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 01/30/2023. 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 observation, interview and record review, it was confirmed that the facility failed to provide services to assist the resident in activities of daily living including bathing and washing hair, toileting and bowel and bladder management. Findings include but not limied to:
During an unannounced site visit on 1/30/2023, Compliance Specialist (CS) observed Resident #2 (R2) who had skin flakes covering their shirt and appeared unkept.
A review of the facility's shower schedule revealed that R2 is only scheduled for one shower weekly.
During separate interviews Staff #6-Staff #8 (S6-S8) and R2 stated:
*R2 needs three people to assist with transfers.
*R2 did not get a shower last week.
*Swing shift is often short staffed.
*R2 prefers showers on swing shift.
*The facility shower aide is not able to do R2's shower because they need so much help for transfers and R2 prefers them after their shift is done.
These findings were reviewed with Staff #1 (S1) on 1/30/2023.
Plan of Correction: Technical assistance was provided by Compliance Specialist on how to input data into Acuity- Based Staffing Tool (ABST) for residents who require assistance from more than one staff member. Facility will audit and update their ABST with this information. Facility is implementing an on-call phone number to help with call-outs and staffing. They are actively hiring staff. Executive Director to ensure that R2 was provided a shower on 1/30/2023.
Based on observation, interview and record review it was confirmed that the facility failed to implement services. Findings include but not limited to:
During an unannounced site visit on 1/30/2023, Compliance Specialist (CS) reviewed Resident #2 (R2)'s service plan dated 12/29/22 and progress notes for December 2022 and January 2023 which revealed that resident had at least two falls during that time and inconsistency in service planning for transfers. The service plan stated that R2 required use 1-2 person assistance with transfer pole. There were handwritten notes on this section of the service plan that stated "2 person minimum." A progress note dated 1/24/2023 stated it was recommended two person assisted using slideboard. No Temporary Service Plans (TSPs) were in the service plan binder.
During separate interviews, Staff #4 (S4), Staff #7-#8 (S7-S8) stated:
*We did a slideboard training with R2 but it did not go well.
*R2 requires three person assistance with transfers because they are so weak and shaky.
*They use the wheelchair or bedcane to push off of and don't use a transfer pole.
CS observed that there was not a transfer pole at the resident's bedside.
These findings were reviewed with S1 on 1/30/2023.
Plan of Correction: Facility just changed Electronic Medical Records and is now using Point Click Care. Facility to audit all service plans for accuracy within 30 days and adjust staffing accordingly.
Based on record review and interview it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:
During an unannounced site visit on 1/30/2023, Compliance Specialist (CS) reviewed Resident #1 (R1)'s Medication Administration Record for January 2023 which revealed four occassions when a medication was not given or documented.
These findings were reviewed with S1 who was unsure why the meds were not given or documented.
Plan of Correction: Facility to conduct a weekly MAR audit each Monday and any discrepancies will be discussed in their standup meeting.
Based on on observation, interview and record review it was confirmed that the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include but not limited to:
During an unannounced site visit on 1/30/2023, Compliance Specialist observed the facility's iAlert call system board which revealed that two unsampled residents had waited over 41 minutes and 1 hour 27 minutes before receiving assistance.
A review of the facility's posted staffing plan revealed the need for:
Day: 3 Caregivers (CG) and 2 Medication Technicians (MTs)
Swing: 3 CGs and 1 MT
Noc: 1 CG and 1 MT
During separate interviews Staff #6-Staff #8 (S6-S8) and R2 stated:
*R2 needs three people to assist with transfers.
*R2 did not get a shower last week.
*Swing shift is often short staffed.
*R2 prefers his showers on swing shift.
*The facility shower aide is not able to do R2's shower because they need so much help for transfers and R2 prefers them after their shift is done.
These findings were reviewed with Staff #1 (S1) on 1/30/2023.
Plan of Correction: Technical assistance was provided by Compliance Specialist on how to input data into ABST for residents who require two person assistance. Facility will audit and update their ABST with this information. Facility is implementing an on-call phone number to help with call-outs and staffing. They are actively hiring staff.