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 8/24/2022.  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

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on interview and record review, it was determined that the facility failed to  update an acuity-based staffing tool (ABST). Findings include, but are not limited to:

During an unannounced site visit on 8/24/2022, the Compliance Specialist (CS) observed the facility's ABST dashboard was not reflective of the facility's current census.

In an interview on 08/24/22, Staff #1 (S1) reported that the facility is using the ODHS ABST tool however there are 2 residents that had not been admitted into the ABST at the time of the site visit. One was admitted to the facility in August and the other in June.

On 08/24/2022, findings were reviewed with and acknowledged by S1.

Facility Plan Of Correction:

S1 and CS added the two residents to the ABST tool, corrections were made on site.