Print Inspection: 35LU

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 02/24/2023.  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 and record review, it was confirmed the facility failed to carry out medications as prescribed. Findings include:

During separate interviews on 02/24/2023, Staff #1-2 (S1 and S2) were aware of the medication error. The facility proceeded to investigate, notify physicians, obtain new written orders as needed, notified local adult protective services, and conducted and in-service and retraining to med tech.

A review of Resident #1 (R1) medication administration records (MARs) for February 2023, progress notes for 01/24/2023-02/24/2023 as well as the facilities policy and procedures for medication errors. CS identified that on 02/05/2023 R1 was not given medication X due to staff error. A same day incident report and proper notifications were made. The medication error was followed by alert charting for R1.

On 02/24/2023, these findings were reviewed and acknowledged by S1.

Plan of Correction: The facility documented the incident, filled out a med error report and followed up per their policy and procedure. Training was provided to med tech.

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 an interview on 02/24/2023, Staff #1 (S1) stated that their current staffing levels are 2 Med Tech (MT) and 3 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. S1 was unable to express how they use their Acuity Based Staffing Tool (ABST) to generate their current staffing levels based on the amount of caregiving time indicated in the tool.

During an unannounced site visit on 02/24/2023, Compliance Specialist (CS) observed 2 MT and 3 CG working.

A review of the posted staffing plan and the facility ' s ABST. The ABST tool has inaccurate numbers stating that on day shift the facility needs 70.51 hours of care resulting in 9 CG needed. For swing 64.08 hours with 8.5 CG needed and NOC with 26.68 hours with 3.5 CG needed.

On 02/24/2023, these findings were reviewed and acknowledged by S1.