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 10/18/2022.  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 interviews and record review it was confirmed the facility is not providing designated awake caregivers in each building. Findings include:

Interviews with Staff # 4 and Resident # 1 on 10/18/2022 with both stating that they have witnessed the facility leaving one of the cottages without staff during NOC shift on more than one occasion with the most recent being the night of 10/17/2022. Staff # 4 further stated that 2 of the 3 cottages has multiple residents that are 2-person assist and that during NOC shift if one of those cottages need assistance, the caregiver from the cottage with most independent residents will leave that cottage to assist the other cottages when needed, leaving that cottage without staff.

Review of facility staff scheduled for October 2022 reveal multiple days in which the NOC shift only had 3 staff for all 3 cottages with some cottages having multiple 2-person assist residents. Review of facility posted staffing plan indicates that NOC shift should be staffed with 3 caregivers and 1 med tech. If one of the cottages with 2-person assist resident would need assistance a staff member from the other cottage would have to leave their cottage without a staff member to assist the other cottages

Based on interview and record review it was confirmed that the facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity Based Staffing Tool. Findings include the following:

During an unannounced site visit on 10/18/2022 Compliance Specialist (CS) reviewed the facilities Acuity Based Staffing Tool (ABST) against the facilities current posted staffing plan and staff schedule. The facility is scheduled to staff the NOC shift with 3 caregivers and 2 med techs. Review of facility staff schedule for October 2022 reveal that the facility is consistantly staffed with 3 caregivers and 1 med tech and on some occasions staffing with only 3 care staff for NOC shift.

Interview with Staff # 3 on 10/18/2022 who stated that there are occasions in which the facility is staffed with only 3 staff on NOC shift and there are times when one of the care staff will have to assist another care staff and would leave their cottage unattended while assisting the other care staff.