Print Inspection: CHOW012914

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure resident injuries were promptly investigated to rule out abuse and/or neglect and reported to the local Department office if abuse could not reasonably be ruled out for 1 of 1 sampled resident (# 6) who experienced injuries of unknown cause. Findings include, but are not limited to: Resident 6 was admitted to the facility in 02/2021 with diagnoses including vascular dementia and type 2 diabetes mellitus. The resident’s clinical record was reviewed, dated 03/17/26 through 07/05/26, interviews with the resident and staff were conducted and observations of the resident were made. The following was identified: * 04/21/26 - Staff documented the resident complained of left finger pain and presented with diffuse bruising and swelling. Staff further documented the resident did not know what happened or how s/he sustained the skin injury. On 04/22/26, it was documented that the resident had “acute non displaced fracture” of the fourth finger; and * 06/10/26 - Staff documented the resident had a bruise on his/her “right arm just above the elbow.” Staff further documented the resident did not know what happened or how s/he sustained the skin injury. On 07/07/26 at 12:15 pm, the resident was observed operating the power wheelchair throughout the facility. When asked about the skin injuries, the resident stated s/he was unsure how the wound occurred. The resident was unable to state what happened regarding skin injuries. On 07/07/26 at 11:08 am, the facility was requested to provide documented evidence of an investigation to determine the cause of the skin injuries. Staff 4 (Resident Services Coordinator) reported they did not have any documentation, including incident reports, to rule out the cause of skin injuries. There was no documented evidence the facility immediately investigated the resident’s injuries of unknown cause to rule out suspected abuse or neglect and there was no documented evidence the facility reported the incident to the local Department office. On 07/07/26 at 4:05 pm and 07/08/26 at 9:38 am, the injuries of unknown cause were reported to the local department and confirmation was received. The need to ensure injuries of unknown cause were immediately investigated to rule out suspected abuse or reported to the local office if abuse could not be ruled out was reviewed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 and Staff 5 (Resident Services Coordinator) on 07/08/26 during the exit interview. They acknowledged the findings.

1. Resident #6 injuries of an unknown cause were reviewed and reported to APS. Staff will be re-educated on incident reporting, investigation requirements, documentation and mandatory reporting of injuries of an unknown cause. 2. The community will implement a standardized process requiring staff to immediately report injuries of an unknown cause to a supervisor. During daily clinical jump meeting (Monday - Friday) a review of the 24hr report and 72 hour report on Mondays will occur noting incidents with injury. The licensed nurse, HS administrator, RSC or designee will promptly review the incident, ensure required documentation is completed, initiate an investigation, and report to APS as appropriate when abuse cannot be reasonably ruled out. 3.Incident reports, investigations and progress notes will be evaluated daily (Monday- Friday) during daily clincial jump. Additional audit will take place during weekly health services jump meeting; will be continued without end date. 4.Health services administrator, licensed nurse, and resident services coordinator or designee.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence and personal care for 1 of 1 sampled resident (# 3) whose care was observed. Findings include but are not limited to: Resident 3 was admitted to the facility in 10/2021 with diagnoses including multiple sclerosis and was identified during the acuity interview on 07/06/26 as requiring two-person staff assistance for care. During the survey on 07/07/26, the following was observed: The surveyor entered the resident’s room with permission and observed Staff 8 (MT) and Staff 11 (CG) provide incontinent care between 8:57 am and 9:09 am while the resident was lying in bed, with gloved hands. Both staff touched and removed the residents soiled brief that was saturated and leaked onto a chux pad. Both staff provided incontinent care. Staff 11 cleaned the resident with wipes and applied a clean incontinence product and barrier cream treatment without changing gloves. Throughout the observation, Staff 11 failed to change her gloves or perform hand hygiene between clean and dirty tasks. The need to ensure infection prevention and control practices were followed during personal care was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 and Staff 5 (Resident Services Coordinator) on 07/07/26 at 1:25 pm. They acknowledged the findings.

