OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure infection prevention and control protocols were maintained for 1 of 2 sampled residents (#7) and multiple unsampled residents who were dependent on staff for meal escorts. Findings include, but are not limited to: Resident 7 moved into the facility in 08/2019 with diagnoses including dementia and stroke and was identified in the acuity interview as having a urinary catheter and was dependent on staff for transfers and escorts. Observations of staff transferring the resident were conducted on 02/10/25 and 02/11/25 and revealed the following: a. At 11:18 am on 02/10/25, Staff 14 (CG) and Staff 15 (CG) entered Resident 7’s room to assist him/her with transferring to a wheelchair. Resident 7 was sitting in a recliner with the catheter bag laying on the floor, exposing it to potential contamination. Staff 14 picked up the catheter bag without single-use gloves, and the bag spilled urine onto the floor. She confirmed the catheter bag had a leak. Staff 14 then placed the leaking bag onto Resident 7’s lap. She exited the resident’s room without first performing hand hygiene, grabbed and donned a pair of single-use gloves, and reentered the resident’s room. Staff 14 used paper towels to wipe the spilled urine from the floor. She disposed of the gloves and paper towel and left the room again without performing hand hygiene. Staff 14 then proceeded to physically assist five unsampled residents to the dining room, touching their person and/or their personal mobility devices. b. At 11:35 am on 02/11/25, Staff 15 (CG) and Staff 17 (MT) entered Resident 7’s room to assist him/her with transferring to his/her wheelchair. The resident’s catheter bag was again laying on the floor, exposing it to potential contamination. Staff 17 picked up the catheter bag and placed it on the resident’s lap during the transfer. They assisted the resident to the dining room, then proceeded to assist three unsampled residents to the dining room without first performing hand hygiene, touching their person and/or their personal mobility devices. At 9:38 am on 02/12/25, the observation was shared with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 6 (Operations Specialist). They acknowledged infection prevention and control protocols had not been practiced.

: 1. Resident #7's catheter bag was replaced. Catheter bags will be replaced as needed for any other residents with catheters. 2. The Executive Director, Wellness Nurse, Wellness Director, and Direct Care Staff will receive additional training on Handwashing and Hand Hygiene Policy, Infection Control: Infectious Waste Disposal Policy, and the Job-Aid for Foley Catheter Care & Urinary Leg Bags. 3. THe Welness Director will review this area weekly and with each new hire per the Caregiver Training Checklist. 4. The Executive Director will ensure the corrections are completed and monitored.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

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 ensure non-pharmacological interventions were attempted and documented as unsuccessful prior to PRN psychotropic medication being administered for 1 of 1 sampled resident (# 6) who was prescribed and received as needed psychotropic medications. Findings include, but are not limited to: Resident 6 was admitted to the facility in 04/2024 with diagnoses including Alzheimer’s disease. The resident's 01/01/25 through 02/09/25 MARs, physician’s orders and progress notes were reviewed. Staff were interviewed and the following was identified: Resident 6 had physician’s orders and instructions for the following PRN psychotropic medications for behaviors: *Haloperidol 5 mg every four hours as needed for agitation and hallucinations. *Lorazepam 0.5 mg every two hours as needed for anxiety, insomnia, or restlessness. * Parameters for administration of the medications included the haloperidol was to be administered first, prior to the lorazepam. Although there was non-drug interventions listed on the MAR for staff to try prior to administrating the PRN behavior medications, there was no documented evidence staff attempted non-drug interventions prior to the administration of the medications. Additionally, on 01/02/25, 02/02/25, and 02/11/25 staff did not follow the parameters and administered PRN haloperidol and PRN lorazepam to Resident 6 at the same time. The need to ensure non-pharmacological interventions were documented as attempted and failed prior to the administration of PRN psychotropics and parameters for administration were followed was discussed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 3 (Wellness Nurse/RN) and Staff 6 (Operations Specialist) on 02/11/25. The staff acknowledged the findings. ?

1. All resident Medication Administration Records will be reviewed to ensure resident specific parameters, non-pharmacological interventions, and interventions attempted are in place for PRN psychotropic medications. 2. The Executive Director, Wellness Director, and Wellness Nurse will receive additional training on the Orders Policy. Med-Tech's will receive additional training on documenting interventions attempted. 3. The Wellness Director and Wellness Nurse will review this area weekly and with each new order per the QA - Health Services and Clinical Review Schedule. 4. The Executive Director will ensure the corrections are completed and monitored.

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:

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, enough direct care staff to meet fire safety and evacuation standards based on resident acuity and facility structural design on night shift, and a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs for multiple sampled and unsampled residents. Findings include, but are not limited to: The facility was licensed as a RCF with two floors and a separate, distinct, locked MCC unit. During the acuity interview at 9:11 am on 02/10/25, the RCF consensus was confirmed at 34 residents, and the MCC census was confirmed at 20 residents. Twelve residents were identified as needing two-person assistance for transfers and/or ADL cares, nine on the RCF unit and three on the MCC unit. During a group resident interview at 3:00 pm on 02/10/25, two unsampled residents reported excessive call light response times. The facility’s posted staffing plan, staffing schedule from 02/01/25 to 02/08/25, and call light response times for two unsampled residents from the group interview were reviewed with Staff 1 (ED) and Staff 2 (Wellness Director) at 9:00 am on 02/12/25. The following was identified: The posted staffing plan for the facility RCF was as follows: * Day shift: 3 CG, 1 MT; * Evening shift: 2.5 CG, 1 MT; and * Night shift: 1 CG, 0.5 MT. The posted staffing plan for the facility MCC was as follows: * Day shift: 2.5 CG, 1 MT; * Evening shift: 2 CG, 1 MT; and * Night shift: 1 CG, 0.5 MT. The two unsampled residents called for assistance a total of 32 times from 02/01/25 to 02/08/25. Nine calls were in excess of 20 minutes, ranging from 22 minutes to 61 minutes, or a total of 28% of calls. During the interview at 9:00 am on 02/12/25, Staff 1 stated on night shift, staff offered toileting for residents who needed two-person assistance on a schedule, to accommodate staff lunches. She acknowledged the CG assigned to the MCC unit would not be able to leave the locked unit to assist with unscheduled needs in RCF while one staff was on lunch. She further acknowledged, given the high number of residents requiring two-person staff assistance and the facility design of two RCF floors plus a locked MCC unit, the number of staff scheduled on night shift was insufficient to meet fire safety and evacuation standards. The need to ensure adequate staffing to meet residents’ scheduled and unscheduled needs and fire safety and evacuation standards was discussed with Staff 1, Staff 2 (Wellness Director), and Staff 6 (Operations Specialist) on 02/12/25. They acknowledged the findings. Refer to C363.

1. The community will review the current staffing plan based on acuity, unscheduled needs, and emergency evacuation needs. 2. The Executive Director and Wellness Director received additional training on the Acuity Based Staffing - Oregon Policy and ABST Review Form on 2/27/25. 3. The Executive Director will review the staffing plan will be evaluated with each move in, significant change of condition, and quarterly service plan update per the Acuity Based Staffing - Oregon Policy. 4. The Executive Director will ensure the corrections are completed and monitored.

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 411-054-0037 (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 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 interview and record review, it was determined the facility failed to ensure their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing for 2 of 4 sampled Residents (#s 1 and 6). Findings include but are not limited to: A review of the facility’s ABST revealed the care times and care elements documented for cares provided by staff were not accurate for Residents 1 and 6. On 02/12/25 the need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1 (ED). She acknowledged the findings. ?

1. The community will audit the service plan to the information entered in the ABST portal to ensure care time and care elements are accuurately captured. 2. The Executive Director and Wellness Director received addition on the Acuity Based Staffing - Oregon Policy on 1/23/25 and 2/27/25. 3. The Wellness Director and Executive Director will review the ABST portal data with each move in, significant change of condition, and quarterly service plan update. 4. The Executive Director will ensure te corrections are completed and monitored.

