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 10/19/2022.  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, document review and observation it was confirmed the facility is not providing personal and other laundry services to residents.  Findings include but are not limited to:

In separate interviews on 10/19/2022, Staff #1-5 (S1-5) stated the following:

·S1-2 stated the facility has had a lot of turn over since new administration took over and with the Covid outbreak affecting residents and staff, there have been a lot of call outs. Tasks are not being done timely.

·S3-5 stated resident needs are not being met when it comes to assistance with showers, toileting, laundry and housekeeping and medications are not always administered as scheduled.

Document review of R1-5's service plans on 10/19/2022 revealed all five residents are service planned to receive assistance with laundry 1x per week and as needed.

Document review of the facility's Universal Disclosure Statement (UDS) revealed all residents are to receive assistance with personal laundry and laundering of sheets/towels 1x weekly.

During an unannounced site visit on 10/19/2022, Compliance Specialist observed the following while doing a walkthrough of all three floors:

·Laundry baskets were full and clean laundry had not been put away.

On 10/19/2022. findings were reviewed with and acknowledged by S1.

Facility Plan of Correction:

S1 reports they are actively hiring for all positions to include dedicated housekeeping staff.  

Based on interview and document review it was confirmed the facility is not staffing sufficiently in number to meet the schedfuled and unscheduled needs of the residents.  Findings include but are not limited to:

In separate interviews on 10/19/2022, Staff #1-5 (S1-5) report the facility has had a lot of turnover since new management took over, and a lot of staff have been out sick causing shortages.  S1 reports days where they are not able to meet their posted staffing plan, administration tries to fill in and Staffing Agencies are being utilized to supplement shortages.  S3-5 report resident needs are not being met timely when it comes to assistance with showers, toileting, laundry and housekeeping and medications are not always administered as scheduled.

Document review on 10/19/2022 of the faciity's posted staffing plan, Universal Disclosure Agreement (UDS) and staffing schedule for October confirm that the facility is not staffing to plan and was was not staffed according to plan on the date of the site visit.  

On 10/19/2022, findings were reviewed with and acknowledged by S1.

Facility Plan of Correction:

S1 reports they are actively hiring to fill administrative positions and direct care staff.  They are currently using Staffing Agencies to supplement staff.

Based on interview, observation and document review, it was confirmed the facility failed to fully update their ABST.  Findings include:

In an interview on 10/19/22, Staff #1 (S1) stated the following:

·The facility uses the DHS ABST tool.  

·The ABST has been updated to represent the current census of 14 residents however resident needs have not been updated to reflect changes in care needs due to staffing issues and administration turnover.

·Lack of staffing, increased care needs due to illness and lack of knowledge on how to use the ABST tool has made it difficult to keep up with updating the data.

Document review on 10/19/2022 of Resident #1-3's (R1-3) service plans, temporary service plans and progress notes for October revealed changes in care needs are not being input into the facility's ABST tool. R2,3 had changes in care needs within the last week as a result of Covid, S1 was unable to confirm that the increased care needs were updated in the ABST tool.

During an unannounced site visit on 10/19/2022, the Compliance Specialist (CS) observed facility's ABST during document review. The dashboard is reflecting the correct census of 14 residents; however updates in resident needs have not been updated.  

On 10/19/2022, findings were reviewed with and acknowledged by S1.

Facility Plan Of Correction:

Staff #1 reports that the facility is actively hiring to fill administrative positions, and are in the process of training staff to update the tool.

Based on interview and document review it was confirmed that staff are not completing pre-service training prior to providing care.  Findings include but are not limited to:

In separate interviews on 10/19/2022, Staff #1-5 (S1-5) stated the following:

·S1-2 stated the facility has had a lot of turnover since new administration took over and with the Covid outbreak affecting residents and staff there have been a lot of call outs. Employees responsible for training and documenting training in employee files has fallen behind.

·S2 was unable to locate all employee files and stated they were not sure if all new staff had completed training prior to providing care.

·S4-5 stated they did not complete all required training prior to providing care.

·Due to short staffing, administrative staff were being pulled from their positions to provide care without any training at all.

Document review on 10/19/2022 of S4-5 ' s employee files revealed both had not completed pre-service orientations, required trainings to include dementia training nor had competencies been verified at 30 days prior to providing care.  

On 10/19/2022. findings were reviewed and acknowledged by S1.

Facility Plan of Correction:

S1 reports they are actively hiring to fill administrative positions and direct care staff.  They are working on systems to ensure all new staff are completing required trainings prior to providing care and will audit employee files to make sure all required training and documentation is included.