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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 02/03/25 and 02/12/25.  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 observation, interview, and record review, conducted during a site visit on 02/03/25 and 02/12/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 2 of 3 sampled Residents (#s 1 and 3). Findings include, but are not limited to:

The facility utilized the ODHS ABST, and the census was 82. There were 35 residents who were not updated in the ABST as required, and 2 of 3 sampled Residents' (#s 1 and 3's) service plans and ABST profiles did not match regarding services and acuity.

Resident 1 was not updated in the ABST. His/Her service plan, dated 01/19/25, indicated s/he was a total assist with dressing and toileting. There was no time assigned in the ABST for either task. The service plan indicated Resident 1 was independent with the use of the call pendant. The ABST had no task time assigned for staff to respond to call lights.

Resident 1 was unavailable for interview regarding his/her care needs.

Resident 3 was not updated in the ABST. His/Her service plan, dated 01/19/25, indicated s/he required one person total assist with all bathing/showering needs, but later in the service plan stated s/he was independent with bathing/showering. There was task time assigned in the ABST for assistance with bathing.

On 02/03/25, Resident 3 stated s/he required assistance with bathing and sometimes lower extremity dressing.

The facility's posted staffing plan indicated for day and swing shifts, there were two Med Techs (MTs) and three Caregivers (CGs) scheduled, for night shift, there was one MT and one CG scheduled.

On 02/03/25, there were two MTs and three CGs working day shift.

Staff schedules, dated 01/28/25 through 02/03/25 indicated the facility did not staff according to their posted staffing plan for two of 21 reviewed shifts.

It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 1 and 3.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (LPN Wellness Director), and Staff 3 (Resident Service Director) on 02/12/25.