffing on the overnight shift. At 12:51 pm, the survey team spoke with Staff 1 to request additional information, and at 1:10 pm, Staff 1 presented the updated plan to the survey team, and it was accepted. On 09/19/25 at 2:20 pm, the need to ensure adequate staffing to meet the residents’ scheduled and unscheduled needs and fire safety and evacuation standards was discussed with Staff 1, Staff 2 (Regional Director of Operations), and Staff 3 (Oversight RN). They acknowledged the findings.

1. RCC is arranging one additional caregiver for the nocturnal shift beginning today 9/19/25. ED/RCC will review service plans and ABST for the nocturnal shift with med tech and caregivers that work the AL noc shift to get true time for the ADL’s as well as any care changes that are being assisted with on the shift. ED started this review with FT AL noc med tech and will complete this today. ED/RCC will complete ISP’s and ABST for all residents found to have changes or needing additional time assigned on the ABST. 2. With every ISP update and quarterly evaluation/service plan review ED/LN/RCC will review with noc shift care staff to ensure changes have not been missed prior to completion and updating the ABST to ensure true ADL assistance and times are being established. 3. ED/RCC/LN will evaluate this area of compliance with every ISP, evaluation/service plan change, and ABST update; as well as quarterly. 4. ED/LN will be responsible to ensure compliance is maintained.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must 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 were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 09/16/25 at 9:15 am. The following was identified: * Scratches and scrapes were observed on the doors and door frames of Resident Rooms 111, 112, 211, 228, 242, and restroom near dining room; * There was chipped plaster and paint on walls near Resident Rooms 232, 233, 234, and first floor laundry room; * There were tears or gaps in the fabric base boards throughout the building’s second floor; * Carpet stains were observed in common areas, near Resident Rooms 180, 206, 208, 227, and 239; and * The carpet in Resident Room 213 was heavily soiled with dark stains and emitted a pervasive urine odor that did not dissipate through multiple days of survey. On 09/19/25 at 2:20 pm, the need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Oversight RN). They acknowledged the findings.

1. Scratches and scrapes have been repaired on the doors and door frames of Resident Rooms 111, 112, 211, 228, 242, and restroom near dining room; * The chipped plaster and paint on walls was repaired near Resident Rooms 232, 233, 234, and first floor laundry room; * The tears or gaps in the fabric base boards throughout the building’s second floor have been repaired; * Carpet stains were cleaned in common areas, near Resident Rooms 180, 206, 208, 227, and 239; and * The carpet in Apartment 213 was ordered from the flooring vendor and ED will arrange with family for scheduling the replacement of the floor. 2. Maintenance will conduct daily walk throughs for maintenance needs and use our Maintenance Request System online to track repairs needed. ED will review daily needs and maintenance request log twice weekly for completion. Carpet cleaning schedule will be initiated for common areas and resident apartments. 213 will have floor replaced one time based on family schedule. 3. Maintenance will follow up daily on maintenance needs and weekly on carpet cleaning schedule. 4. ED will review all areas twice weekly to ensure compliance.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by: