Merrill Gardens at Hillsboro

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, were readily available to staff, and provided clear directions regarding the delivery of services for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including apraxia of speech (speech sound disorder), cerebrovascular accident, osteoarthritis, and glaucoma.

Observations were made of the resident on 08/06/25, interviews with the resident, resident’s family member, and facility staff were conducted, and the service plan, dated 06/24/25, was reviewed.

Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Incorrect reference to resident not requiring assist with dressing/undressing;
* Self-administration of medications;
* Instructions on what types of skin impairments to report and to whom;
* Hearing and use of assistive devices;
* Ambulation and use of assistive devices; and
* Incorrect reference to resident evacuation status.

The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 (Resident Care Director/RN) on 08/06/25 at 12:53 pm. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 01/2025 with diagnoses including chronic kidney disease stage 3, asthma, and chronic pain.

Observations were made of the resident, interviews with the resident, resident’s family member, and facility staff were conducted, and the service plan, dated 05/12/25, was reviewed.

Resident 3's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Instructions for signs and symptoms of complications to report while monitoring gastrostomy site and surgical incisions;
* Incorrect reference to resident diet texture; and
* Instructions for signs and symptoms of infection and complications to report when providing care for the Foley catheter.

The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 (Resident Care Director/RN) on 08/06/25 at 12:53 pm. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 04/2025 with diagnoses including transient ischemic attack.

In an interview on 08/04/25 at 11:35 am, Staff 5 (MT/CG), who was present during the acuity interview, indicated the service plans available to staff were in the service plan binder in the medication room.

Review of the service plan that was readily available to staff showed it was last dated 04/15/25 and did not include current information about Resident 4’s medications.


The need to ensure the current service plans were readily available to staff was discussed with Staff 1 (General Manager) and Staff 2 (Senior General Manager) on 08/07/25. They acknowledged the findings.

4. Resident 5 was admitted to the facility in 06/2025 with diagnoses including congestive heart failure.

In an interview on 08/04/25 at 11:35 am, Staff 5 (MT/CG), who was present during the acuity interview, indicated the service plans available to staff were in the service plan binder in the medication room.

Review of the service plan that was readily available to staff showed it was last dated 06/13/25 and did not include current information on moderate assistance with showering twice a week.

The need to ensure the current service plans were readily available to staff was discussed with Staff 1 (General manager) and Staff 2 (Senior General Manager) on 08/07/25. They acknowledged the findings.

5. Resident 1 was admitted to the facility in 01/2025 with diagnoses including insulin-dependent diabetes mellitus.

a. Observations of the resident, interviews with the resident and staff, and review of the resident's most recent service plan, dated 06/19/25, and temporary service plans showed the service plan did not provide clear direction to staff or was not reflective of the resident's needs in the following areas:

* Mobility, including what assistive device to use;
* Management of the blood glucose monitor, including who replaced the sensor and what to do if it was not working;
* History of frequent urinary tract infections;
* History of depression with periods of dissociation and signs and symptoms to look for; and
* Level of assistance needed for showering, toileting, and incontinence management.

b. In an interview on 08/4/25 at 11:35 am, Staff 5 (MT/CG) who was present during the acuity interview, indicated the service plans available to staff were located in the service plan binder in the medication room. Review of Resident 1’s service plan that was readily available to staff showed it was last dated 06/19/25.

In an interview on 08/07/25 at 11:15 am, Staff 2 (Senior General Manager) acknowledged the most recent service plan was not in the binder and had been completed on 07/17/25.

The need to ensure service plans were reflective of resident's current care needs, provided clear direction and readily available to staff was discussed with Staff 1 (General Manager) and Staff 2 (Senior General Manager) on 08/07/25. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to update the service plan following a significant change of condition and ensure resident-specific actions or interventions were determined, documented, and communicated to staff on each shift, with weekly progress noted to resolution for 3 of 5 sampled residents (#s 1, 2, and 3) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2025 with diagnoses including insulin-dependent diabetes mellitus.

The resident's service plan, dated 06/19/25, temporary service plans and progress notes, dated 05/08/25 through 08/04/25, were reviewed, and staff were interviewed. The following was noted:

a. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and weekly progress noted until condition resolved:

* 06/02/25: New antidepressant medication;
* 06/25/25: Changes to insulin;
* 07/17/25: Change in insulin and new medication;

b. The following short-term changes lacked documentation of resident-specific actions or interventions needed for the resident and communication of the determined actions or interventions to staff on all shifts:

* 05/04/25: Non-injury fall;
* 05/23/25: Gout episode;
* 07/21/25: Urinary tract infection;
* 07/21/25: Multiple medication changes; and
* 07/23/25: Eye infection.

c. The following short-term change lacked weekly progress noted until the condition resolved:

* 06/21/25: Non-injury fall.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift, with monitoring at least weekly through resolution was discussed with Staff 1 (General Manager) and Staff 2 (Senior General Manager) on 08/07/25. They acknowledged the findings.



