Print Inspection: RL003929

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and meet the fire safety evacuation standards during the overnight shifts based on resident acuity and facility structural design. Findings include, but are not limited to: During the survey, conducted 04/21/25 through 04/24/25, the ALF was observed to house 51 residents on three floors. On 04/22/25 the facility completed documentation regarding their acuity-based staffing tool (ABST) which documented eight residents who required multi-person transfer or care, living on all three floors. Observations of the community, conducted from 04/21/25 to 04/24/25, revealed that multiple sampled and unsampled residents used walkers and wheelchairs for mobility. The facility's posted staffing plan indicated the night shift, scheduled from 10:00 pm to 6:00 am, consisted of one MT and one CG. In an interview on 04/23/25, Staff 3 (Regional Director of Health Services) reported that their process for evacuating the building in the event of an emergency included calling the operations and administrative staff who lived nearby to assist. Staff 2 (Assistant ED) and Staff 3 reported that a full building evacuation had been conducted in March when a smoky smell had been detected. They reported multiple staff had assisted with the evacuation and the elevator had been used, per the fire department’s approval. Staff 3 stated if the night shift MT and CG were providing care for a resident requiring 2-person assistance and another resident needed assistance, they were to ensure the resident requiring 2-person assistance was “kept safe” while checking on the other resident to determine if s/he could wait. The night shift staffing plan was insufficient to meet the fire evacuation standards of the Department for multiple sampled and unsampled residents based on their acuity and building structural design, and to meet the scheduled and unscheduled needs of the residents. At 1:55 on 04/23/25 the Surveyor requested of Staff 1 (Interim ED), Staff 2, and Staff 3 that a third direct care staff be added to the night shift. The facility provided documentation of three night shift direct care staff on the schedule 04/23/25 through 04/26/25, and reported they would continue to staff their night shift at this level. The need to have a sufficient number of direct care staff to meet the scheduled and unscheduled needs of the residents and fire evacuation standards was discussed on 04/24/25 at 1:30 pm with Staff 1, Staff, 2, and Staff 3. They acknowledged the findings.

Staffing for NOC shift was increased. Routine review of residents evacuation needs will be conducted in conjunction with the service planning process. Routine evacuation drills will take place as per regulations Staffing will be reviewed during daily stand up Quartelry/with a significant change of condition Daily at stand up ALD with ED oversight

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety records dated 10/25/24 through 3/27/25 were reviewed during the survey, conducted 04/21/25 through 04/24/25. The following was identified: * Fire drill documentation indicated all fire drills were being held at 2:00 pm (shift change time) and drills for the independent living part of the facility were documented for the assisted living residents. * In an interview on 04/21/25 at 12:42 pm, Staff 2 (Assistant Executive Director) indicated she informed residents of scheduled fire drills. * There was no documented evidence staff were consistently provided fire and life safety instruction on alternate months from fire drills. On 04/24/25 at 12:30 pm, the need to follow the OFC requirements for fire drills and fire and life safety for staff was discussed with Staff 1 (Interim Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (Director of Health Services, Regional). They acknowledged the findings. No further documentation was provided.

Fire drills for NOC and Day shift have been scheduled along with a all staff fire drill training. Calendar for ongoing alternating fire drills/staff training was established for community to follow. Re-education on the alternating fire drill/training routine was provided to ED and department heads to assure understanding. ED and maintenance director will review adherence to the fire drill/training calendar weekly. Maintenance Director with ED oversight

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: