Print Inspection: U367

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 08/07/24.  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

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

HS:Hours of sleep

LPN:Licensed Practical Nurse

MT:            Medication Technician or Med Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

SP:Service plan

SPT:Service Planning Team

TAR:Treatment Administration Record

Based on interview, and record review, conducted during a site visit on 08/07/24, the facility's failure to provide direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to:

A review of the posted staffing plan indicated the following:

-For day shift (6am-2pm) and swing shift (2pm-10pm), there were two Med Techs (MTs) scheduled and three Caregivers (CGs); and

-For night shift (10pm-6am), there was one MT and two CGs scheduled.

A review of staff schedules, dated 07/01/24 through 08/07/24, indicated there were 37 instances where the facility was not staffing according to their posted staffing plan on one or more shifts that day, including seven instances where no CG was scheduled on shift.

A review of night shift timecards, dated 07/15/24 through 07/25/24, indicated six instances where no MT was scheduled.

Staff 1 (Executive Director) stated the facility did not utilize agency staff to cover shifts. On the days where no MT was scheduled on night shift for this building (Terrace), a MT from another building (Garden) was covering medications.

Interview with Witness 1 (Policy Analyst), indicated Terrace and Garden have separate facility licenses and do not have an exception granted by the department to share staff between the buildings/licenses.

The facility's failure to provide direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 via virtual conference on 08/28/24.

The facility's plan of correction was to add an additional staff to night shift to meet their posted staffing plan of one MT and two CGs.