Print Inspection: VMWB

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 04/25/2023.  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

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 04/25/2023.  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,  record review and observation, it was confirmed that the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:

During an unannounced site visit on 4/25/2023, CS interviewed Staff #1-3 (S1-S3) who stated they did not have access to the facility's ABST. S1-S3 stated that it should be updated when residents move in or move out.

A review of three sampled residents ABST profiles revealed they had not been updated since June 2022. Resident #5 (R5) was not entered into the tool at all.

CS observed the facility's posted staffing plan which stated "these ratios are based off full occupancy" which was not consistent with their current census or ABST data.

These findings were reviewed with S1-S3 on 4/25/2023 who were in agreement.

Plan of Correction: Facility has new administrator and administrator-in-training. Facility to email OPA/CAC on 4/26/2023 to get access to ODHS ABST for the facility. Facility will update all residents within 30 days.

Based on record review and interview,  it was confirmed that the failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. Findings include but not limited to:

During an unannounced site visit on 4/25/2023, Compliance Specialist (CS) reviewed staff training documents for Staff #5, Staff #7-Staff #8 (S5, S7-S8) which revealed one of three did not have a certification for pre-service dementia training.

These findings were reviewed with Staff #1-Staff #3 (S1-S3) who were in agreement.

Plan of Correction: Facility to audit all staff training documents and ensure completion within 30 days.