Print Inspection: PFM1

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 02/20/25.  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 02/20/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled Resident (# 4) was substantiated. Findings include, but are not limited to:

Resident 4's service plan, dated 02/01/24, indicated Resident 4 required one to two medication passes per day and the facility was responsible for the service.

Resident 4's Incident Report, dated 04/16/24 indicated Resident 4 was administered Resident 3's morning medications.

Resident 4's Progress notes, dated 04/01/24 through 04/30/24, indicated s/he was placed on alert charting for the medication error and did not have an adverse reaction to the incorrect medication.

The facility's self-report, dated 04/16/24, indicated Resident 4 had received his/her roommate's morning medications by mistake.

Staff 1 (Executive Director) stated s/he recalled the medication error and Resident 4 received his/her roommate's medication by accident. Staff 1 further stated the staff member who administered the incorrect medication no longer works at the facility.

Resident 4 was no longer in the building and could not be observed or interviewed.

It was determined the facility's failure to carry out medication and treatment orders as prescribed for Resident 4.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (General Manager).  

The facility's plan of correction: The facility provided the staff member additional training on proper medication administration and how to avoid medication errors in the future. The staff member who administered the incorrect medication no longer works at the facility.

Based on interview and record review, conducted during a site visit on 02/20/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1) was substantiated. Findings include, but are not limited to:

Resident 1's service plan, dated 06/30/24, indicated Resident 1 required three to four medication passes per day and the facility was responsible for the service.

The facility's self-report, dated 07/09/24, indicated Resident 1 received his/her roommate's medications. Resident 1's primary care physician ordered Resident 1 to be sent to the hospital for monitoring.

Resident 1's progress notes, dated 07/01/24 through 07/31/24, indicated Resident 1 was put on alert charting to monitor for any adverse reactions due to the medication error after s/he returned from the hospital.

Staff 2 (Regional Manager) stated s/he was the former Executive Director of this facility and remembered the medication error with Resident 1. A staff member had given Resident 1 his/her roommate's medications.

It was determined the facility's failure to carry out medication and treatment orders as prescribed for Resident 1 was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2.  

The facility's plan of correction: The facility provided the staff member additional training on proper medication administration. The facility implemented for staff to take the resident's medication box with them when administering medications. The medication box has a photo of the resident on it. If the resident does not have a photo uploaded to their system, staff are not allowed to pre-pop or pour a resident's medication and must pop it right after verifying the resident's identity and administer the medication.

Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12).

The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool.

Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building.

The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled.

On 02/20/25, there were 14 direct care staff observed working the floor on day shift.

The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time.

On 02/20/25, resident needs were observed to be met.

It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager).

Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12).

The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool.

Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building.

The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled.

On 02/20/25, there were 14 direct care staff observed working the floor on day shift.

The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time.

On 02/20/25, resident needs were observed to be met.

It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager).

Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled Residents (#s 7, 8, 9, 10, 11, and 12).

The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool.

Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building.

The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled.

On 02/20/25, there were 14 direct care staff observed working the floor on day shift.

The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time.

On 02/20/25, resident needs were observed to be met.

It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager).

Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12).

The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool.

Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building.

The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled.

On 02/20/25, there were 14 direct care staff observed working the floor on day shift.

The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time.

On 02/20/25, resident needs were observed to be met.

It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager).

Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12).

The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool.

Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building.

The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled.

On 02/20/25, there were 14 direct care staff observed working the floor on day shift.

The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time.

On 02/20/25, resident needs were observed to be met.

It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager).

Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled Residents (#s 7, 8, 9, 10, 11, and 12).

The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool.

Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building.

The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled.

On 02/20/25, there were 14 direct care staff observed working the floor on day shift.

The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time.

On 02/20/25, resident needs were observed to be met.

It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager).