Print Inspection: 7DP4

Based on interview and record review, conducted during a site visit on 03/06/24, it was confirmed the facility failed to provide prompt access to records for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

During an interview on 03/06/24, Staff 1 (Executive Director) stated Resident 1 had requested an investigation for an incident s/he had been involved in. Staff 1 had not given Resident 1 a copy of the investigation and further stated "incident reports" were not a part of the resident record.

Resident 1 was unable to be interviewed as s/he was not present in the facility during the site visit.

A review of an incident report for Resident 1, dated 12/07/23, indicated the investigation had been completed.

It was determined the facility failed to implement the resident's right to have access to his/her records.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 03/06/24.

Verbal plan of correction: The facility will provide the incident report to the resident.

Based on interview and record review, conducted during a site visit on 03/06/24, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

During an interview on 03/06/24, Staff 1 (Executive Director) stated the facility was "trying to use the state tool" and the facility's ABST was not updated regularly. Staff 1 stated a new "staffing coordinator" had been hired and s/he would be responsible for entering data into the tool going forward.

A review of the facility's ABST, indicated the following:

- The facility used the Oregon Department of Human Services ABST;

-  The facility census was 73, only 67 residents were entered into the ABST;

-  Resident 1's last ABST update was 04/13/22;

-  Resident 2 was admitted to the facility on 10/03/24, s/he was not entered into the ABST; and

-  Resident 3's last ABST update was 07/07/22.

Findings of the investigation were reviewed with and acknowledged by Staff 1 on 03/06/24.

It was determined the facility failed to fully implement and update an ABST.