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 11/01/2022. 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 has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of residents.
Findings include but are not limited to:
During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2, and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated:
-We are looking into contracting with agencies again.
-There is often only one caregiver for the entire facility.
-Staffing is at a crisis level.
-If there were a fire, I would be concerned evacuating with this level of staff members.
-Medications are late due to staffing issues, sometimes showers are missed.
-Laundry is not always done. I have to remind staff to help or it doesn ' t get done.
-Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late.
CS reviewed Staff Schedules for September and October 2022, which revealed the facility is not staffing to their posted staffing plan. CS reviewed the facilities Acuity Based Staffing Tool (ABST); which revealed the facility is not staffing to the levels required per the facilities ABST.
CS reviewed call light logs for 10/02/2022 for all facility residents, which revealed multiple instances of call light response times exceeding 15 minutes.
The above information was shared with S1 and S2 on 11/01/2022.
Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.
Based on interview and record review, it has been confirmed that the facility failed to adopt and implement an Acuity Based Staffing Tool (ABST) as required by rule. Findings include but are not limited to the following:
During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) reviewed Resident #1-Resident #3 ' s service plans dated 10/06/2022, 10/05/2022 and 08/31/2022 against the facilities ABST.
CS interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2 and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated:
-We are looking into contracting with agencies again.
-There is often only one caregiver for the entire facility.
-Staffing is at a crisis level.
-Medications are late due to staffing issues, sometimes showers are missed.
-Laundry is not always done. I have to remind staff to help or it doesn ' t get done.
-Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late.
CS reviewed the facilities staffing schedules for August, September and October, which revealed the facility is not scheduling staffing levels based on the plan created by the facilities ABST.
The above was shared with S1 and S2.
Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job faires. S2 states utilizing an agency is the next step and will start that process ASAP.