Based on interview and record review, conducted during a site visit on 11/18/24, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

A review of Resident 1's physician orders, dated 03/01/24, showed an order for the following:

* Rifaximin 550 mg tablet, one tablet by mouth two times daily, for alcohol cirrhosis.

A review of Resident 1's Medication Administration Record (MAR), dated 05/01/24-05/31/24, indicated the following:

* Between 05/02/24 and 05/06/24, Rifaximin was unavailable; and

* The facility had reordered the medication and was awaiting its delivery.

In an interview, Staff 1 (Assistant Executive Director) and Staff 2 (Resident Services Manager) acknowledged the medication was not available.

The findings were reviewed with and acknowledged by Staff 1 and Staff 2.

The facility's failure to carry out medication orders as prescribed was substantiated.

Verbal Plan of Correction: Med Tech meeting was to be held Thursday 11/21/24 and re-ordering procedure was reviewed. The medication of issue is on cycle-fill now meaning refills come automatically. All Med Techs now have access to Omniview, the online re-ordering source through their house pharmacy.

Based on observation, interview, and record review, conducted during a site visit on 11/18/24, the facility's failure to develop and maintain an Acuity-Based Staffing Tool was substantiated for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:

The facility had five distinct and separate neighborhoods named the following:

* Happy Valley;

* Milwaukie;

* Mount Scott;

* Oregon City; and

* West Linn.

A single posted staffing plan showed the following:

* Day: two med techs, two "care partners," and one float;

* Eve: two med techs, two "care partners," and one float; and

* Night: one med tech and five "care partners."

An observation revealed there were not separate posted staffing plans for each neighborhood.

An observation of Milwaukie neighborhood on night shift revealed only one staff member was working and there was a two-person transfer.

In an interview, Staff 1 (Assistant Executive Director) acknowledged the facility used Universal Workers.

A review of the facility's ABST revealed the tool did not account for Universal Worker time for the following tasks:

* Laundry;

* Housekeeping; and

* Meal service.

A review of Resident 1's ABST profile showed it had not been fully updated in the last quarter.

A review of Resident 1's service plan, dated 11/13/24, and ABST profile revealed the following discrepancies in care time:

* Laundry/housekeeping; and

* Meal times.

A review of Resident 2's service plan, dated 09/11/24, and ABST profile revealed the following discrepancies in care time:

* Ensuring non-drug interventions for behaviors;

* Monitoring behavioral conditions or symptoms;

* Laundry/housekeeping; and

* Meal times.

A review of Resident 3's service plan, dated 09/20/24, and ABST profile revealed the following discrepancies in care time:

* Bathing;

* Laundry/housekeeping; and

* Meal times.

The findings were reviewed with and acknowledged by Staff 1 (Assistant Executive Director) and Staff 2 (Resident Services Manager).

The facility's failure to develop and maintain an Acuity-Based Staffing Tool was substantiated.