Print Inspection: 8ODE

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 10/11/2022.  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 that the facility failed to have enough staff to meet the needs of the residents. Findings include:

Compliance Specialist (CS) reviewed staffing schedules for September 2022 and the posted staffing plan. Per the staffing plan, there should be 4 caregivers (CG) and 1 med tech (MT) for Days and 2 CGs and 1 MT on Nights. The staff work 12-hour shifts. There were multiple days in September that they were staffed below the minimum staffing. The administrator was also picking up shifts as the MT.

During onsite visit on 10/11/22, the facility only had 3 CGs and 1 MT working. They were not staffing per their posted staffing plan.

The above information was shared with Staff #1 on 10/11/22.

In separate interviews on 10/11/21, Staff #1 and 3-4 stated that the beginning half of the week, they only have 3 CG working during Day Shift. Staff #3-4 stated that resident care such as toileting and transfers do take longer when they don ' t have all 4 CGs working.

Facility Plan of Correction:

The facility has been using agency and management to cover call outs. They have new staff hired and currently training. They will be working on an ABST.

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:

Review of staffing schedules for September 2022, posted staffing plan, and service plan for Resident #1. The facility does not have an ABST at this time.

CS observed that the facility is staffed below their posted staffing plan on 10/11/22. The posted staffing plan has not been updated to match the ABST as they do not have one implemented yet.

The above information was shared with Staff #1 on 10/11/22, who acknowledged the findings.

In an interview on 10/11/22, Staff #1-2 stated that the facility does not have an ABST implemented at this time. They are unsure if they will be using the state tool or their own.

Plan of Correction: The facility is hiring more staff and currently training new hires, they will select an ABST and get started working on it right away.