Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 03/12/24.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified:

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

HS:Hours of sleep

LPN:Licensed Practical Nurse

MT:            Medication Technician or Med Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

SP:Service plan

SPT:Service Planning Team

TAR:Treatment Administration Record

Based on observation, interview, and record review, conducted during a site visit on 03/12/25, the facility's failure to consistently have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to:

The facility was divided into two distinct and segregated neighborhoods, Clare and Bridge.

The facility's posted staffing plan, dated 03/04/25, indicated:

*For Clare, four caregivers and one med tech on day shift, three caregivers and one med tech on swing shift, and one caregiver and one med tech that was shared with Bridge.

*For Bridge, four caregivers and one med tech on day shift, two caregivers and one med tech on swing shift, and one caregiver and one med tech that was shared with Clare House.

On 03/12/25, in Clare, there were two caregivers and one med tech observed on day shift. In Bridge, there were four caregivers and one med tech observed on day shift.

The facility's staff schedule, dated 03/05/25 through 03/12/25 indicated from 03/06/25 through 03/12/25, for Clare and Bridge, there were eight instances where the facility was not staffing according to their posted staffing plan.

Staff 1 (Executive Director) stated there were 11 residents who required the assistance of two staff members for care in Clare and Bridge.

The facility's posted staffing plan did not account for the number of staff for residents who required two staff members for care.

It was determined the facility's failure to consistently have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated.

The findings of the investigation were reviewed with or acknowledged by Staff 1 and Staff 2 (District Director of Operations) on 03/28/25 via virtual conference.