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 03/28/2023.  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, observation and record review it was confirmed that the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include the following:

During an unannounced site visit on 03/28/2023 in an interview with Staff #1 (S1) it was stated that they were unsure if the facility had an ABST and that they were told that they should staff at four caregivers and one med tech for day and swing shift and one caregiver and one med tech for NOC shift.

Compliance Specialist (CS) reviewed Service Agreements for Resident #1- #3 (R1-R3) as well as a generated Service Plans By Provider sheet that was provided to CS by Staff #2 (S2) and was stated that was the facility ABST. CS found that for R1 the facility provided ABST addressed eight of the 22 required elements, for R2 eleven elements were addressed and for R3 fifteen elements were addressed. None of the reviewed residents had all 22 activities of daily living and other care related tasks addressed.

CS observed while onsite staff encouraging residents to go to the TV room and assisting residents with ambulating to the TV room for activities, but a review of the facility ABST it does not appear to address this element of the residents care needs.