OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to update the initial resident evaluation during the 30 days following move-in, and/or failed to ensure the most recent quarterly evaluation was relevant to the needs and conditions of the resident for 3 of 4 sampled residents (#s 1, 2, and 3) whose initial or quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the community in 03/2024 with diagnoses including atrial fibrillation, acute kidney failure and shortness of breath. The resident’s most recent quarterly evaluation dated 01/30/25, MAR dated 02/01/25 through 02/21/25, service plan, and intermediate service plans were reviewed, and staff were interviewed. The evaluation was not relevant to the current needs and conditions of the resident in the following areas: * Skin issues; * Treatments; and * Toileting assistance. On 02/20/25, the need to ensure quarterly evaluations were relevant to the needs and conditions of the residents was discussed with Staff 1 (ED), Staff 2 (RN), Staff 4 (RCC), Staff 5 (RCC), Staff 6 (Business Office Manager), and Staff 25 (Regional Nurse Consultant). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 05/2023 with diagnosis’s including hypertension. In interviews with Staff 9 (MT) and Staff 13 (CG), on 02/19/25, it was reported Resident 3 smoked independently off campus. On 02/19/25, survey requested from Staff 4 (RCC) a copy of Resident 3’s smoking evaluation for their ability to smoke safely. Staff 4 reported she was unable to find a copy of a smoking evaluation since 05/2023. There was no current documented evidence Resident 3 had been evaluated for the ability to smoke safely. On 02/19/25 at approximately 1:15pm, Staff 4 provided survey with a smoking evaluation for Resident 3. On 02/20/25, the need to ensure quarterly smoking evaluations were completed for residents who smoked was discussed with Staff 1 (ED), Staff 2 (RN), Staff 5 (RCC), and Staff 6 (Business Office Manager). They acknowledged the findings. 3. Resident 1 was admitted to the facility in 11/2024 with diagnoses including Amyotrophic Lateral Sclerosis (ALS). a. During an interview with Staff 3 (Vice President of Operations) on 02/19/25 at 11:35 am, she reported the facility had started to update but did not complete the 30-day evaluation for Resident 1. b. Resident 1’s quarterly evaluation was completed on 02/02/25. The evaluation was not updated to reflect the resident's current needs and condition in the following areas: * Bowel and Bladder: Toileting assistance; and * Adaptive devices for eating/drinking. On 02/20/25, the need to ensure 30-day evaluations were completed/updated for new admissions, and quarterly evaluations were updated and reflective of the resident's needs and condition was discussed with Staff 1 (ED), Staff 4 (RCC) and Staff 25 (Regional Nurse Consultant). They acknowledged the findings.

1. Evaluations for residents #'s 1, 2 & 3 have been updated to accurately reflect the residents current needs. 2. Evaluations will be completed prior to admission, within 30 days, quarterly and with a significant change of condition. Commuity has implemented an evaluation/service planning tool to aid in tracking due dates for evaluations, service plan updates, service plan meetings and ABST updates. All evaluations and service plans will be reviewed for accuracy at time of completion. Triggered ancillary evaluations will be reviewed during daily standup to ensure they are completed timely. 3. The evaluation schedule will be reviewed daily during the clinical review meeting, including all ancillary evaluations 4. The Executive Director will be responsible for maintaining this system.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition had resident-specific instructions or interventions developed and communicated to staff on all shifts, and/or weekly progress documented until resolution for 3 of 4 sampled residents (#s 1, 2 and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2024 with diagnoses including Amyotrophic Lateral Sclerosis (ALS). The resident's 02/04/25 service plan, 11/21/24 through 02/18/25 interim service plans, progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without resident specific actions/interventions developed and communicated to staff, and/or progress noted at least weekly until resolved in the following areas: * 11/2024 - Admission to facility; * 12/05/24 - Fungal rash; and * 01/29/25 - Elevated blood pressure, with instruction to check blood pressure daily and provide a low sodium diet. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, and/or actions/interventions developed and communicated to staff was discussed with Staff 1 (ED), Staff 4 (RCC), and Staff 25 (Regional Nurse Consultant) on 02/20/25. They acknowledged the findings. 2. Resident 2 moved into the community in 03/2024 with diagnoses including atrial fibrillation, acute kidney failure, and shortness of breath. The resident’s progress notes dated 12/02/24 through 02/19/25, service plan dated 01/31/25, and intermediate service plans were reviewed, and interviews with staff were conducted. The following was identified: There was no documented evidence the following changes of condition were monitored with weekly progress noted until resolution: * 12/22/24 – Bed bug infestation; * 01/03/25 – Sore on bottom; * 01/11/25 – Scabs on right shoulder; and * 01/23/25 – Rash under left side of stomach fold. During an interview at 3:30 pm on 02/19/25, Staff 25 (Regional Nurse Consultant) confirmed there was no evidence these changes of conditions were monitored at least weekly until resolution. The need to ensure weekly progress was noted until resolution for short-term changes of condition was discussed with Staff 1 (ED), Staff 2 (RN), Staff 4 (RCC), Staff 5 (RCC), Staff 6 (Business Office Manager), and Staff 25 (Regional Nurse Consultant). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 09/2021 with diagnoses including osteoarthritis, skin melanoma, and multiple sclerosis. Review of Resident 4's progress notes, dated 11/19/24 through 02/19/25, revealed the resident experienced the following changes of condition: * On 1/23/25, a progress note reported a “pressure sore on left big toe;” and * On 02/05/25, a progress note described a bruise on the resident’s right calf “approx. the size of a baseball and yellow/green/purple in color.” There was no documented evidence the skin conditions were monitored for progress at least weekly, to resolution. On 02/20/25, the need to ensure monitoring of skin conditions weekly to resolution was discussed with Staff 1 (ED), Staff 2 (RN), Staff 5 (RCC), and Staff 6 (Business Office manager). They acknowledged the findings.

