Print Inspection: RL013463

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 complete, update and review the acuity-based staffing tool (ABST) evaluation for each resident before a resident moved in and when the resident experienced a significant change of condition, 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 1 moved into the facility in 07/2026. The resident’s ABST evaluation was not created until five days after move-in, not prior to move-in. b. Resident 2 experienced a significant change of condition in 06/2026. The ABST evaluation was last updated on 04/06/26. c. On 08/10/26 at 1:42 pm, when survey entered the facility, the posted staffing plan was observed in the lobby and noted it was effective 07/01/26: * Day and evening shifts: Three CGs and one MT per neighborhood “dependent on census”; and * Night shift: One CG and one MT per neighborhood. On 08/10/26, the facility’s ABST showed the minimum direct care staff required to address scheduled needs were: Quail Gardens: * Day shift – 4.5 (rounded up from 4.14); * Swing shift – 4 (rounded up from 3.68); and * NOC shift – 2.5 (rounded up from 2.20). Centennial Ridge: * Day shift – 4.5 (rounded up from 4.38); * Swing shift – 4.5 (rounded up from 4.1); and * NOC shift – 2.5 (rounded up from 2.49). On 08/12/26 at 4:30 pm, Staff 1 (ED) stated the ABST minutes did not include time for unscheduled resident needs. In addition, she confirmed the facility was not using the results of the ABST to develop and update the posted staffing plan. The need to ensure residents’ ABST data was updated following a significant change of condition and prior to move-in, 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 08/12/26 at 4:05 pm. She acknowledged the findings.

Administrator reached out to ODHS ABST contact and had Zoom call on Monday 8/18 to review line-by-line expectations for the ABST and time. It was found that MSC was "doubling up" time by counting tasks twice (for instance; including transfer time under transfer question but also in toileting and showering questions). Other timed tasks were evaluated and adjusted. This Administrator asked clarifying questions about certain regulations as pertained to the ABST and how to find out and verify for self, the time stamps to ensure nothing gets missed. Administrator then went through and updated every question for every resident and compared to service plan, staff input, and eMAR/eTAR. ODHS ABST contact wasn't sure about accoutning for staff time during meal time for independent residents and stated she would follow up. Did double up and add extra time for two-person transfers/changes. Revamped ABST shows MSC is adequately staffed at this time for both neighborhoods including extra for unscheduled needs. Discussed using rounding to reasonable 1/2 person vs using percentage to account for unscheduled needs. Staffing plan will be updated this week. Updating ABST added to admission checklist to ensure completion prior to admission. Also added to quarterly and COC update checklist used by RCCs. Weekly apt added to the calendar for ABST update weekly to correlate with who is due (quarterly and sig change of condition). Will be employing the RCCs to update ABST along with other Level of Care eval and service plan updates. Administrator to audit and ensure completion and compliance weekly. RCCs will turn in completed checklists prior to scheduled care conference each week. Administrator will then confirm completion/update and compare to posted staffing plan, updating as needed. New template being built for staffing plan that will be posted next week.

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 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C363.

Refer to C363 POC

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate residents for activities in all required areas and to develop individualized activity plans from the evaluations for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: A review of service plans for Residents 1, 2, and 3, and interviews with Staff 1 (Administrator) and Staff 3 (Activities Director), revealed the following: 1. There was no documented evidence of activity evaluations for Residents 1 and 2 which addressed the following required elements: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. 2. For Residents 1, 2, and 3 there was no documented evidence of individualized activity plans which addressed what, when, how, and how often staff should offer and assist the resident with activities were developed and documented. The need to ensure the facility completed an activity evaluation addressing the required elements and developed an individualized activity plan based on the evaluation for each resident was discussed with Staff 1 (Administrator) and Staff 3 (Activities Director) on 08/12/26 at 4:15 pm. They acknowledged the findings.

Point-Click-Care Eval form "Activities" section missing exact verbiage and area for information pertaining to the regulation. Upon further investigation with RN Consultant and Life Enrichment Coordinator, the information is split up between different sections, not all listed in "Activities". RN Consultant is going to update Service Plan with preferred verbiage from SOD report and space for documentation of resident's: current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptions necessary for the resident to participate, and indentification of activities for behavioral interventions. This information is also repeated in the Level of Care under sections such as, "Cognition/Judgement/Behavior", "Activities", and in the "All About Me" and "How My Day Unfolds" forms. Once the form is updated, Life Enrichment Coordinator will utilize Life Story information and current evals to fill in the information needed as the evaluations come due (roughly updating 2-4 residents a week) until all are completed. Training with Life Enrichment Coordinator to ensure verbiage is included in the "edits" sections to customize specifics. The Level of Care Eval is a smart form that only includes the "how often, who, how, what" sections if "independent" is not checked. Those listed as independently able to manage their activities are not assigned staff and frequency. I will also work with the Life Enrichment Coordinator to include those details in her narrative as she completes the form so that even if the form doesn't trigger it - it's in there.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: