Print Inspection: RL011970

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 ensure the Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements staff were providing to residents for 3 of 4 sampled residents (#s 1, 2 and 3) whose ABST evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 06/2023 with diagnoses including pulmonary hypertension and chronic kidney disease. Observations of Resident 2, interviews with staff, and review of Resident 2’s 02/19/26 service plan and ABST were completed. Observation and interview with staff on 05/19/26 at 9:45 am showed Resident 2 was primarily confined to bed and required two-person staff assistance for ADL care, including repositioning, transfers, incontinence care, bathing and dressing. Staff reported Resident 2 was on a two-hour schedule for repositioning and incontinence checks. The following ABST areas were not reflective of the time staff spent providing ADL assistance and care to Resident 2. * Monitoring physical conditions or symptoms; * Providing treatments, including skin care, wound care and/or antibiotic treatment; * Supervising, cueing or supporting while eating; and * Safety checks. On 05/21/26 at 8:45 am, the need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident was reviewed with Staff 1 (ED) and Staff 5 (Regional Director of Operations). They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2020 with diagnoses including arthritis and depression. Observation and interview of the resident, interviews with staff, and review of the 03/11/26 service plan and Resident 1’s ABST data was completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks and fall prevention; * Responding to call lights; * Monitoring behavioral conditions or symptoms; * Providing non-drug interventions for behavior; * Providing assistance with bathing; and * Providing assistance with dressing and undressing. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 5 (Regional Director of Operations) on 05/21/26 at 8:26 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2025, with diagnoses including dementia, Diabetes, and hypertension. Review of Resident 3’s service plan, dated 04/30/26, temporary care plans, individual ABST minutes, and interviews with care staff and the resident revealed the following: The resident's care time and care elements were found not reflective in the following areas: * Personal hygiene, such as shaving and mouth care; * Grooming, such as nail care and brushing hair; * Dressing and undressing; * Bathing; and * Cueing or redirecting due to cognitive impairment or dementia. On 05/21/26 at 8:40 am, the need to ensure the facility ABST accurately captured care time and care elements staff were providing for each resident was discussed with Staff 1 (ED) and Staff 5 (Regional Director of Operations). They acknowledged the findings.

1.) HWD/ALD/ED/Designee have updated the sampled residents ABST minutes to reflect outlined concerns noted. 2.) HWD/ALD/ED/Designee will review all residents and will have minutes/roster updated by EOD 6/10/2026 to accurately reflect current care needs. Community will be on a weekly call with RDO/RNC to review ABST for accuracy - we will run this call unti AOC date of 7/20/2026. 3.) Weekly and as needed. 4.) HWD/ALD/ED/Desginee.

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 ABST evaluations were completed before a resident moved in, and failed to update and review ABST evaluations no less than quarterly at the same time the residents’ service plans were updated for 4 of 4 sampled residents (#s 1, 2, 3 and 4) and multiple unsampled residents. Findings include, but are not limited to: Review of clinical records, including service plans and ABST evaluations for Residents 1, 2, 3, and 4 identified Resident 4’s ABST evaluation was not completed prior to move in. ABST evaluations for Residents 1, 2 and 3 were not updated and reviewed no less than quarterly at the same time the residents’ service plans were updated to reflect the residents' care needs and determine the staffing numbers required to meet residents’ scheduled and unscheduled needs. The ABST evaluation dates for multiple unsampled residents, reviewed during the survey, identified the ABST evaluations had not been reviewed and updated in the last 90 days (quarterly). On 05/21/26 at 8:45 am, the need to ensure the ABST evaluations were completed before a resident moved in and updated and reviewed no less than quarterly at the same time residents’ service plans were updated was reviewed with Staff 1 (ED) and Staff 5 (Regional Director of Operations). They acknowledged the findings.

1.) HWD/ALD/ED/Designee have updated the sampled residents ABST minutes to reflect outlined concerns noted. 2.) HWD/ALD/ED/Designee will review all residents and will have minutes/roster updated by EOD 6/10/2026 to bring frequency of updates to current, then will update at new move in, change in condition, quarterly, or as needed. Community will be on a weekly call with RDO/RNC to review ABST for accuracy - we will run this call unti AOC date of 7/20/2026. 3.) Weekly and as needed. 4.) HWD/ALD/ED/Desginee.

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:

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 and recorded according to Oregon Fire Code (OFC), fire and life safety instruction was provided to staff on alternate months from fire drills, and that the facility met the applicable evacuation level. Findings include, but are not limited to: During the relicensure survey, 05/18/26 through 05/21/26, the survey team identified the following concerns: 1. Review of the facility’s fire drills from 12/2025 through 05/18/26 revealed the following: * Fire drills were not conducted on alternating months with fire life safety training; and * Drills were not conducted on alternating shifts to include all three shifts. In an interview on 05/19/26 at 2:10 pm, Staff 1 (ED) and Staff 2 (Health and Wellness Director) indicated there had been several staffing changes and it was discovered neither fire drills nor fire life safety training for staff had been conducted. 2. The assisted living facility was home to 40 residents residing on three floors, including four residents who required two-person assistance for transfers and to provide for their care needs. Three of the residents who required two-person assistance resided on upper floors of the facility. The posted staffing plan revealed the facility scheduled two staff on the overnight shift, from 10:00 pm to 6:00 am. Based upon the number of two-person transfers on upper floors of the facility and having two staff scheduled from 10:00 pm to 6:00 am, they were unable to meet the applicable evacuation level. An interview with Staff 1 and Staff 2 on 05/20/26 at 8:57 am confirmed they were actively working to move residents who required two-person transfers to the first floor of the facility. The need to ensure the facility conducted and recorded fire drills according to the Oregon Fire Code, provided fire and life safety training to staff on alternating months from fire drills, and met the applicable evacuation level was discussed with Staff 1 and Staff 5 (Regional Director of Operations) on 05/21/26 at 8:26 am. They acknowledged the findings.

1.) RDO completed May 2026 fire drill and training for the staff. ED/HWD/ALD/MCD completed 1.) RDO completed May 2026 fire drill and training for the staff. ED/HWD/ALD/MCD completed 4 in-services to cover Fire Life Safety topics for current staff. June 2026 fire drill will be conducted and will include the full evacuation for staff training purposes. RDO/ED had the (2) residents who resided on upper floors moved down to ground floor by 5/23/2026. The community increased night shift staffing to (2) Caregivers and (1) Med Aide from 10:00pm-6:00am. 2.) ED/AED/HWD/Designee will conduct monthly unannouced fire drills for both AL and MC along with monthly Fire Life Safety training. 3.) Monthly and as needed. 4.) ED/AED/HWD/Designee 4 in-services to cover Fire Life Safety topics for current staff. June 2026 fire drill will be conducted and will include the full evacuation for staff training purposes. 2.) ED/AED/HWD/Designee will conduct monthly unannouced fire drills for both AL and MC along with monthly Fire Life Safety training. 3.) Monthly and as needed. 4.) ED/AED/HWD/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 residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) and Staff 5 (Regional Director of Operations) on 05/19/26 at 2:10 pm. There was no documentation that residents were provided fire training within 24 hours of admission and again at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 05/19/26 at 2:10 pm, Staff 1 and Staff 2 indicated there had been several staffing changes and it was discovered documentation of resident training on admission and annually was not completed. Staff 1 acknowledged the need to provide the residents fire and life safety training.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) and Staff 5 (Regional Director of Operations) on 05/19/26 at 2:10 pm. There was no documentation that residents were provided fire training within 24 hours of admission and again at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 05/19/26 at 2:10 pm, Staff 1 and Staff 2 indicated there had been several staffing changes and it was discovered documentation of resident training on admission and annually was not completed. Staff 1 acknowledged the need to provide the residents fire and life safety training.

1.) ED/HWD/MCD in-serviced all residents on Fire Life Safety and evacuation routes by 6/10/2026. All AL residents were provided an evacuation map in May 2026. Full evacuation training in scheduled for June 2026. 2.) ED/AED/HWD/Designee will in-service residents at move in on our Fire Life Safety and evacuation plans. Community will keep file of in-service forms and will host monthly fire drills alternating floors/shifts to include a different sample of residents monthly. 3.) Monthly and as needed. 4.) ED/AED/HWD/Designee

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