Print Inspection: Z9KN

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 11/29/2022.  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 that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:

Review of staffing schedules for November 2022, posted staffing plan, ABST, Resident #1 ' s service plan, and call light logs for 11/06/22-11/07/22.  There were 9 call light response times for Resident #1 ranging from 20-42 minutes. The ABST reported 10.72 Staff needed on day shift and the posted staffing plan shows 8 Staff (3 med techs and 5 resident care partners). The November staffing schedules show less than 10 staff working on multiple days due to call outs. They are not staffing per the ABST, and the posted staffing plan does not reflect the ABST.

The above information was shared with Staff #1 on 11/29/22, who acknowledged the findings.

In an interview on 11/29/22, Staff #1 stated that they will normally only check the call light response times if there is a complaint. The facility expectation is that staff are responding to the call lights in less than 15 minutes.

Plan of Correction:

Facility will staff per the ABST and staffing plan. Retraining and reminders for staff at change of shift regarding call light response times. Regular auditing of the call light logs to ensure staff are responding timely.

Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:

Review of staffing schedules for November 2022, posted staffing plan, ABST, call light response times and service plan for Resident #1. Resident #1 had 9 call light response times on 11/06/-22-11/07/22 that were between 20-42 minutes. The ABST reported 10.72 Staff needed on day shift for 11/29/22 and the posted staffing plan shows 8 Staff (3 med techs and 5 resident care partners). The November staffing schedules show less than 10 staff working on multiple days during day shift due to call outs. They are not staffing per the ABST, and the posted staffing plan does not reflect the ABST. The facility census is 131 and only 122 residents are entered into the tool. Resident #1 has care needs that are not entered into the tool (including time spent responding to call lights).

The above information was shared with Staff #1 on 11/29/22, who acknowledged the findings.

In an interview on 11/29/22, Staff #1 stated that the facility is using the state ABST. The ABST is not currently updated with all the residents and their care needs. They have had some changes to their census. Resident #1 has had recent changes to their care needs which are not reflected on the ABST.