Print Inspection: T1S8

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 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:

In an interview on 8/11/2022 with Staff #1 (S1) stated that the facility has an internal assessment tool, but it does not determine times or frequency 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 (CS) viewed the current staffing plan dated July 2022 on 8/11/2022. There is only one staffing plan for entire campus. Staffing numbers for memory care (MC) and assisted living facility (ALF) staff are combined and treated as one entity. Unable to determine staffing numbers for ALF.

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

Facility Plan of Correction:

Executive Director states that they will investigate the ODHS web site and speak with their main office regarding adapting the ODHS ABST tool.