2. Resident 2 was admitted to the facility in 11/2024 with diagnoses including apraxia of speech (speech sound disorder), cerebrovascular accident, osteoarthritis, and glaucoma.

Clinical records, including the current service plan, dated 06/24/25, progress notes from 05/06/25 through 08/04/25, and outside provider notes were reviewed, and interviews with facility staff were conducted.

a. The following significant change of condition lacked documentation the facility updated the service plan as needed:

* 07/04/25: unwitnessed fall resulting in resident’s rib fracture.

b. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 05/19/25: Physician note recorded “vitals are more suggestive of orthostatic changes and would encourage increased fluid intake”;
* 06/04/25: Progress note recorded “Resident showing signs of decline of cognition…”;
* 07/18/25: Unwitnessed non-injury fall; and
* 08/01/25: Progress note recorded increased confusion.

The need to ensure the facility updated the service plan following a significant change of condition, evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 (Resident Care Director/RN) on 08/06/25 at 12:53 pm. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 01/2025 with diagnoses including chronic kidney disease stage 3, asthma, and chronic pain.

Clinical records, including the current service plan, dated 05/12/25, progress notes from 05/03/25 through 08/04/25, and outside provider notes were reviewed, and interviews with facility staff were conducted.

a. The following significant changes of condition lacked documentation the facility updated the service plan as needed:

* 07/11/25: Gastrostomy tube placement and change in diet texture; and
* 07/17/25: Foley catheter placement.

b. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 07/17/25: Started new medication Lasix (diuretic);
* 07/29/25: Gastrostomy tube removed;
* 07/30/25: Foley catheter removed;
* 07/31/25: ER visit for suprapubic pain and acute cystitis with hematuria, foley catheter re-inserted; and
* 07/31/25: Started new medication ciprofloxacin (antibiotic).

The need to ensure the facility updated the service plan following a significant change of condition, evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 (Resident Care Director/RN) on 08/06/25 at 12:53 pm. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 3 sampled residents (# 3) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 01/2025 with diagnoses including chronic kidney disease stage 3, asthma, and chronic pain.

A review of the resident's clinical record, dated between 05/03/25 and 08/04/25, identified the following:

a. An after-visit summary dated 07/11/25 listed the procedures performed for Resident 3 during a recent hospital stay, including “gastrostomy tube placement.” Additionally, Resident 3 was discharged on the Nissen diet (the diet progresses from full liquid diet to soft, easily swallowed, easily chewed food).

The gastrostomy tube placement and change in diet texture constituted a significant change in condition requiring an RN assessment.

b. An after-visit summary from a recent hospital stay, dated 07/17/25, stated “you [resident] were also having some urinary retention… A foley catheter was inserted…”

The foley catheter placement constituted a significant change in condition requiring an RN assessment.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment for either of the significant changes of condition.

The need to ensure an RN assessment was completed for residents who experienced a significant change of condition was reviewed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 (Resident Care Director/RN) on 08/06/25 at 12:53 pm. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 6 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2025 with diagnoses including chronic kidney disease stage 3, asthma, and chronic pain.

Resident 3's current physician orders and MARs from 01/01/25 through 08/04/25 were reviewed, and interviews with facility staff were conducted.

The resident was hospitalized from 07/12/25 through 07/17/25 for pleural effusion (build-up of fluid in lungs) and acute hypoxic respiratory failure (shortness of breath needing extra oxygen to help breath). The hospital after-visit summary, dated 07/17/25, contained the following physician orders:

* “Weigh yourself daily…Report a gain of 2-3 or more pounds in a 24-hour period or 4-5 or more pounds in 1 week to your physician.”

There was no documented evidence the resident’s weight was obtained as prescribed.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 (Resident Care Director/RN) on 08/06/25 at 12:53 pm. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 01/2025 with diagnoses including insulin-dependent diabetes mellitus.

The resident's 07/01/25 through 08/04/25 MARs, medical prescriber's orders, and progress notes, dated 07/01/25 through 08/04/25, were reviewed and noted the following:

1. A physician’s order dated 07/17/25 indicated an order for cranberry extract–d-mannose, take 1,000 mg two times daily for urinary tract infection. The MAR revealed the medication was entered twice, one entry as “D-Mannose 500mg 2 capsules…two times per day” and the second entry “Cranberry extract-D-Mannose...500mg take 2 capsules…twice daily.” The MAR indicated the resident was administered 2,000 mg twice daily on seven occasions between 07/18/25 at 8:00 pm through 07/21/25 at 8:00 pm.

2. The resident had a physician's order, dated 07/21/25, for nitrofurantoin monohydrate (antibiotic), one capsule every 12 hours for five days. The MAR revealed the medication was administered for seven days, from 07/21/25 at 8:00 pm through 07/28/25 at 8:00 am, not five days as ordered.

3. A physician’s order, dated 06/23/25, indicated “Everyday at 8:00 am, 12:00 pm, 4:00 pm and 8:00 pm open [Resident 1’s blood sugar monitor] app on [his/her] phone and enter the blood sugar reading into the computer.” The MAR revealed blanks seven times between 07/01/25 and 07/23/25.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (General Manager) and Staff 2 (Senior General Manager) on 08/07/25. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 1 of 4 sampled residents (#1) who chose to self-administer their medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 01/2025 with diagnoses including insulin-dependent diabetes mellitus.