1. Staff to be re-educated immediately on hand hygiene, glove changes, and assuring proper infection control practices are in place during dirty to clean instances example: performing peri care. 2.Staff will receive TSL infection control training approved by ODHS during orientation, annually, and as needed. The direct supervisors or designee will complete routine observations to ensure proper infection control practices. 3. Weekly infection control observations ongoing to assure competency then monthly. 4.Health services administrator, licensed nurse, resident services coordinator and designee.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and PRN medications included resident-specific parameters with staff instructions for 3 of 4 sampled residents (#s 1, 3 and 6) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure. Resident 1’s 06/01/26 through 07/06/26 MARs were reviewed during the survey and were found to be lacking accurate information and resident-specific parameters to guide unlicensed staff in the following areas: • Multiple PRN pain medications containing acetaminophen were used without clear instructions and precautions to prevent exceeding the 3000 mg per day limit; and • Multiple PRN bowel care medications lacked clear parameters for when to administer and which medication to be given first. The need for resident-specific parameters and clear instruction to unlicensed staff who administered medications was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator) at 11:30 am on 7/8/26. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 10/2021 with diagnoses including multiple sclerosis. Resident 3's 06/01/26 through 07/06/26 MAR were reviewed. The following was identified: * Multiple PRN cough medications, did not have clear parameters to instruct unlicensed staff regarding when the medications should be administered, and which medication should be given first. The medications were not administered to the resident during the review period. The need for resident-specific parameters and clear instruction for PRN medications to unlicensed staff who administered medications was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator) at 1:25 pm on 07/07/26. They acknowledged the findings. 3. Resident 6 moved into the facility in 02/2021 with diagnoses including vascular dementia and type 2 diabetes mellitus. Resident 6's 06/01/26 through 07/06/26 MAR were reviewed. The following was identified: * Multiple PRN pain medications, including tramadol, lidocaine patch and Tylenol, lacked clear parameters regarding when they should be administered, and which medication should be given first. Tramadol was administered to the resident on three occasions during the review period; and *Multiple PRN bowel care medications lacked clear parameters for when to administer and which medication to be given first. The medications were not administered to the resident during the review period. The need for resident specific parameters and clear instruction for PRN medications to unlicensed staff who administered medications was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator) at 1:35 pm on 07/07/26. They acknowledged the findings.

1. All identified resident MAR's were reviewed and updated to include resident-specific PRN parameters and clear administration instructions. All Med Techs will be re-educated by licensed nurse or designee. 2.New and updated medication orders will be reviewed by the licensed nursed, HS Administrator and or designee. 3. Two systems are in place to ensure PRN medications have appropriate administration parameters. 1.) Med Techs will identify PRN orders without parameters, document "DO NOT GIVE – Notify Nurse," and then notify the nurse. The licensed nurse verifies all PRN orders during the final medication review before administration. 2.) During weekly quality meetings PRN orders are reviewed to identify and correct any missing administration parameters. Together, these processes will provide multiple layers of oversight to support resident safety and regulatory compliance on a weekly and ongoing basis. 4. Health services administrator, license nurse, resident services coordinator and designee.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure ABST care time accurately reflected resident care needs for 2 of 5 sampled residents (#s 2 and 4) whose ADL care time and service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 08/2023 with diagnoses including osteoarthritis. Resident 4’s clinical record was reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. Review of Resident 4’s ABST showed inaccurate minutes recorded for care time in the following areas: * Dressing and undressing; * Toileting, bowel, and bladder management; * Bathing; * Transfers; and * Ambulation. On 07/07/26 at approximately 1:05 pm, the need to ensure resident ABST evaluations accurately captured care time and care elements was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2023 with diagnoses including chronic atrial fibrillation and syncope (fainting or passing out). Resident 2’s clinical record was reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The resident was observed to have bandages on his/her lower legs and forearm throughout the survey. The resident’s individual ABST minutes were not reflective of the care time provided by staff in the following areas: * Monitoring of physical conditions; and * Time providing treatments. The need to ensure resident ABST evaluations accurately captured care time and care elements was reviewed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator) on 07/08/26 at 11:00 am. They acknowledged the findings.

1. ABST's for affected residents were reviewed and corrected to accurately reflect residents care needs and service plans 2. ABST's will be reviewed with each service plan update and or with significant resident care needs change to ensure care minutes accurately reflect services provided. 3. ABST audits will be completed monthly. 4. Health services administrator, resident services coordinator and 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:

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 completed prior to a resident moving in for 1 of 1 sampled resident (#5) who had recently moved into the facility. Findings include, but are not limited to: Resident 5 was admitted to the facility in 07/2026 with diagnoses including dementia. The facility ABST was reviewed on 07/06/26 and revealed Resident 5’s ABST had not been entered. During an interview with Staff 2 (Health Services Administrator) on 07/06/26 at 11:23 am, it was reported she had been on vacation and confirmed Resident 5’s ABST information had not been entered. On 07/07/26 at approximately 1:25 pm, the need to ensure the ABST was reviewed and updated prior to resident move-in was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), Staff 4 (Resident Services Coordinator), and Staff 5 (Resident Services Coordinator). They acknowledged the findings.

1. Resident # 5's ABST questionaire was completed. Current residents ABST's will be reviewed to verify completion and accuracy. 2. An ABST completion checklist will be used before move-in and after significant changes to ensure required evaluations are completed timely. 3. Move-in records and ABST's will be audited ongoing. 4. Health services administrator, resident services coordinator and 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: