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 ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 3 moved into the facility in 04/2025 with diagnoses including schizophrenia. The move-in evaluation failed to address the following elements: * Customary routines, including eating and bathing; * Spiritual, cultural preferences and traditions; * Ability to use call system; and * Recent losses. The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Administrator) and Staff 2 (Director of Operations) on 05/21/25. The findings were acknowledged.

To correct this deficiency, we have updated our evaluation form to incorporate all required elements, ensuring that these questions are addressed prior to move-in. This revised form will now be utilized for all screenings and evaluations. Additionally, the facility administrator will conduct regular reviews of the evaluation form and make necessary updates in response to any changes in the OARs to maintain compliance.

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 ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 5 moved into the facility in 07/2025 with diagnoses including paranoid schizophrenia. The move-in evaluation failed to address the following elements: * Customary routines, including sleeping; * Interest, hobbits, social, leisure activities; * Spiritual, cultural preferences and traditions; * Mental Health issues including presence of thought disorders or behavioral or mood problems, history of treatment and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Independent activity of daily living including housework and laundry and transportation; * Pain with pharmaceutical and non-pharmaceutical interventions including how a person expressive pain or discomfort; * Indicators of nursing needs including potential for delegated nursing tasks; * Complex medication regimen; and * Environmental factors that impact the resident’s behavioral including but not limited to noise, lighting, and room temperature. The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Administrator) on 08/11/25. The findings were acknowledged.

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 observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition had actions or interventions communicated to staff on each shift, and the condition was monitored with weekly progress noted until resolution for 2 of 2 sampled residents (#s 1 and 2) who experienced short term changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into facility in 03/2021 with diagnoses including Type 2 diabetes, traumatic brain injury, and dementia. Observation of Resident 1, interviews with staff and review of the resident's 04/26/25 service plan, progress notes dated 02/20/25 through 05/20/25, and incident investigations were reviewed. Fall prevention interventions listed on the service plan included care staff to remind Resident 1 to use a 4-wheeled walker while ambulating throughout the facility, encourage use of the 4-wheeled walker and to pull a call light as needed for assistance, and anti-slip tape was placed near the resident’s bed. Additionally, staff were to remind Resident 1 to make sure a chair was behind him/her before they sat down, assist with donning shoes, and to encourage Resident 1 to practice what was learned from home health PT and OT. On 05/21/25, Resident 1 was observed to utilize a wheelchair for means of mobility and could self-propel it using his/her feet. During an interview on 05/21/25 at 1:10 pm, Staff 5 (MA/Universal Worker) stated Resident 1 had been using a wheelchair for their primary means of mobility for approximately the last month. a. Resident 1 had the following short-term changes of condition that lacked documentation of what action or intervention was needed, the determined action or intervention communicated to staff on each shift, and the condition monitored with weekly progress noted until the condition resolved: * 03/02/25 – Unwitnessed fall in the common area; * 03/05/25 – Two unwitnessed falls in bedroom; * 03/06/25 – Unwitnessed fall in bedroom; * 03/12/25 – Found on floor in bedroom; * 03/24/25 – Unwitnessed fall in the dining room with right knee abrasion; * 04/04/25 – Unwitnessed fall; * 04/09/25 – Started an antibiotic; * 04/09/25 – Right great toenail removal; * 04/13/25 – Two unwitnessed falls in bedroom; * 04/14/25 – Return from hospital after unwitnessed fall; * 04/29/25 – Started two new medications; and * 05/08/25 – Unwitnessed fall in bedroom. b. Resident 1 had the following short-term changes of condition that lacked documentation of what action or intervention was needed, and the determined action or intervention was communicated to staff on each shift: * 03/17/25 – Unwitnessed fall in bedroom; and * 03/24/25 – Slid out of chair in dining room. The need to ensure short term changes of condition had actions or interventions communicated to staff on each shift, and the condition was monitored with weekly progress noted until resolution was discussed with Staff 1 (Administrator) and Staff 2 (Director of Operations) on 05/21/25. The findings were acknowledged. 2. Resident 2 was admitted in 04/2022 with diagnoses which included neurogenic bladder, urethral injury and had a history of urinary tract infections. Observations of Resident 2, interviews with staff and the resident were conducted, and the 02/12/25 service plan and progress notes dated 02/03/25 through 05/18/25, were reviewed. Resident 2's progress notes indicated s/he was started on antibiotics on 04/09/25 for a urinary tract infection. The facility initiated short-term change monitoring. However, no monitoring until resolution was documented. Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Administrator) and Staff 2 (Director of Operations) during interviews on 05/21/25. They acknowledged the findings. No further information was provided.