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 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:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - 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: ?Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 2 of 4 sampled Residents (#s 1 and 3) and multiple unsampled residents, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to: The facility was licensed as a RCF with a separate, distinct MCC unit. 1. During the acuity interview, four residents were identified as having recently moved into the facility, two residents were identified as having experienced a recent significant change of condition, and the facility census was confirmed as 54 residents. The facility’s ABST was reviewed with Staff 1 (ED) at 9:00 am on 02/12/25. The following was identified: a. The four residents who recently moved into the facility had no ABST evaluations. b. Resident 1, who experienced a significant change of condition, requiring meal escorts and full physical feeding assistance, did not have evidence the ABST was updated with the significant change of condition. c. Thirty-three out of 54 residents’ ABST evaluations did not have evidence they were updated no less than quarterly, at the time of the service plan update. During an interview at 9:00 am on 02/12/25, Staff 1 stated the facility was updating and reviewing residents’ ABSTs “at the beginning of the month and at admission.” 2. The facility’s posted staffing plan and staffing schedule from 02/01/25 to 02/08/25 were reviewed with Staff 1 and Staff 2 (Wellness Director) at 9:00 am on 02/12/25. The following was identified: The posted staffing plan for the facility RCF was as follows: * Day shift: 3 CG, 1 MT; * Evening shift: 2.5 CG, 1 MT; and * Night shift: 1 CG, 0.5 MT. The posted staffing plan for the facility MCC was as follows: * Day shift: 2.5 CG, 1 MT; * Evening shift: 2 CG, 1 MT; and * Night shift: 1 CG, 0.5 MT. Review of the facility schedule from 02/01/25 to 02/08/25 revealed the facility failed to staff per the posted staffing plan on three shifts in RCF and ten shifts in MCC, or 27% of total shifts. During the interview, Staff 2 provided evidence that one of the shifts had been covered by the facility’s Wellness Directors. No documentation of coverage was provided for the remaining shifts. The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly, and the need to ensure consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1, Staff 2, and Staff 6 (Operations Specialist) on 02/12/25. They acknowledged the findings.

1. The commuity will complete an audit to ensure that all current residents have been entered into the ABST portal. 2. The Executive Director and Wellness Director received additional training on the Acuity Based Staffing - Oregon Policy on 2/27/25. 3. The Wellness Director and Executive Director will review the ABST portal data and update the Acuity Based Staffing Review Form with each move in, significant change of condition, and quarterly service plan update. The community will maintain "as worked schedules" showing staffing per the posted staffing plan. 4. The Executive Director will ensure te corrections are completed and monitored.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - 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:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. 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 C 330.

1. The community will determine a method to ensure residents' privacy and dignity is maintained during personal ADL care and will provide a lock on bathroom doors in shared suites. 2. The Executive Director and Maintenance Director will receive additional training on the Apartment Turn Checklist (Bathroom). 3. The Maintenance Director will review with each apartment turn per the QA: Apartment Turn Checklist. 4. The Executive Director will ensure corrections are completed and monitored.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. 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. Findings include, but are not limited to: Refer to C 295, C 360, C 362, C 363 and H 1510.

Refer to C 295, C 360, C 362, C 363, and H 1510.

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:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure documentation all preservice orientation training requirements had been completed by 4 of 4 staff (#s 10, 12, 13, and 16) prior to beginning their job duties and LGBTQIA2S+ training had been completed by 1 of 3 long-term non-direct care staff (#11). Findings include, but are not limited to: Staff training records were reviewed with Staff 6 (Operations Specialist) and Staff 9 (Business Office Director) on 02/12/25. The following was identified: a. There was no documented evidence Staff 10 (Cook), hired 10/16/24, completed the following required preservice orientation training: * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food and fluids, preventing wandering, and use of a person-centered approach. b. There was no documented evidence Staff 12 (MT), hired 01/07/25, completed the following required preservice orientation training: * Approved LGBTQIA2S+ course. c. There was no documented evidence Staff 13 (CG), hired 09/05/24, completed the following required preservice orientation training: * Infectious disease prevention training; and * Preservice dementia training. d. There was no documented evidence Staff 16 (CG), hired 11/20/24, completed the following required preservice orientation training: * Approved Home and Community-Based Services course. e. There was no documented evidence Staff 11 (Cook), hired 09/13/23 completed the required biennial LGBTQIA2S+ course. The need to ensure all preservice orientation training was completed by staff prior to beginning job duties and to ensure LGBTQIA2S+ training was completed biennially was discussed with Staff 1 (ED), Staff 6, and Staff 9. They acknowledged the findings. ? ?

1. The community will complete an audit of all employee trainign records to ensure that all pre-service orientation training and LGBTQIA2S+ training has been completed. 2. The Executive Director and Business Office Director will receive additional training on the QA: Staff Records Checklist - Oregon form. 3. The Business Office Director will verify completion of staff training upon hire and monthly per the QA - Business Office Review Schedule. 4. The Executive Director will ensure corrections are completed and monitored.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

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 C 330.

Refer to C 330.

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: