Print Inspection: FGU5

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 01/25/2023.  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 the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include:   

During an interview on 1/25/2023, Staff #1 (S1) stated that their current staffing levels are 2 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. S1 was unable to express how they use their Acuity Based Staffing Tool (ABST) to generate their current staffing levels based on the amount of caregiving time indicated in the tool. S1 acknowledged Resident #1 (R1) 22 activities of daily living (ADLs) hours are incomplete in the tool and that R1 has lived in the facility since July 2022.  

During an unannounced site visit on 1/25/2023, Compliance Specialist (CS) observed 2 MT and 2 CG working.   

A review of the posted staffing plan, facility ' s ABST, service plan and progress notes for Residents #1-2 (R1 and R2) and the breakdown of their hours indicated for all 22 ADLs. The ABST tool has inaccurate numbers stating that on day shift the facility needs 70.22 hours of care resulting in 9 CG needed. For swing 65.06 hours with 8 CG needed and NOC with 26.67 hours with 3.5 CG needed. The ABST tool shows not all residents are completed with accurate numbers into the tool. R1 shows no hours needed when their service plan indicates they do need assistance with some ADLs.  

On 1/25/2023, these findings were reviewed and acknowledged by S1.  

Plan of Correction: The facility will reevaluate their ABST to reflect to correct hours of care provided to the residents and correct time needed for residents'  current needs.