This deficiency will be corrected by performing a full audit of resident records over the past 60 days; it will be conducted to identify any additional residents with a short-term change of condition lacking proper documentation or follow-up. A Change of Condition Tracking Tool will be introduced to monitor compliance. Monthly audits will be conducted by the Administrator for the next 6 months to ensure ongoing compliance. If trends are identified, corrective actions will be implemented immediately.

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 411-054-0037 (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 they were staffing to meet the requirements under the Specific Needs Contract and to ensure their acuity-based staffing tool (ABST) evaluations were completed prior to residents moving into the facility, including 1 of 1 sampled resident (#3) and one unsampled resident. Findings include, but are not limited to: ABST data was reviewed during the survey, from 05/20/25 through 05/21/25. The following was identified: a. Upon entrance of the facility, a copy of the staffing plan was requested. The facility provided a copy of the staffing plan on 05/20/25 at 2:49 pm, which included the following information: * Day shift: three universal workers; * Evening shift: three universal workers; and * Night shift: two universal workers. The Specific Needs Contract stated, “Contractor shall provide a minimum ratio of 1 direct care staff for every 6 residents, with a total of three (3) direct care staff at full capacity on day and evening shifts. On night shift, Contractor shall provide a minimum ratio of 1 staff for every 8 residents, with a total of two (2) direct care staff at full capacity.” The facility had 16 residents serviced by the contract, which would equate to the three direct care staff for day/evening and two for night shift. In an interview with Staff 1 (Administrator) and Staff 2 (Director of Operations) on 05/21/25 at 11:25 am, it was stated the facility was using the Specific Needs Contract to determine appropriate staffing levels, as it was significantly higher than the ABST. The previous weeks’ staffing schedule for the universal workers was reviewed with Staff 1 and Staff 2 on 05/21/25 at 11:28 am and revealed four out of 21 shifts, or 19% of the shifts, were not staffed to meet the requirements of the Specific Needs Contract. Staff 1 and Staff 2 acknowledged the facility failed to staff to the Specific Needs Contract the week of 05/11/25 to 05/17/25. b. Upon survey entry on 05/20/25, two universal workers were observed in the facility. During an interview with the staff on 05/20/25, it was confirmed there were the only two present universal workers for the day shift at time of survey entry. c. Upon review of the ABST data, Resident 3 moved into the facility on 04/10/25 and an unsampled resident had moved into the facility on 04/17/25, respectively. However, their ABST evaluations were not completed until 05/20/25, during the survey event. During an interview with Staff 1 on 05/21/25 at 11:30 am, she acknowledged that the ABST evaluations were not completed prior to the residents moving in, as required. The need to ensure the facility was staffing to meet the requirements under the Specific Needs contract and to ensure the ABST evaluation was completed before a resident moved in was discussed with Staff 1 and Staff 2 on 05/21/25 at 11:30 am. The findings were acknowledged.

To correct this deficiency, the facility has incorporated the Acuity-Based Staffing Tool (ABST) into our pre-admission checklist, ensuring all evaluations are completed prior to move-in. This addition will prevent any new residents from being overlooked in staffing assessments. Furthermore, we have hired an on-call universal worker to reinforce staffing coverage and meet the requirements outlined in the Specific Needs Contract. To maintain compliance, staffing levels and ABST implementation will be monitored daily to identify and address any deficiencies or necessary adjustments. The facility administrator will oversee this process to ensure continued adherence to OAR 411-054-0037 and the successful completion of this correction.

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C252 and C613.

1. What actions were taken to correct the rule violation To correct the rule violation, we reviewed the re- licensure survey report received and completed all corrective tasks—including remediating environmental and documentation gaps, and filing proof of each correction in compliance. 2. How the system will be corrected to prevent recurrence To prevent recurrence, we will implemented an POC Tracking Log that captures every inspection report receipt date, draft and approval dates, submission date, Department acceptance date, and status of each corrective task, revised the facility’s standardized workflow with firm deadlines for logging, drafting, submitting, and documenting corrections. 3. Frequency of evaluation We will evaluate the area daily by confirming that new inspection reports are entered into the POC Tracking Log within one business day, weekly by having the Residential Care Coordinator review the log for pending POCs and outstanding tasks, monthly by conducting a formal audit of the log to verify timeliness and completion of corrective actions, and quarterly. 4. Individuals responsible for completion and monitoring The Administrator will receive and log all inspection reports and oversee the timely drafting and submission of POCs, the Residential Care Coordinator will maintain and audit the POC Tracking Log, generate weekly reminder reports, and present monthly audit findings to the Management team, The Administrator will execute assigned corrective actions and provide evidence of completion.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to: On 05/20/25 and 05/21/25 the exterior of the facility was toured. The following was identified: The concrete pathways had several areas of drop-offs of three inches or greater measured from the concrete surface to the planting bed along the front of the building. At the end of the sidewalk to the left side of the building, the sidewalk ended and had a seven-and-a-half-inch drop-off from the concrete surface to the planting bed. On 05/21/25 at 9:30 am, the areas were toured with Staff 4 (Maintenance). He confirmed he was aware of the drop offs. The need to ensure all exterior pathways were maintained in good repair was discussed and toured with Staff 1 (Administrator) and Staff 2 (Director of Operations). The findings were acknowledged.

To correct this deficiency, the facility has implemented structural modifications to address drop-off hazards. A mini fence has been installed at drop-offs exceeding 7 inches, while smaller drop-offs (1–2 inches) have been properly filled to eliminate potential risks. Additionally, a daily walkthrough has been incorporated into the administrator’s morning routine to ensure ongoing monitoring and maintenance. This process will be conducted systematically to identify and promptly address any new concerns. The facility administrator will oversee this correction to completion, ensuring continued compliance with OAR 411-054-0300 and maintaining a safe environment for residents and staff.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and maintained in good repair. Findings include, but are not limited to: The facility was toured on 05/20/25 and 05/21/25 and the following was observed: a. Exterior of building: * Dirt and debris were found on patio table and gazebo roof in the courtyard, smoking area, and front porch; * The front porch area and courtyard had boxes of sand and concrete mix stacked on tables and the ground; * There was an accumulation of moss and debris throughout the roof; * Two planters contained dead plants at the front of the building; * There was rotted wood observed at the roof adjacent to the gutter at the right of the entry to the building; * There was overgrown grass and foliage at the back of the building; and * There was a hole in the exterior window of Room 12. b. Interior of the building: * A transition strip was missing, and linoleum was peeling in the shared shower room adjacent to Room 12; * The carpet had a dark stain to the left of the door in front of Room 1; * There were multiple stains throughout the carpets in Room 8 and 12; * There were multiple stains on the carpet adjacent to the dining area and throughout the hallways; * An electrical outlet lacked a cover near the entrance; and * A round table in the living area had scratches and scrapes. The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator), Staff 2 (Director of Operations), and Staff 4 (Maintenance) on 05/21/25. They acknowledged the findings.

To address this deficiency, the facility has initiated a comprehensive cleaning and maintenance plan to ensure all interior and exterior materials and surfaces are kept clean and in good repair. Exterior corrections include removing dirt and debris from patio tables, gazebo roofs, the courtyard, smoking area, and front porch. Boxes of sand and concrete mix have been relocated from tables and the ground to appropriate storage areas. Moss and debris accumulation on the roof is currently being addressed through scheduled cleaning. Overgrown grass and foliage at the back of the building will be trimmed regularly to maintain the landscape. Additionally, rotted wood near the gutter at the entryway is scheduled for repairs. Previously identified issues, including dead plants in front planters and a hole in the exterior window of Room 12, have been fixed. Interior corrections include replacing the missing transition strip and addressing peeling linoleum in the shared shower room adjacent to Room 12. Carpet stains in Room 1, Room 8, Room 12, and throughout the hallways and dining area will undergo deep cleaning. The uncovered electrical outlet near the entrance has been repaired, and the scratched round table in the living area is scheduled for refinishing. A daily inspection checklist has been implemented to monitor progress, with assigned staff ensuring timely corrections. The facility administrator will oversee this process and confirm that all corrective measures are completed by July 20, 2025. Moving forward, routine inspections and maintenance schedules will be enforced to maintain compliance with OAR 411-054-0300

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 08/11/25 and the following was observed: The carpet had a dark stain to the left of the door in front of and inside of Room 1. The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator) and Staff 4 (Maintenance) on 08/11/25. They acknowledged the findings.

1. What actions will be/were taken to correct the rule violation for each example/resident. To correct the rule violation, the carpet stain in Room 1 was replaced with vinyl flooring on 08/15/2025. A comprehensive inspection of all carpeted areas will be completed by 09/25/2025. 2. How will the system be corrected so this violation will not happen again. To ensure this does not recur, we will revise the daily housekeeping checklist to include mandatory carpet- condition checks, implement a weekly environmental audit spot-checking entry thresholds and common-area carpets, and establish a quarterly deep-clean schedule for all carpets. The Maintenance Coordinator will coordinate all corrective and preventive cleaning measures. 3. How often will the area needing correction be evaluated? These areas will be evaluated daily by the Universal Workers, weekly by the Residential Care Manager through audit reviews, and monthly by the Safety Committee. The Universal Workers will monitor and initial each daily check, the Residential Care Manager will oversee weekly audits and checklist compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Administrator is responsible to see that the corrections are completed and monitored.

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: