OAR 411-054-0037 (4-7) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete, update, review, and document 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 and corresponding with resident service plan updates, updating 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 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. (a) The posted staffing plan must incorporate: (A) The total ABST care time in minutes per shift, per day. If a proprietary ABST does not have this functionality, at a minimum the ABST total time must be shown in daily minutes as referenced in paragraph (2) of this rule. (B) The unscheduled care needs of residents. (C) The staffing requirements outlined in OAR 411-054- 0070(1). (D) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (E) The 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. (F) The facility’s distinct and 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. Each distinct and segregated area must have a posted staffing plan. (G) The staffing needs required under the Specific Needs Contracts, if applicable. (b) The facility must maintain staffing documentation to show consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (c) The facility must maintain historical posted staffing plans. The posted staffing plan must contain the date(s) it was effective. Records must be kept for a minimum of three years. (6) CONSISTENTLY MEETING NEEDS. The facility must consistently meet the scheduled and unscheduled needs of all residents, 24 hours a day, seven days a week. (7) 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 a 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 numbers as indicated in 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 update and review the acuity-based staffing tool (ABST) evaluation for each resident when the resident experienced a significant change of condition, or no less than quarterly and corresponding with residents’ service plan updates for 3 of 3 sampled residents (#s 2, 3, and 4), failed to use the results of the ABST to develop and routinely update the posted staffing plan, and failed to ensure the staffing plan outlined the staffing numbers required to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to: a. Resident ABST records were reviewed on 09/28/26. The following was identified: * Resident 2 experienced a significant change of condition in 08/2026, and the most recent service plan was dated 09/25/26. The resident’s ABST evaluation was last updated on 01/05/26. * Resident 3’s most recent service plan was dated 09/25/26. The resident’s ABST evaluation was last updated on 03/25/26. * Resident 4’s most recent service plan was dated 07/09/26. The resident’s ABST evaluation was last updated on 02/06/26. b. On 09/28/26 at 10:26 am, the posted staffing plan was observed in the facility lobby. The staffing plan was not dated and indicated the following: * Day shift (6 am – 2 pm): Four caregivers and one MT; * Evening shift (2 pm -10 pm): Four caregivers and one MT; and * Night shift (10 pm – 6 am): Two caregivers and one MT. On 09/29/26 at 9:02 am, Staff 1 provided a document titled “Employee Staffing Ratios and Time” and indicated the current staffing plan was as follows: * Day shift: Six CG’s and two MT’s; * Swing shift: Six CG’s and one MT; and * Night shift: Three CG’s and one MT. On 09/30/26 at 12:50 pm, Staff 1 (ED) acknowledged the posted staffing plan was outdated and not what he was currently staffing. c. On 09/28/26, the facility’s ABST showed the minimum direct care staff required to address scheduled needs were: * Day shift – 11 (rounded up from 10.676); * Swing shift – 10.5 (rounded up from 10.468); and * Night shift – 2 (rounded up from 1.02). On 09/30/26 at 12:50 pm, Staff 1 acknowledged he did not use the results of the ABST time per shift to develop and update the posted staffing plan. The need to ensure residents’ ABST data was updated following a significant change condition and no less than quarterly, the facility used the results of the ABST to develop and routinely update the posted staffing plan, and the staffing plan outlined the staffing numbers required to meet the scheduled and unscheduled needs of the residents was reviewed with Staff 1 on 09/30/26 at 2:00 pm. He acknowledged the findings.

1)ABST & Staffing plan are to be updated for each resident according to the following schedule: a) Before the resident moves in. b) Whenever there is a significant change in condition. c) Monthly and corresponding with resident Service Plan updates. 2)Staffing plan consistent with ABST standard and scheduled updates shall be posted according to outlined details of the following items: a) Required and actual/current ABST care time in minutes per shift, per day. b) Required and actual/current staffing numbers to meet the scheduled and unscheduled care needs of residents. 3)Staffing plan will be evaluated and modified according to ABST scheduled parameters as specified in item number (1). 4) Executive Director & Director of Health Services will monitor and evaluate the correction monthly.

OAR 411-054-0037 (4-7) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete, update, review, and document 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 and corresponding with resident service plan updates, updating 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 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. (a) The posted staffing plan must incorporate: (A) The total ABST care time in minutes per shift, per day. If a proprietary ABST does not have this functionality, at a minimum the ABST total time must be shown in daily minutes as referenced in paragraph (2) of this rule. (B) The unscheduled care needs of residents. (C) The staffing requirements outlined in OAR 411-054- 0070(1). (D) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (E) The 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. (F) The facility’s distinct and 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. Each distinct and segregated area must have a posted staffing plan. (G) The staffing needs required under the Specific Needs Contracts, if applicable. (b) The facility must maintain staffing documentation to show consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (c) The facility must maintain historical posted staffing plans. The posted staffing plan must contain the date(s) it was effective. Records must be kept for a minimum of three years. (6) CONSISTENTLY MEETING NEEDS. The facility must consistently meet the scheduled and unscheduled needs of all residents, 24 hours a day, seven days a week. (7) 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 a 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 numbers as indicated in the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training ? Pre-service Temporary rule language in effect until 02/05/2027 (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS? RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures per OAR 411-054-0090 and 411-054-0093. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility?s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident?s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 15, 16, 17, and 18) completed all required pre-service orientation training. Findings include, but are not limited to: Staff training records were reviewed on 09/29/26 at 9:50 am with Staff 1 (ED) and Staff 5 (RCC), and the following was identified: a. There was no documented evidence Staff 17 (MT), hired 06/05/26, and Staff 15 (MT), hired 06/15/26, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; * Infectious disease prevention training; and * Home and Community-Based Services training. b. The date of completion for Residents’ Rights training was not documented to ensure the training topic was completed prior to beginning their job duties for Staff 16 (CG), hired 08/01/26, Staff 18 (Cook), hired 04/03/26, and Staff 17. The need for staff to complete all required pre-service orientation training was discussed with Staff 1 at 2:00 pm on 09/30/26. He acknowledged the findings.

To make sure that Pre-service orientation for all employees are done prior to beginning their job responsibilities. All employees must complete the following required training: 1) Pre-service Orientation which includes position description with their job responsibilities. 2) Resident rights including the Department-approved LGBTQIA2S+ training. 3) Abuse and reporting. requirements. 4) Fire safety and emergency procedures per OAR 411-054-0090 and 411-054-0093. 5) Infectious disease and prevention. 6) Home and Community Based Services training. 7) Food Handling. 8) Pre-Service Dementia training for all direct care staff. The Resident Care Coordinator will be responsible for staff compliance and the complete documentation of all trainings prior to beginning their assigned jobs and duties.

OAR 411-054-0070 (3-4) Staffing Requirements and Training ? Pre-service Temporary rule language in effect until 02/05/2027 (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS? RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures per OAR 411-054-0090 and 411-054-0093. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility?s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident?s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: