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 minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs and to meet the fire safety evacuation standards as required by the fire authority or the Department. Findings include, but are not limited to: The facility consisted of three distinct areas in a single one-story building that housed 27 residents at the time of the survey. Distinct area A housed 10 residents, area B housed 12 residents, and area C housed 5 residents. The current facility staffing plan and Acuity-Based Staffing Tool (ABST) were reviewed, and interviews with facility staff were conducted. The following was revealed: * Area A had two residents who required two-person assist; * Area B had one bed-bound resident who required two-person assist; * Area C had one bed-bound resident who required two-person assist; * During the acuity interview, the facility stated there was one resident in the facility who needed two to three persons to assist with transfers; and * According to the facility’s actual staffing plan, two direct care staff were scheduled to cover the night shift, leaving only one staff available to assist residents who required two-person assist while the other staff was on break. During an interview on 03/12/26 at 10:29 am, Staff 1 (ED) stated the facility’s night shift staffing policy was to instruct direct care staff not to leave the premises during breaks, therefore making the staff available in case any second person assist is needed. However, no written policy was available. The need to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs, and to meet the fire safety evacuation standards as required by the fire authority or the Department, was reviewed with Staff 1 and Staff 2 (Regional Director of Clinical Operations) on 03/12/26 at 10:48 am. They acknowledged the findings.

A written policy has been developed stating that night shift staff are not permitted to leave the building during their meal break. Due to the requirement to remain on-site, night staff will be paid for their meal break. If a meal break is interrupted for any reason related to resident care or operational needs, the meal break will be restarted once the interruption has been concluded. All night shift staff will be notified of the implemented policy and provided education on expectations regarding meal periods and on-site requirements. Supervisors will review the policy with staff and ensure understanding. Supervisors will monitor compliance through shift coverage checks and timekeeping reviews. Any violations of the policy will be addressed promptly through corrective action as appropriate. This policy will be reviewed annually.

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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 03/09/26, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed the following: * Staff were not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated. The requirements regarding fire drills were discussed with Staff 4 (Maintenance) and Staff 1 (ED) on 03/11/26 at 1:24 pm. They acknowledged the findings.

The Executive Director has reviewed fire drill requirements with all department heads, emphasizing that residents must be evacuated or relocated during each fire drill to the extent consistent with safety and resident condition and alternating fire areas. • Maintenance manager will ensure that all future fire drills include resident evacuation or relocation. • Staff conducting fire drills are required to fully complete fire drill documentation, including escape routes used, number of occupants evacuated or relocated, encountered problems, start and end time of drill, and resident participation issues. The facility’s fire drill policy and documentation form was reviewed and it clearly outline required drill elements, including evacuation/relocation procedures and documentation expectations. • Fire drill documentation templates were reviewed to ensure mandatory fields for: • Start and End Time • Notification method • Escape route(s) used • Number of residents evacuated or relocated • Problems encountered • Resident resistance or non-participation The Executive Director or designee will review fire drill documentation after each drill for completeness and compliance with evacuation and documentation requirements. • Any identified deficiencies will be addressed promptly with additional staff education or corrective action as needed. A monthly review of documents will be preformed by the Executive Director and Maintenance Manager.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed, at least annually, on fire and life safety procedures according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 03/11/26 at 11:12 am. On 03/11/26 at 11:55 am, Staff 4 (Maintenance) was asked to explain the facility's process for re-instructing residents on fire and life safety procedures. Staff 4 reported he was responsible for providing fire and life safety training to all residents. However, the facility was unable to produce any documented evidence confirming the training had been given at least annually. The need for residents to be re-instructed on fire and life safety procedures at least annually, per the OFC, was discussed with Staff 4 and Staff 1 (ED) on 03/11/26 at 1:24 pm. They acknowledged the findings.

The Executive Director will initiate resident fire and life safety in-service to management on OAR 411-054-90 to ensure residents receive required education. • Residents have been provided instruction on fire and life safety procedures, including fire alarm response, evacuation routes, areas of refuge, and actions to take during a fire emergency. • Documentation will be reviewed to ensure resident instruction is recorded and retained. • A standardized annual fire and life safety education schedule has been implemented to ensure all residents receive instruction upon admission and at least annually thereafter. • A tracking log will be utilized to document resident participation, dates of instruction, topics covered, and any resident refusals or limitations. • The Executive Director will review resident fire and life safety instruction log to ensure annual instruction is completed and documented for all residents. • Any missed or incomplete instruction will be addressed promptly through re education and/ or corrective action. • Audits will be conducted the selected month(s) annual instruction is due by the Executive Director and or Maintance Manager.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: