Provider Details

Aging and People with Disabilities

Safety, Oversight and Quality

Oregon Department of Human Services Logo

Print Inspection: FF1X

Provider Information


Footsteps at Lake Oswego

3900 KRUSE WAY PLACE
Lake Oswego, OR 97035

Provider ID
50R484
Administrator
Shannon Kandel
Phone
(503) 635-7000
Email
skandel@thespringsliving.com

Inspection Details


Date
4/21/2025
Event ID
FF1X
Inspection type(s)
Complaint Investig.
Deficiencies cited
2

Citation Details


C0360: Staffing Requirements and Training: Staffing


Visit Number
1
Visit Date
4/21/2025
Corrected Date
N/A
Details

Based on observation, interview, and record review, conducted during a site visit on 04/21/25, the facility's failure to implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:


A review of the facility's ABST indicated the following required staffing hours:

* Day: 33.8 hours;

* Evening: 28.2 hours; and

* Night: 9.8 hours.


A review of the facility's posted staffing plan indicated it was not consistent with the ABST:

* Day: three caregivers and one med tech;

* Evening: two caregivers and one med tech; and

* Night: one caregiver and one med tech.


An observation of day shift staffing showed the facility was not staffed to their ABST.


In an interview, Staff 1 (Administrator) stated residents' ABST profiles were updated regularly, including quarterly.


A review of the facility's ABST indicated multiple resident profiles had not been updated in the last quarter.


The findings were reviewed with and acknowledged by Staff 1.


The facility's facility's failure to implement an Acuity-Based Staffing Tool was substantiated.

C0363: Acuity Based Staffing Tool - Updates & Plan


Visit Number
1
Visit Date
4/21/2025
Corrected Date
N/A
Details

Based on observation, interview, and record review, conducted during a site visit on 04/21/25, the facility's failure to implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:


A review of the facility's ABST indicated the following required staffing hours:

* Day: 33.8 hours;

* Evening: 28.2 hours; and

* Night: 9.8 hours.


A review of the facility's posted staffing plan indicated it was not consistent with the ABST:

* Day: three caregivers and one med tech;

* Evening: two caregivers and one med tech; and

* Night: one caregiver and one med tech.


An observation of day shift staffing showed the facility was not staffed to their ABST.


In an interview, Staff 1 (Administrator) stated residents' ABST profiles were updated regularly, including quarterly.


A review of the facility's ABST indicated multiple resident profiles had not been updated in the last quarter.


The findings were reviewed with and acknowledged by Staff 1.


The facility's facility's failure to implement an Acuity-Based Staffing Tool was substantiated.