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 9/8/2022. 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 the facility does not have enough staff to meet the scheduled and unscheduled needs of the residents.
Findings include:
During onsite interviews on 9/8/2022 both Resident #1 and #2 (R1 and R2) stated that the facility is understaffed and that the call light can take up to 30 minutes to an hour to be answered. R2 stated that most staff respond to her, " I am busy since we are short staffed today." Compliance Specialist (CS) also interviewed Staff #3 who stated their concerns about the facility being understaffed.
CS observed on unscheduled site visit on 9/8/2022 there to only 4 caregivers and 2 med techs working.
Record review for site visit on 9/8/2022 of the staff schedule for August 2022, the posted staffing plan and call light logs from 7/18/2022-9/22/2022. Review of the call light logs revealed 65 times where the call lights exceed a 15-minute response time. Review of the staff schedule shows multiple days where the facility is understaffed based on their posted staffing plan. The posted staffing plan shows there should be 5 caregivers and 2 med techs working on day shift.
Verbal POC: The facility is using agency for staffing and hiring more staff, staff will get more training on the proper procedure for answering call lights.
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:
During onsite interview on 9/8/2022 with Staff #1 and Staff #4 (S1) and (S4) both stated that the facilities current census was 91 residents and stated only 89 residents were entered into ABST. S4 stated that Resident #2 (R2) ABST needed to be updated because their hours for caregiving services do not reflect their actual needs.
Compliance Specialist (CS) observed no posted staffing plan during onsite visit on 9/8/2022.
Record review of the facilities ABST shows Resident #3 (R3) doesn ' t need any time with completing specific housekeeping or laundry services performed by staff, however, while CS was interviewing R3 there was a caregiver helping with laundry services.
Verbal POC: Will add residents in before they move in S1 will reach out to policy analyst to get further clarification on how to use the tool properly when it comes to answering the 22 ADL questions adequately.