Living Springs Homes LLC

OAR 411-049-0125(7)(g) Sub CG Req: CPR & FA (7) SUBSTITUTE CAREGIVER REQUIREMENTS. (g) Substitute caregivers must complete CPR and First Aid training and certification within 30 calendar days of the start of employment. Certification must be maintained according to the standards established in (2)(b)(D) of this rule.

It was observed that Caregiver 3 did not have a valid first aid certification at the time of inspection. Caregiver 3 completed an online first aid certification while the licensor was present in the home. This caregiver does not work alone in the home.

Provider's statement as written: "First Aid Certification completed will ensure in future its done on time. Administrator will monitor the records upon hiring a caregiver" Accepted by the LLA 2/13/26.

OAR 411-049-0125(7)(k) Sub CG Req: HCBS Training (7) SUBSTITUTE CAREGIVER REQUIREMENTS. (k) All substitute caregivers must complete HCBS training as outlined in OAR 411-049-0125(2)(f).

It was observed that Caregiver 4 did not have the required HCBS training completed at the time of inspection. This caregiver does not work alone in the home.

Provider's statement as written: "HCBS training for Caregiver 4 completed. In future Admin will ensure all classes are completed in a timely manner. Admin to monitor the records every month for accuracy. Resident Manager to monitor every 2 weeks." Accepted by LLA on 2/13/26.

OAR 411-049-0125(7)(m) Sub CG Req: Workbook (7) SUBSTITUTE CAREGIVER REQUIREMENTS. (m) A substitute caregiver must complete the Department's Caregiver Preparatory Training Study Guide (DHS 9030) and Workbook (DHS 9030-W) and receive instruction in specific care responsibilities from the licensee or administrator prior to working or training in the home. The Workbook must be completed by the substitute caregiver without the help of any others. The Workbook is considered part of the required orientation to the home and residents.

It was observed that Caregiver 4 did not have a completed caregiver workbook or workbook certificate on file at the time of inspection. This caregiver does not work alone in the home.

Provider's statement as written: "Caregiver had already completed work book, all necessary certificates in file now, attached in this paperwork. Resident manager to ensure all certificates are in file every 2 weeks" Accepted by LLA on 2/13/26.

OAR 411-050-0720(16)(a-g) Safety: Floor Plans (16) FLOOR PLAN. The licensee must develop a current and accurate floor plan that indicates:(a) The size of rooms.(b) Which bedrooms are to be used by residents, the licensee, caregivers, and for adult day services and room and board tenants, as applicable.(c) The location of all the exits on each level of the home, including emergency exits such as windows.(d) The location of wheelchair ramps.(e) The location of all fire extinguishers, smoke alarms, and carbon monoxide alarms.(f) The planned evacuation routes, initial point of safety, and final point of safety.(g) Any designated smoking areas in or on the AFH's premises.

It was observed that the posted floor plan listed a bedroom as being a resident's bedroom when it is currently being used by a caregiver, as noted in the previous year's inspection report.

Provider's statement as written: "Floor plan corrected to show Bedroom 1 as Admins Room. Hence reducing occupancy to 4 residents. This will remain unless request is submitted for 5 residents (copy attached)." Accepted by LLA on 2/13/26.

OAR 411-050-0745(1)(c)(C) Facility Records: Documentation Orientation (1) FACILITY RECORDS. Completed facility records must be kept current, maintained in the AFH, and made available for review upon request. Facility records include, but are not limited to: (c) Proof the licensee and all other caregivers have met and maintained the minimum qualifications at each home where they train or work, as required by OAR 411-049-0125, including:(C) Documentation of orientation to the AFH on the Department's form (APD 0349) for the administrator, resident manager, floating resident manager, shift caregivers, and substitute caregivers, as applicable.

It was observed that Caregiver 1 and Caregiver 2 had caregiver orientation forms on file which were not signed by a trainer/administrator of the home. It was observed that Caregiver 4 did not have a caregiver orientation completed on file in the home. This caregiver does not work alone in the home.

Provider's statement as written: "Caregivers orientation forms signed (attached on email) Resident Manager to ensure all documents are signed and filled during hire process. Admin will monitor every month" Accepted by LLA on 2/13/26.

OAR 411-050-0745(1)(h) Facility Records: Evacuation Drills (h) Records of evacuation drills according to OAR 411-050-0725, including the date, time of day, evacuation route, length of time for evacuation of all occupants, names of all residents and occupants, and names of residents and occupants that required assistance.

It was observed that the evacuation drills on file were missing the description of assistance needed for all residents, an accurate reporting of which residents needed substitutes to complete the drill, and the total time to evacuate residents to the initial and final points of safety.

Provider's statement as written: "Fire drills completed to show description of assistance needed by residents. This will be accurately reported in future. Admin will ensure proper completion of document every month." Accepted by LLA on 2/13/26.

OAR 411-051-0105(6) Resident Care: Activities (6) ACTIVITIES. The licensee or administrator must make available at least six hours of activities per week, not including television and movies, that are of interest to the residents. Information regarding activity resources is available from the LLA. Activities must be oriented to individual preferences as indicated in the resident's care plan. (See OAR 411-051-0115). Documentation of the activities offered to each resident and the resident's participation in those activities must be recorded in the resident's records.

It was observed that Resident 1 was not being offered at least 6 hours of person-centered activities per week by staff members and that "watching television" was counted as an activity.

Provider's statement as written: "Weekly activity logs corrected. In future they will be accurately filled as learnt. Admin/resident manager to monitor every week to ensure proper completion of document (copy attached)." Accepted by LLA on 2/13/26.

OAR 411-051-0130(2) Medication: Carry Out Orders (2) WRITTEN ORDERS. The licensee or administrator must obtain and place a signed order in the resident's record for any medications, dietary supplements, treatments, or therapies that have been ordered by a prescribing practitioner. The written orders must be carried out as prescribed unless the resident or the resident's legal representative refuses to consent. The prescribing practitioner must be notified if the resident refuses to consent to an order.

It was observed that Resident 1 had a medication listed on their MAR and available in the home but did not have a signed doctor's order for the PRN medication.

Provider's statement as written: "Medication D/C order obtained from PCP. Medication in home discarded. Resident manager to monitor MARs/available meds in the home weekly. D/C order attached." Accepted by the LLA 2/13/26.

OAR 411-051-0130(6)(c) MARs: Immediately Initialed (6) MEDICATION ADMINISTRATION RECORD. A current, written MAR, or electronic MAR (see OAR 411-050-0755(4)), must be kept for each resident and must: (c) Be immediately initialed by the caregiver administering the medication, treatment, or therapy as it is completed. A resident's MAR must contain a legible signature that identifies each set of initials.

It was observed that Resident 1's MAR had documentation on the back of the MAR indicating that a PRN medication had been administered twice a day from 11/1/25 - 11/14/25 (the time given, reason, and outcome of administration was recorded) however, there were only initials on the front of the MAR indicating the PRN was administered from 11/1/25 - 11/7/25. One week of administration was not initialed on the main MAR page.

Provider's statement as written: "Late entry correction completed. In future PRN medications to be properly entered on the MAR and initialed properly. Resident Manager to ensure this proper recording every day." Accepted by LLA on 2/13/26.

OAR 411-051-0130(7)(a) MARs: PRN Medication: Documentation (7) PRN MEDICATIONS. Prescription medications ordered to be given ""as needed"" or ""PRN"" must have specific parameters indicating what the medication is for and specifically when, how much, and how often the medication may be administered. Any additional instructions must be available for the caregiver to review before the medication is administered to the resident. (a) PRN DOCUMENTATION. As needed medications must be documented on the resident's MAR with the time, dose, the reason the medication was given, and the outcome.

It was observed that Resident 1's MAR indicated that they were administered two doses of a PRN medication on 1/28/26 with no result of giving the PRN recorded on the back of the MAR. It was observed that Resident 1 had initials on their MAR indicating that a PRN medication was administered on 10/31/25, however the documentation on the back of the MAR listed the medication as administered on 10/30/25.

Provider's statement as written: "Proper recording was done and entered as late entry. In future resident manager (RN) will ensure all recordings are done immediately. Admin to follow through every week." Accepted by LLA on 2/13/26.

OAR 411-051-0130(9)(b)(B) Medications: Clearly Labeled (9) MEDICATION CONTAINERS AND STORAGE. The licensee or administrator must ensure the resident ' s prescription medications are packaged in a manner that reduces errors in the tracking and administration of the drugs, including, but not limited to, the use of unit dose systems or blister (bubble) packs. This paragraph does not apply to residents receiving pharmacy benefits through the United States Department of Veterans Affairs if the pharmacy benefits do not reimburse the cost of such packaging. (b) ADVANCED SET-UP. The licensee or administrator may set-up each resident's medications for up to seven calendar days in advance (excluding PRN medications) by using a closed container manufactured for the advanced set-up of medications. (B) The container must be clearly labeled with the resident's name, name of each medication, time to be given, dosage, amount, route, and description of each medication that includes the color, shape and any markings according to the label.

It was observed that Resident 1 had a PRN medication listed on the MAR and in the signed doctor's orders as given every 4 hours as needed, however the pharmacy label for this medication stated to give it every 6 hours as needed.

Provider's statement as written: "PCP given order clarification pharmacy sent medication & proper labeling. Resident manager to ensure all medications brought to home reflect proper administration times (order/med attached)." Accepted by LLA on 2/13/26.

OAR 411-050-0750(2)(j) Resident Records: Significant Events (j) SIGNIFICANT EVENTS AND INCIDENTS. A written report (using form SDS 344 or its equivalent) of all significant incidents relating to the health or safety of the resident, including how and when the incident occurred, who was involved, what action was taken by the licensee and staff, as applicable, and the outcome to the resident. A copy of the report must be sent to the resident's representative, and case manager, if applicable.

It was observed that Resident 1 had a significant event occur and there was no incident report completed or detailed narration on file regarding the incident.

Technical Assistance Provided. Written plan of correction not required.

OAR 411-050-0750(2)(k) Resident Records: Narratives (k) NARRATIVE OF RESIDENT'S PROGRESS. Narrative entries describing each resident's progress must be documented at least weekly and maintained in each resident's individual record. All entries must be signed and dated by the person writing them.

It was observed that Resident 1 had printed narrative entries that did not all list the author of each narrative/were not signed by the author either physically or electronically.

Technical Assistance Provided. Written plan of correction not required.

OAR 411-050-0715(2)(b) Fac Standards: Stairways (2) ACCESSIBILTY. (b) All interior and exterior stairways must be unobstructed, equipped with handrails on both sides, and appropriate to the condition of the residents. (See also OAR 411-050-0725(4)(c)).

There were no handrails for 1 step upstairs and 1 step downstairs leading into the caregiver living quarters at the time of the inspection.

Technical Assistance Provided. Written plan of correction not required.

OAR 411-050-0715(3) Fac Standards: General Condition (3) GENERAL CONDITIONS. The building, including the interior and exterior premises, furnishings, patios, decks, and walkways, as applicable, must be clean, in good repair and well maintained.

There were trees in the backyard leaning towards the AFH and the fence needed repaired at the time of the inspection.

Technical Assistance Provided. Written plan of correction not required.

OAR 411-050-0715(9)(e)(C) Bedroom: Door Passage (e) RESIDENT BEDROOM DOORS. (C) A master key to all the residents' bedroom door locks must be immediately available to the licensee and all other caregivers in the home.

One of the resident bedrooms listed on the floor plan was being used as a caregiver bedroom and the door did not function with the master key at the time of the inspection.

Technical Assistance Provided. Written plan of correction not required.

OAR 411-050-0720(16)(a-g) Safety: Floor Plans (16) FLOOR PLAN. The licensee must develop a current and accurate floor plan that indicates:(a) The size of rooms.(b) Which bedrooms are to be used by residents, the licensee, caregivers, and for adult day services and room and board tenants, as applicable.(c) The location of all the exits on each level of the home, including emergency exits such as windows.(d) The location of wheelchair ramps.(e) The location of all fire extinguishers, smoke alarms, and carbon monoxide alarms.(f) The planned evacuation routes, initial point of safety, and final point of safety.(g) Any designated smoking areas in or on the AFH's premises.

The homes floor plan shows there are currently 5 resident bedrooms however one of the bedrooms was being used by staff at the time of the inspection.

Technical Assistance Provided. Written plan of correction not required.

OAR 411-051-0110(1)(a)(C) PAS: Assess Needs (a) Before admission, the licensee or administrator must conduct and document a screening using the Department's current Adult Foster Home Screening and Assessment and General Information form (SDS 0902) to determine if a prospective resident's care needs exceed the license classification of the home. The screening must: (C) Include medical diagnoses, medications, personal care needs, nursing care needs, cognitive needs, communication needs, night care needs, nutritional needs, activities, lifestyle preferences, and other information, as needed, to assure the prospective resident's care needs shall be met.

The screening form for Resident #1 was missing information in the describe section at the time of inspection.

Technical Assistance Provided. Written plan of correction not required.

OAR 411-051-0130(2) Medication: Carry Out Orders (2) WRITTEN ORDERS. The licensee or administrator must obtain and place a signed order in the resident's record for any medications, dietary supplements, treatments, or therapies that have been ordered by a prescribing practitioner. The written orders must be carried out as prescribed unless the resident or the resident's legal representative refuses to consent. The prescribing practitioner must be notified if the resident refuses to consent to an order.

There were 3 routine medications that had an order to be administered every 12 hours for Resident #1 however the MAR shows these medications are being administered at 8am and 5pm each day at the time of the inspection. There were 2 PRN medications for Resident #1 that were listed on the MAR but there was no order available for review for these medications at the time of the inspection. There was another routine medication for Resident #1 that was written on the MAR however there were 3 conflicting orders for this medication and the MAR did not match the current order. There was a routine medication for Resident #1 that was to be administered 2 tabs every 6 hours 1 day, then 2 tablets every 8 hours for 1 day then 1 tablet every 12 hours for 1 day then 1 tablet once daily for 1 day. The December 2024 MAR shows this medication was administered at 8am, 12pm, 5pm and 8pm on day 1, day 2 shows the medication was administered at 8am, 12pm and 4pm.

Providers statement as written: "Order changed to Q 12 hours 8am and 8pm. Order to be written appropriately and checked by Admin {REDACTED]. Will check order once given every 2 weeks 01/22/25." "Order was completed already. Will ensure all orders are written separately. Admin {REDACTED} to ensure this and monitor every 2 weeks.1/22/25" Verification and statement of correction accepted by AB on 01/24/25

OAR 411-051-0130(2) Medication: Carry Out Orders (2) WRITTEN ORDERS. The licensee or administrator must obtain and place a signed order in the resident's record for any medications, dietary supplements, treatments, or therapies that have been ordered by a prescribing practitioner. The written orders must be carried out as prescribed unless the resident or the resident's legal representative refuses to consent. The prescribing practitioner must be notified if the resident refuses to consent to an order.

Providers statement as written: "All written orders will be transcribed as they are and for any clarification, the MD will be contacted. Order clarification obtained, (attached). All orders in the future will be confirmed by an N in house every two weeks. 2/6/25" Statement of correction accepted by AB on 02/11/25

OAR 411-051-0130(3) Medication Supplies (3) MEDICATION SUPPLIES. The licensee or administrator must have all currently prescribed medications, including PRN medications, and all prescribed over-the-counter medications available in the home for administration. Refills must be obtained before depletion of current medication supplies. Attempts to order refills must be documented in the resident's record.

There was an order for a PRN medication for Resident #1 that was not available for administration at the time of the inspection. There were 2 PRN medications listed on the MAR for Resident #1 but were not available for administration.

Providers statement as written: "Documented attempts for refills or D/C order. Admin to follow up and ensure completed. 1/17/25" "Order clarification sent to PCP. Awaiting order. 1/17/25" "The PRN orders were for one time only. (see attached explanation) hence were completed and cannot be refilled, and not D/C'd. Have been removed from MARS 22 weeks Admin to ensure such meds are removed from MARS 1/22/25" Statement of correction accepted by AB on 01/24/25.

OAR 411-051-0130(6)(a) MARs: Details (6) MEDICATION ADMINISTRATION RECORD. A current, written MAR, or electronic MAR (see OAR 411-050-0755(4)), must be kept for each resident and must: (a) List the name of all medications administered by a caregiver, including over-the-counter medications and prescribed dietary supplements. The MAR must identify the dosage, route, date, and time each medication and supplement is to be given.

There was an order for 2 PRN medications for Resident #1 that were not listed on the residents MAR at the time of the inspection.

Providers statement as written: "Request sent to PCP for completion. Admin to followup and ensure its done. 1/17/25" "PRN medication have been listed on the MARS, sincee theyre OTC, theve been marked with resident name. Admin to ensure all meds are properly listed in MAR every 2 weeks. Statement of correction accepted by AB on 01/24/25.

OAR 411-051-0130(10) Medications/Supplies: Disposal (10) DISPOSAL OF MEDICATION. Outdated, discontinued, recalled, or contaminated medications, including over-the-counter medications, may not be kept in the home and must be disposed of within 10 calendar days of expiration, discontinuation, or the licensee or administrator 's knowledge of a recall or contamination. The licensee or administrator must contact the local DEQ waste management company in the home's area for instructions on proper disposal of unused or expired medications. Prescription medications for residents that have died must be disposed of within 24 hours according to section (11) of this rule.

There was a routine medication in December 2024 for Resident #1 where the order was completed however there were still 4 pills remaining in the pill bottle at the time of the inspection.

Providers statement as written: "Medication disposed as Inspection progressed. Admin to follow up and ensure there's no recurrence of the same. 1/15/25." "Medications disposed. Admin to check in the cabinets and ensure all such medications are discarded every 2 weeks 1/22/25" Statement of correction accepted by AB on 01/21/25.

OAR 411-051-0130(6)(c) MARs: Immediately Initialed (6) MEDICATION ADMINISTRATION RECORD. A current, written MAR, or electronic MAR (see OAR 411-050-0755(4)), must be kept for each resident and must: (c) Be immediately initialed by the caregiver administering the medication, treatment, or therapy as it is completed. A resident's MAR must contain a legible signature that identifies each set of initials.

Providers statement as written: "All medications will be signed immediately after dispensing. All medications were signed. (attached). In the future, all medications will be signed immediately after being given. In house administrator will monitor on daily basis. 2/6/25." Statement of correction accepted by AB on 02/13/25

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During a follow-up inspection, it was observed that Caregiver 3 had a background check approval that listed their position title as "household member". It was observed that Caregivers 4, 5, and 6 had background check approval letters that listed their position titles as "Other (AFH/Contracted Licensed Health Care)". Statement of Correction due by 3/5/2024.

Provider's statement as written: "Have ensured other caregivers records are well done for future and will redo the care role applications. Have emailed BCU for correction." Statement of Correction Accepted and Verified By JK on 03/05/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During a follow-up inspection, it was observed that Caregivers 2, 3, and 4 did not have SAM exclusion list results available on file to review. Statement of correction due by 3/5/2024.

Provider's statement as written: "Will Ensure all Exclusions are completed and in file Have completed the Sam exclusion. Attached in an email to licensor" Statement of Correction Accepted and Verified By JK on 03/05/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During a follow-up inspection, it was observed that Caregiver 1, 5, and 6 did not have a caregiver orientation form on file for review. Statement of Correction due by 3/5/2024.

Provider's statement as written: "All caregivers orientation documents must be in the file completed. Emailed to licensor." Statement of Correction Accepted and Verified By JK on 03/05/2024.

Adult Foster Homes must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the follow-up visit conducted on 02/23/2024 .  The adult foster home was evaluated for compliance with Oregon Administrative Rule 411, Divisions 049, 050, 051, and 052. The following deficiencies were identified:

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that there were no narratives available for review for Resident 2 in their record book. It was observed that the administrator had current caregiver records stored on a personal computer and not available for review in the home at the time of the inspection. Statement of correction due by 02/29/2024.

Provider's statement as written: "Narratives are now in the Folders. They will be available in the folder, in the home at all time. All records will be printed and in folder not stored in personal computer. This did not affect any resident Corrected 2/23/2024. All caregiver records are to be in the facility record book and not computer All records are in file or presented to licensor in a later visit. This didn't affect the resident." Statement of correction not accepted by JK on 3/13/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that Resident 1 did not have a completed screening form available for review in their file. Statement of correction due by 02/29/2024.

Provider's statement as written: "Screening forms will be filed as soon as done. Screening form in folder now. Copy emailed to licensor. No resident is affected by this." Statement of Correction Accepted and Verified By JK on 03/05/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that Resident 2 does not have a care plan written and on file. Statement of correction due by 02/29/2024.

Provider's statement as written: "Care plan completed for the resident and in file. Emailed to the licensor. Care plans will be kept in file and not in computer. Copy sent to licensor 2/28/24." Statement of Correction Accepted and Verified By JK on 03/13/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that Resident 2 had a PRN medication that was empty with no refill available in the home. Statement of correction due by 02/29/2024.

Provider's statement as written: "PRN medications will be restocked in time and if pharmacy can't provide due to patient inability to pay, PCP will be notified to issue D/C order. Medication in the home now. Picture sent to licensor. Pt not affected." Statement of Correction Accepted and Verified By JK on 03/05/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that the current MAR for Resident 3 only had one signature with a corresponding set of initials when more than one person was signing off as administering medications. It was observed that the MAR for Resident 1 did not have any signature with corresponding initials to show who was administering medications. It was observed that Resident 1 had four doses of 8AM medications that had not been initialed when the licensor arrived at the home at 9:45AM. It was observed that Resident 2 had fourteen doses of 8AM medications that had not been initialed when the licensor arrived at the home at 9:45AM. It was observed that Resident 3 and Resident 4 each had seven doses of 8AM medications that had not been initialed when the licensor arrived at the home at 9:45AM. Statement of correction due by 02/29/2024.

Provider's statement as written: "All medications will be initialed upon giving them to residents. All medications are signed now. Pts are not affected by this deficiency." Statement of Correction Accepted and Verified By JK on 03/05/2024.

Based on observation, interview and record review, it was determined the licensee failed to meet this rule as evidenced by: During annual renewal inspection, it was observed that both Resident 1 and Resident 2 had  medication listed on their doctor's orders which were not being administered but there was no discontinue order on file for the medication. Statement of correction due by 02/29/2024.

Provider's statement as written: "Medications have now been provided after PCP authorized them. Pictures of the medications sent to licensor. PCP to be followed till they act/respond. No pts are affected by this deficiency." Statement of Correction Accepted and Verified By JK on 03/05/2024.

Adult Foster Homes must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of an unscheduled onsite inspection for renewal conducted on 02/24/2024. The adult foster home was evaluated for compliance with Oregon Administrative Rule 411, Divisions 049, 050, 051, and 052. The following deficiencies were identified:

Based on record review, interview, and documentation review, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Caregiver 4's record revealed Caregiver 4's background check expired on 03/08/2023. Documentation did not include a current background check or background request form. 2. A review of Caregiver 5's record revealed Caregiver 6's background check expired on 04/20/2023. Documentation did not include a current background check or background request form. 3. In an interview, Caregiver 1 acknowledged Caregiver 4 and Caregiver 6 did not have current approved background checks and Caregiver 4's and Caregiver 6's records did not include a background request form. 4. In an interview, Caregiver 1 acknowledged Caregiver 4 and Caregiver 6 did not have a current, approved background checks. 5. A review of the home's posted staffing plan, dated June 1, 2023, revealed Caregiver 4 did not work alone during any shift. 6. A review of the home's posted staffing plan, dated June 1, 2023, revealed Caregiver 5 did not work alone during any shift. 7. A review of the Oregon Criminal History and Abuse Records Database System (ORCHARDS) website revealed no submission of a new background check for Caregiver 4. 8. A review of the ORCHARDS website revealed Caregiver 5 submitted for a new background check on May 31, 2023. Correct by: 06/19/2023

An application was submitted for BG on 06/09/23 for Caregiver 4. Awaiting results. A new BG was issued for CG 5. Attached. Will renew in future before expiry. Corrected on: 06/09/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Caregiver 6's record revealed current First Aid certification. Documentation did not include current CPR certification. 2. In an interview, Caregiver 1 acknowledged Caregiver 6's record was missing current CPR certification. Correct by: 06/19/2023

Record in place. Attached here. Will ensure all documents are in file. Corrected on: 06/09/2023

Based on observation and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. During a home tour, the licensors observed a bathroom on the second floor. The bathroom sink was tested for water. While being tested, the licensors observed water leaking onto the floor of the bathroom under the sink. 2. In an interview, Caregiver 1 acknowledged the sink was leaking. Caregiver 1 reported Caregiver 1 had already made a request to have the sink fixed. Correct by: 06/19/2023

Sink immediately fixed on 6/9/23. Will keep track of all repairs. Corrected on: 06/09/2023

Based on observation and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. During a home tour, the licensors requested Caregiver 1 to test the resident room doors with the master key. 2. In an interview, Caregiver 1 reported Caregiver 2 had the master key. Caregiver 1 reported Caregiver 2 was not available during the inspection. There was no key accessible for the other caregivers in the home. Correct by: 06/19/2023

Caregiver 2 provided the key upon arrival. In place and accessible. Corrected on: 06/09/2023

Based on documentation review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of the home's fire drill documentation revealed the last drill conducted was dated 02/21/23. Documentation did not include a drill conducted within 90 days. 2. In an interview, Caregiver 1 acknowledged a fire drill was overdue and not conducted within 90 days. Correct by: 06/19/2023

Have updated our records. Missing document put in file on 06/09/23. Corrected on: 06/09/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Caregiver 3's record revealed no documentation indicating Caregiver 3 was not listed on The U.S. Office of Inspector General's Exclusion List or the U.S. General Services Administration's System for Award Management Exclusion List. 2. In an interview, Caregiver 1 acknowledged Caregiver 3's record did include documentation indicating Caregiver 3 was not listed on either of the Exclusion Lists. Correct by: 06/19/2023

Will ensure exclusion lists in file on time. Corrected on: 06/09/2023

Based on documentation review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of the home's documentation of monthly checks for smoke alarm, carbon monoxide alarm, and fire extinguisher testing revealed the last test was conducted in April 2023. There was no documentation of the testing for the month of May 2023. 2. In an interview, Caregiver 1 acknowledged the alarm tests were not current. Correct by: 06/19/2023

Attached. Will ensure alarm tests are tested on time. Corrected on: 06/09/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's record revealed weekly narratives; however, the last entry in the narratives was dated 05/19/2023. 2. A review of Resident 2's record revealed weekly narratives; however, the last entry in the narratives was dated 05/03/2023. 3. In an interview, Caregiver 1 acknowledged the narratives were not current. Correct by: 06/19/2023

Will ensure all progress notes are completed on time. Corrected on: 06/09/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's record revealed a care plan with updates; however, the last update for Resident 1's care plan was dated 04/08/2022. 2. A review of Resident 2's record revealed a care plan with updates; however, the last update for Resident 2's care plan was dated 10/04/2022. 3. A review of Resident 3's record revealed a care plan with updates; however, the last update for Resident 3's care plan was dated 11/24/2022. 4. In an interview, Caregiver 1 acknowledged the care plans were not updated every six months. Correct by: 06/19/2023

All care plans reviewed and signed. Will be reviewed on time. Corrected on: 06/09/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's record revealed no signed medication order for one over the counter (OTC) medication. 2. A review of Resident 1's record revealed a medication administration record, dated March 2023 through June 2023, included the OTC medication, and was provided to Resident 1 daily. 3. In an interview, Caregiver 1 acknowledged a signed medication order for the OTC medication was not available for review. Correct by: 06/19/2023

Will ensure all medication records including OTC are renewed. All OTC mediation orders reviewed, everything well documented. Corrected on: 06/10/2023

Based on record review, observation, and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's record revealed no signed changed order for three "as needed" (PRN) over the counter (OTC) medications. 2. A review of Resident 1's record revealed a medication administration record, dated March 2023 through June 2023, included the three OTC medications; however, there was no documentation to indicate Resident 1 was provided the medications. 3. A review of Resident 1's physical medications revealed no supply of the three OTC medications. 4. In an interview, Caregiver 1 reported Resident 1 no longer needed the medications. Correct by: 06/19/2023

D/C order for OTC requested. Will ensure all orders are followed with PCP. All orders in place. Corrected on: 06/10/2023

Based on record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 3's record revealed a signed order for a medication. The order indicated the medication was to be provided three times a day. 2. A review of Resident 3's record revealed a medication administration record (MAR) dated March 2023 through June 2023. The MAR included the medication and stated to take the medication, "once daily". 3. In an interview, Caregiver 1 acknowledged the error. Correct by: 06/19/2023

All medications have been clarified with PCP. Records updated. Will ensure all records are up to date in future. Corrected on: 07/10/2023

Based on observation and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's medications revealed one medication was stored in Resident 1's room in an unlocked drawer in the nightstand. 2. In an interview, Caregiver 1 acknowledged the medication was not stored in a locked, central location. Correct by: 06/19/2023

The [medication] in resident room kept in lock box now. In future, all medications must remain in locked box. Corrected on: 06/09/2023

Based on observation, record review and interview, it was determined the licensee failed to meet this rule as evidenced by: 1. A review of Resident 1's physical medications revealed two PRN medications were expired. The expiration dates for the two medications were dated 03/03/2022 and 09/28/2022. 2. A review of Resident 1's medication administration record, dated March 2023 through June 2023, revealed the medications were not provided to the resident. 3. In an interview, Caregiver 1 acknowledged the medications were expired. Correct by: 06/19/2023

PRN medications were replaced. Called pharmacy on 06/09/23. Medications sent same day. Will ensure to reorder PRN medications before expiry. Corrected on: 06/09/2023

Adult Foster Homes must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of an onsite inspection for renewal conducted on 06/09/2023 The adult foster home was evaluated for compliance with Oregon Administrative Rule 411, Divisions 049, 050, 051, and 052. The following deficiencies were identified: