The findings of the on-site investigation, conducted 07/13/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MT:            Medication Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

Based on interview and record review, conducted during a site visit on 07/13/23, it was confirmed the facility failed to failed to evaluate the resident within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

In an interview on 07/13/23, Staff 1 (Administrator) stated s/he did not recall the specifics around the discharge of Resident 2 from the hospital in February, but there have been consistent issues with not getting notifications from the discharge planner from the hospital.

In an interview on 07/13/23, Staff 3 (RN) stated they often don't get notified that a resident is ready for discharge until Friday afternoon so s/he will do their best to schedule with the discharging facility a time to evaluate the resident, but s/he is the only one that performs evaluations of residents when they are ready to return to the facility and is not able to always respond immediately to a request to evaluate. S/he further stated s/he could not recall the specifics around Resident 2's discharge from the hospital in February 2023, but did recall that Resident 2 was not ready to return to the facility right away and the hospital was very upset because they were ready to discharge resident.

A review of Resident 2's progress notes indicated a note entered on 02/27/23 stated Staff 3 evaluated resident at the hospital, followed by a note, dated 02/28/23, indicated resident returned to facility that evening.

On 02/23/23, Witness 1 notified The Department Resident 2 was ready for discharge as of 02/21/23, the facility had been notified via phone call on 02/21/23 that resident was ready for discharge, but the facility had failed to return calls to schedule an evaluation of resident for discharge.

The facility failed failed to evaluate the resident within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 07/13/23.

Verbal plan of correction:

The facility will have other staff trained on how to evaluate a resident for discharge and if need be the administrator will complete the evaluations to ensure that residents ready for discharge are evaluated within 24-hours of being notified. They will begin training immediately.

Based on interview and record review, conducted during a site visit on 07/13/23, it was confirmed the facility failed to provide qualified, direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

In an interview on 07/13/2023, Staff 1 (Administrator) stated their staffing plan was to have four caregivers and two med-techs on day and swing shift, and one med-tech and one caregiver on NOC and this staffing plan has been in place for several months, including the month of March 2023.

A review of staff timecards, dated 03/09/23 and 03/10/23, indicated the following:

* On 03/09/23 had four employees working day, three employees working swing and two employees working NOC shift.

* On 03/10/23 had three employees working day and swing and two employees working NOC shift.

A review of call light logs, dated 07/07/23 - 07/13/23, indicated four instances Resident 3 waited over thirty minutes.

The facility failed to provide qualified, direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 07/13/23.

Verbal plan of correction:

Staff 1 stated the following:

* I have hired more staff since the reviewed period.  

* I am over staffed as of now but I am continuing to hire with active advertising.

* Staffing is corrected as of now but I will continue to hire, even for on call purposes.

Based on interview and record review, conducted during a site visit on 07/13/23 it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 3 of 3 sampled residents (#s 3, 4, and 5) whose ABST were reviewed. Findings include, but not limited to:

A review of the facility's ABST for Resident's 3, 4 and 5 indicated the tool did not include all 22 ADLs including:

*Personal hygiene such as shaving and mouth care

*Repositioning in bed or chair

*Supervising, cueing, or supporting while eating

*Cueing or redirecting due to cognitive impairment or dementia

*Ensuring non-drug interventions for behaviors

*Assisting with Leisure Activities

*Monitoring physical conditions or symptoms

*Monitoring behavioral conditions or symptoms

*Assisting with communication, assuasive devices for hearing, vision, speech

*Responding to call lights

During interview, Staff 1 (Administrator) and Staff 2 (Executive Director) stated their management company had reached out to AL Advantage (service planning and ABST platform) but AL advantage refused to change their ABST to be compliant with Oregon rule.

The findings were reviewed with and acknowledged by Staff 1 and 2.

The facility failed to fully implement an Acuity-Based Staffing Tool.

Verbal plan of correction: Staff 1 will email the facility's ODHS OPA by end of day 07/13/23 to get access to state ABST. They will have everyone input into state tool within 90 days.