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 08/05/25.  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 interview and record review, conducted during a site visit on 08/05/25, the facility's failure to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan for 2 of 3 sampled residents (#s 1 and 2) was substantiated. Findings include, but are not limited to:

Resident 1's service plan, dated 02/21/25, indicated s/he was to receive two showers weekly.

Resident 1's ABST profile (undated) had ten minutes assigned once weekly for bathing.

Resident 2's service plan, dated 01/08/25, indicated:

-Resident 2 had a wound to his/her left upper leg; and

-Resident 2 regularly received cream, ointment, or minor dressing changes for treatment of skin issues.

Resident 2's ABST profile (undated) did not have time assigned for either task.

It was determined the facility's failure to complete service plans reflective of resident needs was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Health and Wellness Director) on 08/12/25 via email.