Print Inspection: BYX8

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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 05/20/24.  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 observation, interview and record review, conducted on 05/20/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool for 3 of 6 sampled residents (#5, 6, and 7). Findings include, but are not limited to:

A review of the facility's Resident List Report, dated 05/20/24, indicated the current census was 48 residents.

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

* The facility adopted the ODHS ABST tool, which included all 22 distinct ADLs.

* There were 45 residents entered into the tool. Residents 5, 6, and 7 were unaccounted for.

* The facility's ABST generated staffing time to meet the predictable scheduled needs of residents 24 hours a day.

During an interview, Staff 1 (Executive Director) stated the following:

-When residents were out of facility at the hospital, Staff 1 deleted them from the facility's ABST.

-Resident 6 and Resident 7 were currently out of the facility at the hospital.

-Resident 5 was currently in the facility but had been out of the facility at the hospital for approximately 30 days. S/He had forgotten to add Resident 5 back into the tool when Resident 5 returned to the facility.

A review of the posted staffing plan exceeded the ABST and indicated the following:

In the RCF, there were:

* Day shift (6am - 2pm): six CG and one MT, one activity worker, and one "other worker";

* Evening shift (2pm - 10pm): five and half CG, one MT, one activity worker, and one "other worker"; and

* Night shift (10pm - 6am): three CG and one MT.

In the MCC, there were:

* Day shift (6am - 2pm) : one CG and one MT;

* Evening shift (2pm - 10pm): one CG and one MT;  and

* Night shift (10pm - 6am): one CG and one MT.

Throughout the site visit on 05/20/24, the Compliance Specialist observed in the MCC there were two CG and one MT on day shift and in the RCF on day shift there were eight CGs, two MTs, one activity worker, and one resident care coordinator.

During an interview, Staff 19 (Caregiver) stated Resident 6 had been out of the facility in the hospital for about a week and a half. Resident 7 went out to the hospital last night during night shift. Resident 5 was currently in the facility.

A review of Residents 1, 2, and 3 service plans, dated 05/13/24, 04/05/24, and 03/05/24 respectively, and ABST profiles indicated the following:

* Resident 1's profile was last edited on 05/20/24 and matched their service plan.

* Resident 2's profile was last edited on 05/20/24 and matched their service plan.

* Resident 3's profile was last edited on 05/20/24 and matched their service plan.

At 11:35 am, Resident 1 was out of the facility unable to be interviewed.  

In an interview at 12:21 pm, Resident 2 stated his/her care needs were being met. S/He had a shower and his/her hair was groomed today.

It was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 05/20/24.