OAR 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of Updates/Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review 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 at the same time the resident?s service plan is updated 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 routinely 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. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) 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. (g) Distinct posted staffing plans for 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. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) 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 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 exception or the ABST. This Rule is not met as evidenced by: 363 Based on observation, interview and record review, it was determined the facility failed to ensure the posted staffing plan was reflective of the staffing needs calculated and the staffing levels exceeded the number of staff indicated by the acuity-based staffing tool. Findings include, but are not limited to: Review of the facilities ABST entries, staff schedule, calculated staffing hours and posted staffing plan were completed and showed the following: * The facility’s ABST indicated that 11 to 12 staff were needed for day and evening shift, dependent on the day of the week. * The facility was staffing 10 staff on day and evening shifts, eight caregivers and two medication technicians. * The facility’s ABST indicated five staff were needed for the night shift. * The facility was staffing five staff on the night shift, four caregivers and one medication technician. Observations of the facility between 08/26/24 and 08/28/24 showed 10 staff were present and, on the floor, working. Residents received needed care, activities provided, behavior interventions were provided and unplanned needs were met. In an interview on 08/27/24, Staff 1 (ED) indicated they were aware they needed more staff and were actively working towards getting more staff for the floor. Staff 1 indicated an agency contract was in process as well as attempting to hire additional staff. The need to ensure the facility staffing plan and staff working on the floor, exceeded ABST staffing calculations was discussed with Staff 1. She acknowledged the findings.

C363 1) ABST is updated for each resident before move in, 30 days, 90 days, and any COC. Staffing plan is posted at front entryway with required staffing. We have hired and continue to hire additional staff and we have contracted with an agency to provide additional staffing when needed due to call outs, etc. to ensure that we are meeting staffing requirements. 2) ED will review the ABST tool weekly to ensure compliance with staffing needs and send to RSD for scheduling. 3) Weekly review of ABST to ensure compliance 4) ED and RSD

OAR 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of Updates/Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review 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 at the same time the resident?s service plan is updated 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 routinely 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. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) 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. (g) Distinct posted staffing plans for 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. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) 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 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 exception or the ABST. 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 the Oregon Fire Code, fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 03/2024 and 08/2024, showed fire drill documentation was lacking in the following areas: * The escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; and * The number of occupants evacuated. The fire drills were not completed at least every other month on alternating shifts. Additionally, the records reviewed did not show life safety training was provided on alternating months from the fire drills. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training, was discussed with Staff 1 (ED) and Staff 23 (Campus Maintenance Director) on 08/27/24 and 08/28/24. The staff acknowledged the findings.

C420 1) Disaster training was conducted with staff on 9/4/2024. An evacuation drill is scheduled for 9/25/2024. A fire drill with the missing components will be conducted for each shift on 9/30/24, 10/7/24, and 10/14/24 2) Fire drills will be completed and reviewed every other month by Plant Ops Director and ED using alternating shifts. Life Safety training will be completed at inservices on alternating months. 3)Monthly review of all drills and safety training to ensure compliance. 4) ED, POD, Campus POD

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 08/26/24 and 08/27/24 showed the following areas in need of cleaning or repair: * Multiple walls, doors, baseboards and door frames in the facility had scrapes, dings, chips, missing pieces of wood or spills; * Carpet and laminate flooring was pulling apart at the doorway to Room 149; * Room 145 had chips, gouges and scrapes to the interior walls, bathroom floor pulling away at the transition in the doorway; * Room 138 scraped, gouges wall near the recliner with pieces of drywall missing; * Apple neighborhood laundry area and peeling pieces of dry wall near the machine water connections; * Daisy neighborhood laundry area had a large chunk of linoleum missing and edges peeling away between the two machines; * Numerous black/gray carpet stains, of various sizes, in the common areas of all four neighborhoods; * Large, deep gouges and numerous small scratches were noted to the dining room floors in all four neighborhoods; * Multiple dining room chairs and common area furniture with stains, spills and or debris on the seats or backs; * Two patio chairs located in the Apple/Butterfly courtyards had darkly stained cushions with burn holes in the seat of one of the chairs; * Room 127 had a scraped door and the floor was pulling away at the transition to the common area creating a separation in the two flooring types; * Room 104 had cracked and separating floor in the center of the room; * The Butterfly neighborhood had two large leather chairs with spills, rips with one chair severely worn down to the mesh fabric layer; * Missing transition pieces from carpet to laminate flooring near the kitchenettes in all four neighborhoods. The missing pieces were both large and small with debris accumulated in the gaps; * Large gaps between the carpeting and the concrete surface located in the center of the facility between the four neighborhoods. Transition pieces were missing as well as large amounts of debris gathering in the different gap areas. There were a few gap areas creating a potential trip hazard; and * Significant black stains to the carpet were noted near the kitchen door and along the hallway around the center of the facility. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 08/27/24 and 08/28/24. The staff acknowledged the findings.

C513 1) All flooring issues are currently being reviewed for approval, we are obtaining bids and working with our licensee. A request for extension for flooring needs was submitted on 9/16/24. All walls, doors, baseboards, and door frames will be cleaned and repainted to ensure compliance. 145 interior walls to be repaired and repainted, bathroom flooring under review for approval. 138 interior walls to be repaired and repainted. Neighborhood laundry areas to be repaired and repainted. All dining room chairs have been deep cleaned and will be on the weekly neighborhood cleaning schedule to ensure compliance. Outside cushions with stains, holes have been discarded, new cushions have been ordered and will arrive 10/7/24. 127 door will be repaired and repainted. Neighborhood chairs noted to have stains and rips have been discarded. 2) Weekly cleaning schedules have been updated to ensure all neighborhood furniture and flooring are kept clean and in good repair to ensure compliance. Monthly painting schedule created to ensure all walls, doors, and other areas that get knicked and scuffed with wheelchairs and walkers are kept in compliance. 3) ED and POD will continue daily walk throughs and identify areas needing attention and update cleaning and painting schedules as needed. 4) ED, POD, Campus POD

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:

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. This is a repeat citation. Findings include, but are not limited to: Refer to C363, C420 and C513.

Z142 Please refer to POCs for C363, C420, and C513

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: