Print Inspection: 99VF

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 9/30/2022.  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 and record review, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:

In review of Resident #1-2 ' s Service Plans on 09/30/22, it was determined that they are not being updated quarterly. Resident #1s service plan was last revised on 4/24/20 and Resident #2s service plan was last revised on 07/21/22.

Interviews with Staff #1-2 stated that the facility is behind on their quarterly updates. It was difficult to coordinate care planning during covid. If a resident has any changes, they have been updated in a temporary service plan (TSP), although they are not current on the actual quarterly updates. They currently use PCC which has not been correctly tracking the service plans that are due to be updated. The nurse has a list and was keeping track. Staff #1 states there are more residents that need updated service plans and they are working on it.

Plan of correction:

Determine how many residents need quarterly updates. The ED, RN, and RCC will immediately get started on updates. This could take an estimated 6 weeks.

Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:

In review of staffing schedules for September 2022, posted staffing plan, ODHS ABST, and service plans for Residents #1-2. The ABST shows 5 residents as incomplete. All resident information is not currently updated in the ABST and Residents #1-2 have outdated service plans by over a year.

The above information was shared with Staff #1 on 09/30/22, who acknowledged the findings.

In an interview on 09/30/22, Staff #1-2 stated that the RCC has been updating the ABST. They had some new move-in recently. They will get that finished right away.

Plan of Correction:

The ED, RCC, and RN will start immediately on updated the ABST and make sure the service plans are updated as well. They will make sure the posted staffing plan reflects the staffing from the ABST.