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 7/7/2022. 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, observation and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:
Review of staffing schedules for June and July 2022, posted staffing plan, ABST summary, and service plan for Resident #1. The ABST shows the facility needs 5 caregivers (CG) and 1 med tech (MT) for Days and Swing shift, and 1 CG and 1 MT for NOC shift. The posted staffing plan shows that they have 2.5 CG and 1 MT for Days and Swing shifts, and 1 CG and 1 MT for NOC shift.
CS observed that the facility is staffed below their staffing as reported on the ABST on 07/07/22. The posted staffing plan has not been updated with the current staffing levels from the ABST.
The above information was shared with Staff #1 on 07/07/22, who acknowledged the findings.
In an interview on 07/07/22, Staff #1 stated that the facility is using their own ABST. It pulls information (for the required ADLs) straight from the service plans to determine their acuity and staffing levels. They are not currently staffing to the new staffing levels as they do not have the staff to do so. They are currently hiring and are in the process of training new staff. Resident #1 missed their scheduled appointment due to the facility not getting them ready on time.
Plan of Correction: The facility is hiring more staff and currently training new hires, they will staff per the ABST and update the posted staffing plan, and hope to have a specific person for showers, transportation, and coordinating appointments when fully staffed.