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 04/27/2023. 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 the facility did not implement a service plan that reflects the resident's needs as identified in the evaluation. Findings include:
During separate interviews on 04/27/2023, Staff #1-3 (S-3) stated that the facility does have an issue with cleaning Resident #1 (R1) room. S2 stated that it is difficult to clean R1 ' s room because of their dog who can be aggressive towards staff members. S3 stated that housekeeping should be done on a weekly basis.
During an unannounced site visit on 04/27/2023, Compliance Specialist (CS) observed Resident #1 (R1) room to have clutter and multiple Styrofoam containers spread through.
A review of R1 service plan states that R1 has requested staff remove trash from apartment three times a week.
On 04/27/2023, these findings were reviewed and acknowledged by S1.
Based on interview, observation, 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 04/27/2023, Staff #1-2 (S1-2) stated that their current staffing levels are 1 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. S1 stated that there was a MT in training that would be working half their shift on day and the other half on swing shift.
During an unannounced site visit on 04/27/2023, Compliance Specialist (CS) observed 1 MT and 2 CG working.
A record review of the posted staffing plan, staff schedule for April 2023, Resident #1-2 (R1 and R2) service plans dated 02/01/2023 and 03/13/2023, progress notes from 03/26/2023 - 04/27/2023, and the breakdown of their care on the facility's ABST. The exported data in the ABST showed 42 of the 46 residents entered in the tool to not have been evaluated quarterly with last updated dates ranging from 06/14/2022-10/04/2022. S1 stated that a new resident currently moved into the facility on 04/26/2023 had not yet been added into the ABST. The ABST tool showed the care staff needed for each shift was, day: 5, swing: 4, and NOC: 1, showing the facility is understaffing based on their hours indicated in their tool.
On 04/27/2023, these findings were reviewed and acknowledged by S1.