Print Inspection: Q8TY

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 determined that facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include, but is not limited to:

In separate interviews on 8/11/2022 with Staff #1 & S2 (S1 & S2).

 * S1 stated that the facility does not have a tool in place to determine caregiving hours. S1 was unable to communicate how hours are determined for providing care.

 * S2 stated that "Resident #1 (R1) is a two person assist. During the night and 2-3 evening shifts weekly there is only one caregiver and one nurse to assist with care. The nurse also covers and aids the assisted living facility leaving just one person alone to provide all care. Then they need to call for assistance and will need to wait until another caregiver shows up".

Facility records reviewed by Compliance Specialist (CS) on 8/11/2022 of posted staff plan dated July 2022, R1 ' s temporary service plan (TSP) & current service plan.

 * There is only one staffing plan for the entire campus. Staffing numbers for memory care (MC) and assisted living facility (ALF) staff are combined into one plan. Staffing Plan shows 1 nurse and 2 caregivers for the nocturnal shift.

 * R1 TSP and service plan shows resident is a 2 person assist for care and needs.

Findings were reviewed and acknowledged with S1 on 8/11/2022.

Facility Plan of Correction:

Executive Director (ED) states she will reach out to their main office about aquiring an ABST. ED states that R1 is moving 8/11/2022 to a different care setting.

Based on interview and record review it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but is not limited to:

Interview on 8/11/2022 with Staff #1 (S1) stated that the facility has an internal tool that they use that goes over a residents care and needs. Internal tool is completed by S1. After further review S1 states that it does not determine times for tasks. "At this time the facility has no aquity-based staffing tool in place." S1 was unable to communicate how hours are determined for providing care.

Compliance Specialist viewed current posted staffing plan dated July 2022 in place  during site visit on 8/11/2022, which shows both memory care (MC) and assisted living facility (ALF) staff combined as one entity. CS was unable to determine staffing numbers for MC individulally.

Findings were reviewed and acknowledged with S1 on 8/11/2022.

Facility Plan of Correction:

Executive Director states that they will look into the ODHS web site and speak with their main office.