1. RN has evaluated residents # 1, 2 & 4 for any changes of condition and has resolved the need for on-going weekly monitoring. 2. To prevent recurrence, staff will be reeducated on our alert charting guidelines and when to notify the RN. 24 hour summary will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will include a RN assessement, and ongoing monitoring at least weekly until resolution. ISPs will be written to communicate to staff the areas needing to be monitored and clear instructions as to what to monitor and when to notify the nurse. 3.This system will be evaluated five days a week as part of daily stand up meeting, which includes a review of all residents on alert charting. This system will further be evaluated monthly as part of the CQI process which includes a review of all residents with a change of condition. 4. The RN and Executive Director will be responsible for maintaining this system.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

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 observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. The failure to have adequate staff to meet the residents scheduled and unscheduled needs on night shift placed residents at high risk for harm. Findings include, but are not limited to: During the entrance conference on 02/19/25 the following was identified: * The facility had 43 residents; * Six residents needed two-person assistance with transfers and/or care; and * One resident was identified to have behaviors, cognitive impairment, a history of multiple elopements and remained a high elopement risk. The staffing plan posted at the front desk on 02/19/25 was as follows: * Day shift 1 MT and 3.5 CG's; * Evening shift 1 MT and 3 CG's; and * Night shift 1 MT and 1 CG. Staff and resident interviews completed on 02/19/25 and 02/20/25 between 9:40 am and 4:30 pm showed the following: A non-sampled resident approached the survey team and expressed concerns regarding the staffing on the weekends and the night shift. The resident indicated there were only two staff on night shift with some occasions when there had been only one. The resident indicated s/he had expressed their concerns to administration but felt ignored. The resident stated the facility “got wild” at night and there were frequently numerous lights going off. Staff did their best and were running to get to everyone. The resident indicated s/he was not the only one with concerns, but s/he was one of the few not afraid to speak up. An additional non-sampled resident indicated there was not enough staff at night, some weekends and some evenings. The staff did the best they could to get to lights quickly, but they needed more help. She reported that as far as s/he knew there were only three in the evenings and only two at night. Staff 22 (Housekeeping) indicated the facility had a red slide that looked like a sled to move residents from the second floor to the first floor in case of a fire or other evacuation needs. The staff indicated she was aware of at least two residents that would need to use the slide down the stairs because of their physical conditions. She believed two staff would be safer and more effective to operate the sled and slide residents down the stairs. Staff 12 (CG), Staff 15 (CG) and Staff 20 (CG) indicated there were multiple residents on the second floor that would require the “slide” to evacuate in the case of an emergency. The staff described the device as a large sled used to slide the residents down the stairs to the first floor when they were unable to walk down the stairs. The staff indicated there were several residents in wheelchairs or with partial paralysis. Additionally, Staff 12, 15 and 20 stated there were several residents who could not stand for long periods who would also need the slide/sled because there would be no guarantee they could stand long enough to get down the stairs. The staff indicated the slide/sled was large and awkward, so two staff were needed to safely maneuver the stairs, ensure the resident did not fall out, and to help transfer the resident from inside the sled at the bottom of the stairs, into a chair and out of the facility as necessary. The staff further indicated night shift had only two staff. They were unsure how two staff could get residents moved down the stairs in the sled and assist the other residents in an emergency. Staff 12 took the surveyor to the location of the sled. The slide/sled was approximately 6-6.5 feet long by approximately 2.5-3 feet wide. The sides of the slide/sled were a few inches in height and there was no seat belts or other straps connected to the interior or exterior of the device. Staff 10 (MT), Staff 12 (CG) and Staff 16 (CG) indicated there were six residents that required two-person assistance for transfers and/or care. The staff stated when the call lights go off on night shift a lot of the time, they were the residents who needed two-person assistance. The staff further indicated there was one resident, Resident 5, who required 1:1 when out of his/her room. The staff stated the resident frequently got up on night shift and wanted hot cocoa and to visit. The resident was on the move a lot, staff had to chase Resident 5 often, and s/he had left the building twice in the last few months. The resident had air tags in his/her clothes due to high elopement risk. The staff indicated night shift only had two staff total and sometimes was down to one staff due to call outs. When staff must track Resident 5, only one staff was left to handle the two person assists and everything else on the two floors. Staff 4 (RCC) indicated Resident 5 was no longer a 1:1 unless s/he left the building then staff had to follow. While in the building the resident was to be kept in line of sight of staff. Staff 1 (ED) stated Resident 5 was no longer a 1:1 unless s/he left the building. Staff were to follow the resident if s/he left the facility, otherwise staff were to keep the resident in line of sight when s/he was out of their room. Staff 1 acknowledged that depending on the resident’s location in the building the staff monitoring him/her would not be able to take care of any other resident needs and essentially become the resident’s 1:1 while s/he was on the move. Staff 1 confirmed night shift had one medication technician and one caregiver. Observations of the facility on 02/19/25, at approximately 9:10 am, Resident 5 was noted to have behaviors around the staff work area and was difficult to redirect. The resident was observed pushing through staff at the front desk after s/he had climbed over a closed baby gate at the opening of the reception desk. Multiple attempts by several staff were made before the resident was willing to exit the area and return to the dining room. Additional observations of the common areas between 02/19/25 and 02/20/25, showed Resident 5 in the dining room or up moving around the halls on the first floor. The resident was intermittently given a walker to utilize but would quickly walk away from the device. Five sampled residents were reviewed for service planned needs and ABST entries. All five residents had multiple areas which were not reflective of the actual time staff required to provide the care to the individual residents. ADL areas with inaccurate time noted included transfers, toileting, dressing and behaviors. The need to ensure resident supervision was maintained throughout each shift and to ensure enough staff were available to meet the scheduled and unscheduled needs of the residents to ensure resident care and safety was discussed with Staff 1 (ED) on 02/20/25. He acknowledged the findings. Staff 1 was asked to increase staffing for night shift to two caregivers and one medication technician. Staff 1 and Staff 5 (RCC) provided names of staff who would be working as the additional staff on night shift beginning 02/20/25 through 02/23/25. They would continue to update the schedule to ensure three total staff on night shift were present going forward.

1. The community has staffed to mandated levels discussed as of 2/20/25 and 2/24/25. 2. The RCC, Staffing Coordinator and ED will meet weekly to discuss ongoing staffing needs. This will include a review of call response times, ABST data and evacuation needs. Staffing levels will be reviewed to ensure appropriate staffing is maintained. 3. Resident acuity and evacution needs will be reviewed prior to admission, within 30 days, quarterly or with significant change of condition and the ABST will be updated to reflect any changes. The schedule will be reviewed daily during the clinical review meeting. 4. The Executive Director will be responsible for maintaining this system.

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 observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: The facility's ABST was reviewed and discussed with Staff 1 (ED) on 02/19/25 and 02/20/25. Review of Residents 1, 2, 3, 4 and 5’s ABST input revealed multiple ADLs were not reflective of the residents' evaluated care needs. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1, Staff 4 (RCC), Staff 5 (RCC) and Staff 25 (Corporate Nurse Consultant) on 02/20/25. They acknowledged the findings. No further information was provided.

1. ABST tool has been updated to accurately reflect time needed to meet all current resident needs, including sampled and unsampled residents. 2. Newly implemented tracking tool will be utilized to ensure ABST is updated and reviewed for accuracy prior to move in, within 30 days, quarterly or with any change of condition. 24 hour report will be reviewed to ensure all changes in condition have been identified and updates have been made. 3. This system will be evaluated weekly to ensure that all necessary updates to the ABST have been completed and that the times are accurate and reflective. This will also include verification that the staffing plan still meets the scheduled and unscheduled needs of the current population. 4.The Executive Director will be responsible for maintaining this system.

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 observation, interview and record review, it was determined the facility failed to ensure resident ABST entries were updated at least quarterly. Findings include, but are not limited to: Review of the facilities ABST entries was completed and showed the following: * The staffing tool showed there were five residents whose ABST entries were not updated at least quarterly in conjunction with the residents’ service plans. The need to ensure all residents’ ABST entries were updated at least quarterly was discussed with Staff 1 (ED) on 02/19/245and 02/20/25. He acknowledged the findings.

