Print Inspection: WT5V

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 a facility monitoring inspection conducted on 01/13/2023.  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, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include:

During an onsite interview on 01/13/2023, Staff #1 (S1) stated the following,

·The facility has not updated their ABST in a couple weeks.

·There are residents who no longer live there who need to be archived and residents who have moved in and have not yet been added to the tool.

·That the facility has not updated change on conditions into the ABST in a while.

·Resident #2-3 (R2 and R3) moved into the facility a week or two ago.

During an unannounced site visit on 01/13/2023, The Compliance Specialist (CS) observed S1 adding R2 and R3 into their tool.

A record review of the Posted Staffing Plan, Staff Schedule for December 2022 and January 2023, Resident #1-3 (R1, R2 and R3) Service Plan, Progress Notes, the breakdown of their care on the facility ' s ABST, and the States internal ABST website. The States internal website shows resident #2-3 were not entered into the tool until CS entered the building. R2-3 service plans show R2 moved in on 01/01/2023 and R3 moved in on 12/22/2022.

On 01/13/2023, these findings were reviewed and acknowledged by S1.