Print Inspection: J99C

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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 05/07/24.  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 during a site visit on 05/07/24 and 05/14/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool for 1 of 3 sampled residents (#3). Findings include, but are not limited to:

On 05/07/24 at approximately 3:28 pm, a review of the facility's ABST indicated the following:

- The facility adopted an ABST and used the ODHS tool.

- All residents were entered into the tool.

- The ABST generated a 24-hour staffing plan.

- The facility's posted staffing plan exceeded the ABST generated staffing.

- The facility was consistently staffing to the levels indicated by the tool.

A review of Resident 3's ABST profile indicated ADL needs were not accurately reflected in the areas of bowel and bladder management, the task time was set to zero minutes.

On 05/07/24, at approximately 1:14pm, the Compliance Specialist (CS) observed the following:

- Resident 3 was in his/her restroom.

- S/He requested assistance from care staff after using the restroom.

- Staff 7 (Med Tech) assisted Resident 3 with ambulation from the restroom to his/her wheelchair.

A review of Resident 3's service plan and evaluation, dated 04/30/24, indicated the following:

-"Toileting [Assistance] Extensive: Resident cannot get to toilet unassisted, and may not be aware of need. Facility will provide assistance, which may include cuing, ambulating to the toilet, assist with clothing, wiping, and cleansing. "

-"Toileting Program Description: Staff assist with toileting during safety checks. Occasionally able to transfer self in regards to toileting. Majority of time staff assist to toilet or physically provide changing of undergarment. Staff encourage resident to assist with some aspect of task as able. 5 Times/Day. "

On 05/07/24, an attempt was made to interview Resident 3 regarding his/her care needs, but s/he provided no additional information.

During an interview on 05/07/24, Staff 1 (Executive Director) stated the following:

-The facility "always overstaff needs."

-There were no residents at the facility who required the assistance of two direct care staff.

-To bridge gaps in staffing, the facility has historically used agency staff.

-The facility has regularly scheduled agency staff and utilize the same staff for consistency of care for residents.

A review of the facility's posted staffing plan indicated the following:

-Day shift 0600-1430: two Med Aides (MT) and three CGs

-Evening shift 1400-2230: two MT and three CGS

-Night shift 2200-0630: one MT and one CG

A review of the staff schedule from 03/31/24 through 05/11/24 indicated the facility was consistently staffing at or above the posted staffing schedule.

During the site visit 05/07/24, the CS observed day and evening shift. For day shift, the facility had three CG, two MT, and an additional designated staff to administer insulin. For evening shift, the facility had three CG which included a delegated staff, and two MTs.

It was confirmed the facility failed to fully implement and update an acuity-based staffing tool for Resident 3.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 05/14/24.