OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 4 of 5 sampled residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 11/2013 with diagnoses including muscular dystrophy, left hemiplegia, and traumatic brain injury. The resident's 02/04/26 through 05/04/26 clinical record was reviewed, staff and the resident were interviewed, and the resident was observed. The service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Storage of vision devices; * How to provide emotional support to the resident at night; * Level of assistance and method of assisting the resident during evacuation; * Locations of pain; * Incontinence care details including where care should be provided; * Grooming and personal hygiene tasks which required assistance and grooming preferences including assistance with lipstick; * Definition of “excessive alcohol intake”; and * Level of assistance required to charge cell phone and preference to have cell phone near right hand. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED) and Staff 3 (Regional RN) on 05/06/26 at 1:20 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2024 with diagnoses of adult failure to thrive, dementia, and hypertension. Observation of the resident, interviews with staff and the residents’ family member, and review of the 04/08/26 service plan were completed during the survey. The service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Ambulation with an assistive device in his/her apartment; * Level of assistance required for transfers; * Level of assistance and assistive devices required in the event of an evacuation; * Level of assistance required for personal hygiene and grooming tasks; and * Level of assistance required for managing eyeglasses. The need to ensure the service plan reflected Resident 3’s current needs and provided clear instruction to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/06/26 at 1:45 pm. They acknowledged the findings. 3. Resident 1 was admitted to the assisted living facility in 11/2024 with diagnoses including end stage renal disease and type 2 diabetes mellitus with diabetic chronic kidney disease. Observations of the resident, interviews with staff and the resident, and a review of the 02/10/26 service plan were completed during the survey. The service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Instructions in the event of a seizure; * Instructions in the event of an evacuation, including the level of assistance required and the use of the assistive devices; and * Instructions for changing continuous glucose monitor sensors. Interviews with care staff revealed they did not know how to change the glucose monitor sensor, and there was no information in the MAR or service plan regarding sensor changes. In addition, the resident went to the emergency room following a seizure and was prescribed a new seizure medication. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 3 (Regional RN) on 05/06/26 at 12:50 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 02/2025 with diagnoses including cerebral infarction (stroke) and alcohol use disorder. The resident’s 02/13/26 service plan was not reflective of the resident’s status and/or did not provide clear instructions to staff in the following areas: * Taking medications with beer; and * Level of assistance and method of assisting the resident during evacuation. On 05/05/26 at 9:32 am, the surveyor observed Staff 4 (RCC) handing Resident 2 medications and Resident 2 taking those medications with beer from a can on a table nearby. In an interview on 05/06/26 at 1:17 pm, Staff 4 and Staff 12 (Lead MT) verified that Resident 2 would no longer take his/her medications with applesauce, as indicated in the current service plan and on the MAR, but would only take them with beer. The need to ensure the service plan was reflective of the resident’s status and care needs was discussed with Staff 1 (ED), Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/06/26 at 1:34 pm. They acknowledged the findings.

1) Service plans for residents #1, #2, and #5 were reviewed by RN to ensure that each is reflective pf residents needs and provides clear direction to care staff regarding resident assistance. 2) All service plans will be reviewed/updated quarterly and condition of change or service. 3) At least quarterly and with changes in service or condition. 4) RN, ED or designee will ensure corrections and monitoring as described.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessed a resident with a significant change of condition and documented findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 2, 3, and 7) who experienced a significant weight change. Findings include, but are not limited to: 1. Resident 7 was admitted to the community in 08/2025 with diagnoses including anxiety disorder and major depressive disorder. Review of Resident 7’s clinical record, including weight records dated 08/06/25 through 04/05/26, identified the following: * 08/06/25 – 216.6 pounds; * 11/05/25 – 193.6 pounds; * 02/05/26 – 161.4 pounds; * 04/05/26 – 152.0 pounds; and * 05/05/26 – 147.6 pounds (during the survey). The record showed the resident had a significant weight loss between 08/06/25 and 11/05/25. The resident lost 23.0 pounds, or 10.81 % of his/her body weight, which represented a significant change in condition. The previous facility RN assessed the resident’s condition, six days after the weight loss was identified. The assessment included a plan for weekly weights for three weeks, and the facility implemented the plan. Review of the three-week weight record indicated the resident continued to lose weight. Between 08/06/25 and 02/05/26, the resident experienced a 55.2 pound loss, or 25.48% of his/her total body weight, in six months. This represented a significant weight loss. There was no documented evidence the facility RN assessed the resident’s condition, including findings, resident status, or interventions implemented as a result of the assessment. On 05/05/26 at 12:50 pm, Staff 3 (Regional RN) reported she scheduled a medical appointment for evaluation of the resident’s weight loss in April 2026. A series of diagnostic tests were completed, and the cause of the weight loss had not been determined. On 05/05/26 at 12:50 pm, Staff 3 (Regional RN) reported a medical appointment for evaluation of the resident’s weight loss was arranged in April 2026. A series of diagnostic tests were completed, and the cause of the weight loss had not been determined. In multiple staff interviews, it was confirmed the resident was independent in all ADLs, including meal intake preferences. Staff reported the resident often skipped breakfast and consumed either lunch or dinner, resulting in one meal a day. The resident received nutritional supplements with alternate meals. During the survey, the resident remained in his/her room, did not attend breakfast, and requested staff to provide lunch in his/her apartment. Staff confirmed the resident received protein shakes with each lunch meal. During the survey, an attempt was made to conduct an interview with the resident; however, the resident declined the interview. In addition, the surveyor was not able to complete meal observations, as the resident remained in his/her room for most of the time during the survey. The need to ensure an RN assessed residents with a significant change of condition and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 3 (Regional RN) on 05/06/26 at 12:50 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2024 with diagnoses of adult failure to thrive, dementia, and hypertension. Review of Resident 3’s clinical record, including monthly weight records dated 11/25 through 04/26, were reviewed during the survey, and the following was identified: * 11/25 - 74.1 pounds; * 12/25 – 77.0 pounds; * 02/26 – 77.8 pounds; * 03/16/26 – 76.4 pounds; and * 04/16/26 – 81.2 pounds. The record showed Resident 3 had a significant weight gain of 5.9% in 30 days between 03/16/26 and 04/16/26. In an interview on 05/05/26 at 11:40am, Staff 3 (Regional RN) confirmed that she was not aware of the significant weight gain and had not completed an RN assessment for significant change of condition. The need to ensure an RN assessment was completed for a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/06/26 at 1:45 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 02/2025 with diagnoses including alcohol use disorder and cerebral infarction (stroke). Resident 2’s 11/2025 through 04/2026 weight records were reviewed, and the following was identified: * 03/13/26 – 138 pounds; and * 04/13/26 – 131 pounds. The resident lost seven pounds in 30 days, or 5% of his/her total body weight. This constituted a significant change of condition. There was no documented evidence an RN assessed the resident’s significant weight loss, and documented findings, resident status, and interventions made as a result of the assessment. In an interview on 05/05/26 at 9:01 am, Resident 2 reported s/he ate all his/her meals in his/her apartment and frequently did not eat the food provided by the facility. Resident 2 reported s/he would often fix frozen pot pies or Hot Pockets® in the microwave if s/he did not like the food served by the facility. The resident’s service plan indicated s/he had a history of alcohol use disorder. On 05/05/26 at 9:32 am, the resident was observed to take medication with beer. The need for an RN to complete a significant change of condition assessment, which documented findings, resident status, and interventions made as a result of the assessment, for all significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/06/26 at 1:34 pm. They acknowledged the findings, and no additional documentation was provided.

1) Residents #2, #3, and #7 were assessed for signifcant change of condition and interventions were put into place. 2) RN or designee will review weight exceptions weeekly for needed reviews. 3) Resident weights will be reviewed at least monthly or as indicated by condition or medical provider order. 4) RN, ED or designee will be responsible for the corrections and monitoring herein.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by an RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (# 1) who received subcutaneous injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to: Pursuant to OAR chapter 851, division 006, delegation process means the process utilized by an RN to authorize a UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions, and outcomes pursuant to OAR 851-045 including comprehensive assessment and reasoned conclusions that identify client problems and risks, educate the UAP, evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. Resident 1 was admitted to the assisted living facility in 11/2024 with diagnoses including end stage of renal disease and type 2 diabetes mellitus with diabetic chronic kidney disease. During the acuity interview on 05/04/26, Resident 1 was identified to be administered a subcutaneous injection daily by a facility UAP. Review of Resident 1's 04/01/26 through 05/04/26 MARs revealed the resident received Lantus (insulin to treat diabetes) once daily and Aspart (insulin to treat diabetes) three times daily. The insulin was given by Staff 8 (MT/CG), Staff 9 (MT/CG) and Staff 12 (Lead MT) on multiple occasions. The MAR indicated the resident used a continuous glucose monitoring sensor instead of traditional fingerstick blood glucose monitoring and the sensor should be changed every 14 days. Review of the resident’s clinical records showed the following: * There was no documented evidence regarding rationale that the task could be safely delegated to Staff 8, 9, and 12; * On 04/03/26, staff documented in a progress note they did not know how to change the continuous glucose monitoring sensor when the resident requested a sensor change. There was no documented evidence the facility delegated the RN to teach staff how to change the continuous glucose monitoring sensors as part of the delegation process; * Staff 8 documented on the MAR she administered Resident 1’s insulin injection on 04/01/26, 04/08/26, 04/01/26 and 04/17/26. The initial evaluation for Staff 8's skills and ability was completed on 04/17/26 which indicated Staff 8 administered insulin to the resident prior to the initial delegation; * Staff 9 documented on the MAR she administered Resident 1’s insulin injection on 04/06/26, 04/21/26 and 04/23/26. The initial evaluation for Staff 9's skills and ability was completed on 04/23/26 which indicated Staff 9 administered insulin to the resident prior to the initial delegation; * The initial evaluation for Staff 12’s skills and ability for insulin injection was completed on 10/14/25 and scheduled for re-evaluation in 90 days, which was approximately 01/02/26. The re-evaluation was completed on 02/26/26, 55 days after the scheduled re-evaluation; and * In an interview via phone on 05/06/26 at 12:50 pm, Staff 15 (Delegating RN) confirmed there was no documentation regarding how to change the sensor. The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by an RN in accordance with the OARs adopted by the OSBN in chapter 851, division 047 was reviewed with Staff 1 (ED), Staff 3 (Regional RN), and Staff 15 on 05/06/26 at 12:50 pm. They acknowledged the findings.

1) RN will ensure delegation process and documentation is followed per OAR and OSBN rule. This will include documenting rationale that the task(s) can be safely delegated to staff regarding delegatable tasks (including but not limited to CBG sensor application/change). RN will also ensure that no staff are providing care/medication requiring delegation prior to the delegation process completion. Re-delegation time limits will be appropriately adhered to. 2) RN and ED will review delegation process/procedure with new staff to ensure training process is followed and only properly delegated staff are providing care/medications falling under that delegation until trainees' delegation is completed. RN and ED will ensure that re-delegation timelines are met by reviewing delegations per OSBN guidelines. 3) RN and ED will review delegations at least every 180 days (based on each delegation date), or earlier depending on judgement of RN. 4) RN will be responsible for these corrections and ED will be responsible to provide oversight.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents who chose to self-administer their medications were evaluated to assure their ability to safely self-administer medication at least quarterly and had a physician's or other legally recognized practitioner's written order of approval to self-administer for 3 of 3 residents (#s 1, 2, and 4) who chose to self-administer medications. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 03/2026 with diagnoses including bipolar disorder. The resident’s clinical record, dated 03/10/26 through 05/04/26, was reviewed, and the following was identified: The resident had move-in orders signed by his/her physician, dated 03/18/26, which did not include approval for the resident to self-administer prescription medication. In an interview on 05/05/26 at 12:02 pm, Staff 3 (Regional RN) confirmed the facility did not have a signed order for the resident to self-administer his/her medication. The need to ensure a resident who chose to self-administer medication had a physician's or other legally recognized practitioner's written order of approval was reviewed on 05/06/26 at 1:20 pm with Staff 1 (ED) and Staff 3. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 02/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 02/04/26 through 05/04/26 clinical record was reviewed, and the following was identified: * A physician order signed 02/23/26 indicated the resident could self-administer a Ventolin HFA Inhalation Aerosol Solution every four hours as needed for shortness of breath or wheezing, without supervision; and * The facility completed a self-medication administration assessment on 05/2025. There was no documented evidence the resident was evaluated quarterly to ensure his/her continued ability to safely self-administer medication. In an interview on 05/06/26 at 1:34 pm, Staff 1 (ED) confirmed the resident had not been evaluated quarterly for his/her ability to safely continue self-administering medication. The need to evaluate the resident’s ability to safely self-administer medication quarterly was discussed with Staff 1, Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/06/26 at 1:34 pm. They acknowledged the findings. No additional documentation was provided. 3. Resident 1 was admitted to the assisted living facility in 11/2024 with diagnoses including end stage renal disease and type 2 diabetes mellitus with diabetic chronic kidney disease. The resident’s 02/04/26 through 05/04/26 clinical record was reviewed, and the following was identified: * A physician order signed 03/18/26 indicated the resident could self-administer Flurometholone (for eye inflammation), one drop in his/her left eye two times per day unsupervised; and * The facility completed a self-medication administration assessment on 05/2025. There was no documented evidence the resident was evaluated quarterly to ensure his/her continued ability to safely self-administer medication. In an interview on 05/05/26 at 9:50 am, Staff 3 (Regional RN) confirmed the resident had not been evaluated quarterly for his/her ability to safely continue self-administering medication. The need to evaluate the resident’s ability to safely self-administer medication quarterly was discussed with Staff 1 (ED), Staff 2 (Senior ED), and Staff 3 on 05/06/26 at 12:50 pm. They acknowledged the findings.

1) Residents #1, #2 and #4 were all assessed for the ability to self administer medications and doctor orders to do so were obtained. 2) Prior to new resident moving into the commuity, RN and ED will ensure there are orders from the primary care provider stating resident may self-adminster medications. After receiving orders for self-administration, the RN will complete a self-med assessment either prior to move-in or the day of move-in. 3) Self-med assessments will be re-evaluated at least quarterly after initial completion. 4) RN, ED and/or designee will continue to monitor to ensure compliance.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an adequate number of direct care staff on the overnight shift to meet fire safety evacuation standards as required by the fire authority or the Department based on the facility’s structural design. Findings include, but are not limited to: The facility’s acuity-based staffing tool was reviewed on 05/05/26 at 12:30 pm. The posted staffing plan indicated there were two direct care staff scheduled for each overnight shift. Staffing schedules showed there were two direct care staff on each overnight shift between 04/27/26 and 05/03/26. At the time of the survey, 05/04/26 through 05/07/26, the facility was home to 55 residents. The facility consisted of three floors, with common areas in the center of the structure, spanning all three floors, and a wing on each side of the common areas on all three floors. It was determined through staff interviews that eight residents living on the second floor and three residents living on the third floor used wheelchairs as their means of ambulation. Interviews between 05/04/26 and 05/07/26 revealed that direct care staff did not know the procedure for evacuating residents who used wheelchairs to ambulate if there was a need to move them to a different floor of the building or outside. There was a “med sled” available on the second floor for moving residents down the stairs. Interviews with direct care staff on 05/06/26 revealed staff were not aware the “med sled” was available and did not know how to use it. In an interview on 05/07/26 at 8:25 am, Staff 5 (Maintenance Director) reported that staff were expected to ensure residents either stayed in their apartments during fire drills or moved them beyond fire doors if the fire was in the vicinity of their apartment. Staff 5 reported there hadn’t been a full evacuation of the building to a designated point of safety outside of the building in the last five years. Staff 1 (ED) acknowledged the facility was not able to demonstrate that two care staff were enough to meet fire evacuation standards, since evacuation had never been taught or practiced. The need to ensure there were an adequate number of direct care staff on the overnight shift to meet fire safety evacuation requirements was discussed with Staff 1, Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/07/26 at 10:10 am. They acknowledged the findings.

1) Care staff will be trained on the location of the med sled, proper use of the med sled, and effectively evacuating wheelchair bounds residents behind a fire door or out of the community. A full evacuation with 2 staff will be performed to ensure the building can meet fire evacuation standards in compliance with OFC and OAR. If able to demostrate meeting of standards, staff will continue to be trained and practice this evacuation annually. If unable to demostrate, staffing levels will be reviewd and adjusted appropriately. 2) ED or designee will review training at least twice annually. Conducting a fire drill on NOC shift quarterly. 3) ED or designee will review twice annually. 4) ED or designee.

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 maintain and accurately capture ABST care time and care elements staff were providing to each resident as outlined in each individual service plan for 4 of 5 sampled residents (#’s 2, 3, 4, and 5). Findings include, but are not limited to: During the survey, from 05/04/26 through 05/07/26, ABST care time and care elements for five sampled residents were reviewed, residents were observed, and staff and residents were interviewed. Resident 2, 3, 4, and 5’s ABST care time and care elements were not reflective of the care services that were provided by staff as outlined in each residents’ individual service plan. The need to ensure the ABST care time and care elements staff were providing as outlined in each individual service plan were accurately captured and maintained was reviewed with Staff 1 (ED), Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/06/26 at 1:45 pm. They acknowledged the findings.

1) Residents 2, 3, 4 and 5 will have a full ABST review including any necessary assessments, staff interview, observation, and resident interview to ensure the ABST is reflective of their service plans and care time required for each. 2) ED, RN and/or designee will ensure ABST is reviewed at least prior to new move-in, quarterly and with any change of condition. 3) Prior to new move-in, quarterly and with any change of condition. 4) RN, ED and/or designee.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated before a resident moved in and/or no less than quarterly at the same time the resident’s service plan was updated for 3 of 5 sampled residents (#s 3, 4, and 5) whose ABST data was reviewed. Findings include, but are not limited to: During the survey, from 05/04/26 through 05/07/26, ABST data for five sampled residents was reviewed. Resident 3, 4, and 5’s ABST data was not updated quarterly at the same time their service plan was updated, and Resident 4’s information was not entered into the ABST prior to moving into the facility. The need to update the ABST according to the schedule in rule was discussed with Staff 1 (ED), Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/06/26 at 1:20 pm, 1:34 pm, and 1:45 pm. Staff acknowledged the findings.

1) Residents 3, 4 and 5's ABST will be reviewed and updated as needed based on staff/resident interview, service plan review, observations and any required assessments to ensure they are reflective and updated in a timely manner per regulation. 2) ED, RN and/or designee will ensure ABST is reviewed at least prior to new move-in, quarterly and with any change of condition. 3) Prior to new move-in, quarterly and with any change of condition. 4) RN, ED and/or designee.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and recorded according to Oregon Fire Code (OFC), and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: On 05/05/25 at 3:28 pm, six months of facility fire drill and fire and life safety records, from 11/2025 through 04/2026, were requested and reviewed with Staff 1 (ED) and Staff 2 (Senior ED). The following was determined: 1. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. 2. Fire drill records lacked documentation of the following required elements: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. 3. During multiple staff interviews, staff failed to identify the designated point of safety. In interview on 05/07/26 at 8:25 am, Staff 5 (Maintenance Director) reported he was at different locations during fire drills and was not able to observe staff activities throughout each drill. He confirmed no residents were relocated during the fire drills. The need to ensure fire drills were conducted according to the OFC and staff were provided fire and life safety instruction on alternate months was discussed with Staff 1, Staff 2, and Staff 3 (Regional RN) on 05/07/26 at 10:00 am during the exit. They acknowledged the findings.

1) Fire and life safety instruction will be provided every other month per OAR for staff including the designated meeting place outside of the building. Fire drill documents will include notes on problems encountered and comments relating to residents who resisted or failed to participate in fire drills as well as the number of residents evacuated. 2) Maintenance director or designee will utilize a yearly, planned schedule of topics for fire and life safety instruction to be provided to staff on alternate months from fire drills. Staff will be trained on the designated meeting place outside of the building. Maintenance director or desginee will ensure fire drill documents will include required notes. 3) ED or designee will review fire drill documentation and fire and life safety instruction on alternating months to ensure compliance. 4) ED or designee.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the Oregon Fire Code (OFC) and other applicable state and local codes as required. Findings include, but are not limited to: The facility was a three-story building with a central common area that connected all three floors. Each floor had a wing on either side of the central common area and was divided into separated sections designated as “high” and “low,” based on room numbers. Facility staff were assigned to care areas according to these high and low room number designations. During the acuity interview on 05/04/26 and other staff interviews throughout the survey, the resident census was identified at 55. Eight residents on the second floor used wheelchairs for ambulation, and three residents on the third floor used wheelchairs for ambulation. During interviews conducted between 05/04/26 and 05/07/26, multiple care staff expressed they had not received training on how to locate or evacuate residents who used wheelchairs for ambulation from different floors. Staff reported they did not know the procedure for evacuating residents with mobility limitations if there was a need to move them to another floor or outside the building. Staff further reported they were not aware of any equipment to use for evacuating residents in the event the elevator was not functioning. Review of the disaster preparedness binder showed no documented evidence the facility conducted emergency preparedness drills at least twice a year. During an interview on 05/07/26 at 10:00 am, Staff 5 (Maintenance Director) stated the facility had not practiced a drill of the emergency preparedness plan that included residents for over five years. The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC, and other applicable state and local codes as required, was discussed with Staff 1 (ED), Staff 2 (Senior ED), and Staff 3 (Regional RN) on 05/07/26 at 10:00 am during the exit. They acknowledged the findings. No further information was provided.

1) A drill of the emergency preparedness plan will be conducted with staff and residents once by 7/6/26 and a second, tabletop drill will be scheduled for before the end of the calendar year for 2026. Staff training for this will include the designated meeting place outside the building, where to find the information regarding each resident's mobility needs during evacuation, how to evacuate those with mobility requiring assistance from different floors, location and use of "med-sled" equipment for evacuation. 2) ED or designee will ensure that these drills will be scheduled each year including any required training. 3) ED or designee will evaluate this requirement at least annually to ensure compliance. 4) ED or designee will be responsible.