Print Inspection: HDJT

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 8/11/2022.  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 and record review it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following:

During an unannounced site visit on 08/11/2022 Compliance Specialist (CS) reviewed the facilities staff schedules for the months of June- August 2022. CS reviewed staff schedules against facilities posted staffing plan. Facility had multiple open shifts that don't appear to have been filled as well as multiple days where the facility was not staffing according to their posted plan.

In an interview with an unsampled resident it was stated that it was their shower day and they had not yet received their shower. CS reviewed residents shower schedule and confirmed that they were scheduled for Thursday morning showers.

In separate interviews with Staff #3 and Staff #7 (S3 & S7) the following was stated:

·I don't believe (unsampled resident) has received their shower yet, I doubt they have

·I don't know if they have had their shower, day shift didn't tell me if they needed a shower still.

Findings were shared with Staff #1 and Staff #8 (S1 & S8) who acknowledged findings.

Based on interview and record review it was confirmed that the facility failed to have an Acuity Based Staffing Tool that accurately reflected the resident population and their needs. Findings include the following:

During an unannounced site visit on 08/11/2022 Compliance Specialist (CS) reviewed the facilities Acuity Based Staffing Tool (ABST) against the facilities current resident roster and found 1 resident in the acuity tool that was no longer on the resident roster and 2 residents on the resident roster that had moved-in in July 2022 that were not listed in the ABST. CS reviewed the most current service plans for Resident #3 and Resident #4 (R3 & R4) against the facility ABST for both residents inconsistencies were identified between each residents service plans and their ABST questions.

In separate interviews with R3 and R4 the following was stated:

·I need assistance with dressing and some incontinence assistance

·I need help getting my shoes on

Neither Residents ABST ' s were reflective of their voiced needs

In an interview with Staff #1 (S1) it was stated that they had not updated their ABST since getting the information put in, but they will work on getting it current and check into the noted inconsistencies.