1. ABST tool has been updated to accurately reflect time needed to meet all current resident needs, including sampled and unsampled residents. 2. Newly implemented tracking tool will be utilized to ensure ABST is updated prior to move in, within 30 days, quarterly or with any change of condition. 24 hour report will be reviewed to ensure all changes in condition have been identified and updates have been made. 3. This system will be evaluated weekly to ensure that all necessary updates to the ABST have been completed and that the staffing plan still meets the scheduled and unscheduled needs. 4.The Executive Director will be responsible for maintaining this system.

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:

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 the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 02/19/25 showed the following areas in need of cleaning and/or repair: * Rooms 107, 109, 110, 116, 118, 203, 209, 219 and 224 had scrapes, dings and/or spills to the doors and door frames; * Common area bathrooms on the first floor had cracked, brown and/or missing caulking around the toilets; * Carpet stains of varying sizes and colors were noted in the center of the dining room and in the front entryway. Additional significant carpet stains were noted from the doorways to the center of the hallway, of rooms 104 and 107. Tile inserts in the dining room floor near the kitchen and the sliding patio doors, were chipped and dinged with small pieces of tile missing; * Two armchairs located on the second floor, center hall, had large spills/stains to the seats and a nearby bar stool was torn and worn at the seams which exposed the fabric underneath the vinyl layer; * Room 117 had significant carpet stains and wall damage. A corner wall in the main living area had large chips, dings and chunks of missing plaster/dry wall. A wall in the bathroom was also dinged, chipped and scrapped with a loose baseboard. The counter top was chipped with missing laminate, and caulking around the toilet was brown and cracked with small missing pieces; and * The resident laundry room had scrapes and spills to the door, as well as a long scrape to the back wall. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 02/19/25. He acknowledged the findings.

1. All repairs and cleanings identified during the survey have been either completed or scheduled for completion. 2. The Executive Director will complete weekly community walkthroughs with the Maintenance Director to identify areas in need of attention and potentially out of compliance. Additionally each resident apt. will be evaluated using our environmental evaluation tool twice a year to identify any repairs needed inside the apt. Expectations for staff reporting needed repairs or cleaning will be reviewed at the all staff meeting in March, and will be reviewed with all new hires during new hire orientation. 3. This system will be monitored weekly by completing walkthroughs. Completion of identified tasks will be reviewed monthly as part of CQI process. Due dates for environmental evaluations will be reviewed during daily standup meetings. 4. The Maintenance Director and Executive Director will be responsible for maintaining this system.

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:

OAR411-004-0020(2)(h) Individual Visitors: Any Time (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (h) Each individual may have visitors of his or her choosing at any time. This Rule is not met as evidenced by: Based on interview and record review it was determined the facility had restricted resident rights to visitors for 1 sampled (#3) and 1 non-sampled resident. Findings include, but are not limited to: During the facility HCBS interview it was determined the facility had 24/7 visiting hours available for most residents. Two residents were identified to have restrictions in place preventing specific family members from coming to the facility due to concerns regarding the visitors conduct. Staff 1 (ED) indicated Resident 3 and a non sampled resident both had restrictions in place related to specific visitors. No individually based limitation (IBL) had been completed regarding the restriction of this resident right. Staff 1 indicated he would get IBLs for both residents completed and submitted for review. The need to ensure an IBL was completed when the need to restrict a residents’ right to visitors at any time, was discussed with Staff 1 and Staff 3 (VP of Operations) on 02/19/25. The staff acknowledged the findings.

1. IBL's have been filed with the appropriate agencies for both identified residents who had restrictions in place for visitors. 2. The community will ensure that HCBS rights are reviewed as part of the service planning process to ensure that they are being guaranteed for all residents. Anytime a need for a restriction on visitation is identified, this will not be put in place without getting an IBL in place as required by regulation. 3. This will be evaluated at time of move in, within 30 days and quarterly thereafter or with a change in condition as part of the evaluation/service planning process. 4. The Executive Director will be responsible for maintaining this system.

OAR411-004-0020(2)(h) Individual Visitors: Any Time (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (h) Each individual may have visitors of his or her choosing at any time. This Rule is not met as evidenced by:

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. This Rule is not met as evidenced by: Based on interview and record review it was determined the facility failed to ensure Individually Based Limitations (IBLs) were completed when the need to restrict a residents’ rights arose. Findings include, but are not limited to: Refer to H1521.

1. IBL's have been filed with the appropriate agencies for both identified residents who had a need for an IBL. 2. The community will ensure that HCBS rights are reviewed as part of the service planning process to ensure that they are being guaranteed for all residents whenever applicable, and that if there is a need for an IBL that is identified and implemented appropriately. 3. This will be evaluated at time of move in, within 30 days and quarterly thereafter or with a change in condition as part of the evaluation/service planning process. 4. The Executive Director will be responsible for maintaining this system.

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. This Rule is not met as evidenced by: