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 9/22/2022. 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 the facility failed to adopt an acuity-based staffing tool (ABST). Findings include but not limited to:
During an unannounced site visit on 09/22/2022 Staff #1 (S1) stated the facility has adopted the ODHS ABST. S1 stated that although care service hours have been recorded into the ODHS ABST, they do not have a system for ensuring staffing levels and patterns are consistent with the acuity of each resident. S1 did not have a system for utilizing data captured in the ODHS to inform the staffing and patterns.
A review of facility section details of the ODHS ABST showed the total caregiving time for each resident for one week. The facility section details printed document, received on site, failed to demonstrate any of the 22 required ADLs.
Plan of Correction: The facility states they will ensure staff understand how the ABST calculation informs staffing levels on each shift and email the CS with the outcome by 9/23/2022.