Print Inspection: J7B6

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 9/22/2022.  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 determined the facility failed to adopt an acuity-based staffing tool (ABST). Findings include but not limited to:

During an unannounced site visit on 09/22/2022 Staff #1 (S1) stated the facility has adopted the ODHS ABST. S1 stated that although care service hours have been recorded into the ODHS ABST, they do not have a system for ensuring staffing levels and patterns are consistent with the acuity of each resident. S1 did not have a system for utilizing data captured in the ODHS to inform the staffing and patterns.

A review of facility section details of the ODHS ABST showed the total caregiving time for each resident for one week. The facility section details printed document, received on site, failed to demonstrate any of the 22 required ADLs.

Plan of Correction: The facility states they will ensure staff understand how the ABST calculation informs staffing levels on each shift and email the CS with the outcome by 9/23/2022.