During the acuity interview on 08/04/25, staff reported the resident had initially self-administered his/her medications, but the facility started administering the medications related to a cognitive decline.

Review of Resident 1’s progress notes, dated 05/08/25 through 08/04/25, indicated on 06/19/25 Resident 1 was found lying on the floor by a family member. Staff 3 (Health Services Director/RN) noted, “it became clear that [s/he] had not taken [his/her] routine medication for 2 days. When questioned about [his/her] Insulin…[s/he] had not been giving it to [himself/herself].” Resident 1 was transported to the hospital “due to [his/her] DM (diabetes mellitus) status and failure to take [his/her] oral or injectable medications for 2 days.” The progress note from Staff 3 indicated “the need for increased services to include administration of medications.”

An evaluation, dated 06/19/25, was reviewed and indicated “Resident does not demonstrate the ability to self-administer medications and requires assistance.” The evaluation did not specify if Resident 1’s ability to self-administer his/her insulin, including the ability to prepare the correct dosage and administer the medication properly, was evaluated.

During an interview on 08/05/25 at 4:30 pm, Staff 3 (Health Services Director/RN) acknowledged the facility began managing the resident’s pills on 06/19/25, but Resident 1 continued to administer his/her insulin. On 08/07/25 at 8:30 am, Staff 3 also acknowledged the self-medication administration evaluation did not specifically address an area to evaluate the ability for a resident to safely administer his/her insulin.

Resident 1 continued to administer his/her insulin until 07/17/25 when a change of condition related to a cognitive decline was completed and indicated staff would “assume responsibility for administering [his/her] insulin to ensure this is injected in a consistent manner.” Between 06/19/25 and 07/17/25 there was no documented evidence of a negative outcome with Resident 1 managing his/her insulin.

During an interview on 08/07/25 at 11:15 am, Staff 2 (Senior Manager) acknowledged the lack of evaluation for Resident 1’s ability to manage his/her insulin at the time the facility evaluated the rest of his/her medications.

The need to ensure residents who chose to self-administer their medications were evaluated thoroughly to assure the residents' ability to safely self-administer medication was discussed with Staff 1 (General Manager) and Staff 2 (Senior General Manager) on 08/07/25. They acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds

(5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements staff were providing to residents for 2 of 5 sampled residents (#s 2 and 3) whose Acuity-Based Staffing Tool (ABST) data was reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including apraxia of speech (sound speech disorder), cerebrovascular accident, osteoarthritis, and glaucoma.

The resident’s (ABST) data, the service plan dated 06/24/25, and temporary service plans were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST calculation did not incorporate expected care time in the following areas:

* How much time is spent monitoring behavioral conditions (wandering) or symptoms;
* How much time is spent cueing or redirecting due to cognitive impairment;
* How much time is spent assisting with communication, assistive devices for hearing;
* How much time is spent dressing and undressing; and
* How much time is spent toileting and bladder management.

The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 (Resident Care Director/RN) on 08/06/25 at 12:53 pm. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 01/2025 with diagnoses including chronic kidney disease stage 3, asthma, and chronic pain.

The resident’s ABST data and the service plan, dated 05/12/25, were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST calculation did not incorporate expected care time in the following areas:

* How much time is spent on bladder management and foley catheter care.

The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 (Resident Care Director/RN) on 08/06/25 at 12:53 pm. They acknowledged the findings.

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 interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated and reviewed for each resident whenever there was a significant change of condition for 1 of 3 sampled residents (#3) who experienced a significant change of condition. Findings include, but are not limited to:

The facility’s ABST data was reviewed on 08/06/25 at 10:10 am and revealed there was no documented evidence Resident 3’s ABST data had been updated following a significant change of condition.

The need to ensure residents’ ABST was updated whenever there was a significant change of condition was discussed with Staff 1 (General Manager), Staff 2 (Senior General Manager), and Staff 3 on 08/06/25 at 12:53 pm. They acknowledged the findings.

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 staff were provided with fire and life safety training every other month and failed to document all required fire drill elements per the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety documentation from 12/2024 through 06/2025 was reviewed on 08/05/25. The following was identified:

1. There was no documented evidence all staff were provided with fire and life safety training every other month.

2. Fire drill documentation did not include one or more of the following required elements:

* Escape route used;
* Number of occupants evacuated; and
* Evidence of alternate routes used.

3. Staff were not aware of the designated point of safety for residents in the event of an evacuation.

The need to provide fire and life safety training to all staff every other month and the need to address all required elements in fire drill documentation was discussed with Staff 1 (General Manager), Staff 2 (Senior General Manager), Staff 3 (Health Services Director) and Staff 10 (Senior Health Services Director) on 08/05/25 at 2:50 pm. They acknowledged the findings.

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: