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 04/19/2023. 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 record review and interview, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:
A review of Resident #1-3 (R1-3) service plan showed that the facility did not update quarterly. The service plans are dated 08/31/2022, 07/27/2022, and 07/17/2022.
On 04/19/2023, these findings were reviewed and acknowledged by S1.
Based on interview and record review it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include:
During separate interviews 04/19/2023, Staff #1-2 (S1-2) stated that their current staffing levels for each building are 1 Med Tech (MT) and 1 Caregivers (CG) every shift for building 910 and 920. For buildings 940 and 950, 1 MT and 2 CG for day and swing shift and 1 MT and 1 CG for NOC shift.
A record review of the posted staffing plan, Resident #1-3 (R1-3) service plans dated 08/31/2022, 07/27/2022, and 07/17/2022, progress notes from 03/29/2023 - 04/17/2023, the breakdown of their care on the facility's ABST, and the ABST for the whole facility. R1-3 service plans had not been updated quarterly. The ABST revealed the facility is not staffing to the levels required per the facilities tool.
On 04/19/2023, these findings were reviewed and acknowledged by S1.
Based on interview and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include:
During separate interviews on 04/19/2023, Staff #1-2 (S1-2) stated that their current staffing levels for each building are 1 Med Tech (MT) and 1 Caregivers (CG) every shift for building 910 and 920. For buildings 940 and 950, 1 MT and 2 CG for day and swing shift and 1 MT and 1 CG for NOC shift. S2 stated that the facility has been attempting to hire another CG for building 950.
A record review of the posted staffing plan, Resident #1-3 (R1-3) service plans dated 08/31/2022, 07/27/2022, and 07/17/2022, progress notes from 03/29/2023 - 04/17/2023, and the breakdown of their care on the facility's ABST. R1-3 service plans had not been updated quarterly. The exported data in the ABST showed 49 of the 54 residents entered in the tool to not have been evaluated quarterly with last updated on 12/12/2022.
On 04/19/2023, these findings were reviewed and acknowledged by S1.