Print Inspection: BEQS

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 07/28/2022.  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 have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:

Review of posted staffing plan, timecards for 07/06/22, call light response times for 07/06/22-07/07/22, Acuity Based Staffing Tool (ABST), and service plans for Residents #1-3. The facility has not completed entering all of the residents into the ODHS staffing tool. The posted staffing plan reports that there are to be 2 med techs and 2 care partners on Days and Swing Shifts and 1 med tech and 1 care partner on Noc shift. The timecards showed 5 staff for days, 3 for swing, and 2 for Noc. The Express payroll invoice did not show any agency staff working on 07/06/22. The facility did not staff per their staffing plan on swing shift for 07/06/22. Call light logs revealed multiple call light response times ranging between 20 minutes to 1 hour and 36 minutes.

The above information was shared with Staff #1 on 07/28/22. Staff #1 acknowledged the findings of the call light response times.

Interviews on 07/28/22, Staff #1 stated that they are using the ODHS ABST, however, they have only entered in about 13 residents out of the 46. The facility ' s expectation is for staff to be responding to call lights within 7 minutes. They are auditing the call light logs about twice per month or if there are complaints. Staff #3-4 stated that there is not enough staff to respond to residents timely. Call lights are going off for longer than 20 minutes. The care staff are also responsible for doing room trays which can take a while.

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:

Review of timecards for 07/06/22, call light log for 07/06/22-07/07/22, posted staffing plan, ODHS ABST, and service plans for Resident #1-3. The ABST has not been updated with all of the residents in the facility. The posted staffing plan is not reflective of the ABST as it has not been fully updated and implemented yet. Call light logs revealed multiple call light response times ranging between 20 minutes to 1 hour and 36 minutes.

The above information was shared with Staff #1 on 07/06/22, who was in agreement.

In an interview on 07/28/22, Staff #1stated that they are using the ODHS ABST, however, they have only entered in about 13 residents out of the 46. They are working on getting this updated. The ABST based staffing plan does not match the facility ' s posted staffing plan because it is not yet finished. The facility 's expectation is for staff to be responding to call lights within 7 minutes. Staff #3-4 stated that there is not enough staff to respond to residents timely. Call lights are going off for longer than 20 minutes.