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 09/07/2022. 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 observation and interview it was confirmed that the facility failed to exercise reasonable precautions that may threaten the health, safety, and welfare of residents. Findings include but not limited to:
During an unannounced site visit on 09/07/2022, Compliance Specialist (CS) observed several staff members not wearing masks while on a tour of the facility.
These findings were reviewed with and acknowledged by Staff #1 (S1) on 09/07/2022, who was in agreement.
Facility Plan of Correction: S1 to complete an in-service with all staff on 09/09/2022.
Based on interview and record review it was confirmed that the facility failed to perform resident services to assist resident in performing activities of daily living. Findings include but not limited to:
During separate interviews Staff #1 (S1), Staff #6, Staff #9 and Resident #1-Resident #3 stated:
*Sometimes showers get pushed to next shift.
*I did not get a shower for 10 days.
*Sometimes there is only 1 CG working on swing shift.
*We are trying to hire more staff.
*Wait times are very long when you push the call light.
*We need more staff.
A review of R1's shower sheets for August and September 2022 revealed that R1 did not receive a shower from 8/28/2022- 09/07/2022.
These findings were reviewed with and acknowlegded by Staff #1 on 09/07/2022 who was in agreement.
Facility Plan of Correction: Facility continues attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.
Based on record review and interview it was confirmed that the facility failed to have the service plan readily available to staff and provide clear direction regarding the delivery of services and include a written description of who shall provide the services
During an unannounced site visit on 09/07/2022 Compliance Specialist (CS) requested a service plan for Resident #6 (R6). No document was able to be produced for this.
During interview, Staff #1 stated that R6 did not have a service plan because they only lived there for 3 days.
Facility Plan of Correction: Executive Director to audit all service plans to confirm they are up to date, available to staff and acknowledged by 9/16/2022.
Based on record review and interview it was confirmed that the facility failed to develop the service plan by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Findings include but not limited to:
A review of Resident #1-#3 service plans revealed that they were only signed by Executive Director. Resident #6 had no service plan.
These findings were reviewed with and acknowledged by Staff #1 on 09/07/2022 who was in agreement and was unable to provide any additional documentation that service planning meetings occurred.
Facility Plan of Correction: Build a better management team. Tuesday and Thursday of the last two weeks of each month will be dedicated to service planning meetings with the service planning team. Facility will document who is present at service planning meetings and involve ED, BOM, Nurse, Resident and family as appropriate.
Based on record review and interview it was confirmed that the administrator failed to be responsible for ensuring adequate professional oversight of the medication and treatment administration system. Findings include but not limited to:
A review of Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3)'s MARs and progress notes for July - September 2022 revealed that all three of these residents have missed doses of medications due to facility running out of medications and not being delivered by pharmacy.
During interview Staff #7 (S7) stated:
*Not all Med Aids order new medications when they are supposed to.
*Residents run out of medications sometimes.
*R1 had been out of a medication for 4 days.
These findings were reviewed with and acknowledged by Staff #1 who was in agreement.
Facility Plan of Correction: S1 to oversee med room. Facility is in the process of changing house pharmacy from Omni to Redcross as Omni has not been able to fulfill their next day delivery promise. Red Cross is a local pharmacy in La Grande. S1 to audit meds and med cart weekly. S1 to discuss med re-order policy with regional team and consider changing re-order time-frame policy. Inservice on med reordering to occur on 09/09/2022.
Based on record review and interview it was confirmed that the facility failed to carry out medication orders as prescribed. Findings include but not limited to:
A review of Resident #1-Resident #3 and Resident #6 MARs and progress notes for July, August and September 2022 revealed many instances of medications being given late and medications not being given because the med was not in the facility.
These findings were reviewed with and acknowledged by Staff #1 on 09/07/2022 who was in agreement.
Facility Plan of Correction: ED to oversee med room. Facility is in the process of changing house pharmacy from Omni to Red Cross as Omni has not been able to fulfill their next day delivery promise. Red Cross is a local pharmacy in La Grande. ED to audit meds and med cart weekly. ED to discuss med re-order policy with regional team and consider changing re-order time-frame policy.
Based on interview and record review it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:
During separate interviews, Staff #1 (S1), Staff #6, Staff #9 and Resident #1-Resident #3 stated:
*Sometimes showers get pushed to next shift.
*I did not get a shower for 10 days.
*Sometimes there is only 1 CG working on swing shift.
*We are trying to hire more staff.
*Wait times are very long when you push the call light.
*We need more staff.
A review of R1's shower sheets for August and September 2022 revealed that R1 did not receive a shower from 8/28/2022- 09/07/2022.
A review of the facility's Acuity Based Staffing Tool on 09/07/2022 revealed the need for 27 hours of care staff during day shift that day, though only 24 hours were scheduled.
These findings were reviewed with and acknowledged by Staff #1 on 09/08/2022 who was in agreement.
Facility Plan of Correction: Facility continues attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.
Based on interview, record review and observation it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include but not limited to:
During interview on 09/07/2022 Staff #1 (S1) stated:
*Facility's census is 34 residents
*They only have 24 hours of care scheduled between two caregivers (CG) and one med aid (MA) for day shift
A review of facility's ABST and staff schedule for September 2022 revealed:
*32 residents had been entered into their ABST
*ABST indicates they have 27 hours of care needed during Wednesday day shift.
*Two CGs and one MA are scheduled on day shift for a total of 24 hours.
Compliance Specialist (CS) observed two CGs and one MA working during day shift.
These findings were reviewed with and acknowledged by Staff #1 (S1) on 09/07/2022 who was in agreement.
Facility Plan of Correction: S1 to have remaining residents entered into ABST by 09/09/2022. Facility continue attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.
Based on interview and record review it was confirmed that facility failed to have a training program that includes methods to determine competency of direct care staff. Findings include but not limited to:
During an interview with Staff #6 (S6) they stated that they did not recall any staff competency checklist being completed prior to working independently. They reported that they had to walk out on their first shift because the other staff member sat in the breakroom for a large portion of the shift. When they returned several days later they worked without supervision on their third day.
During an interview with Staff #8 they reported that S6 worked the first shift independently on 05/15/2022 which was confirmed on their calendar.
A review of S6's training documents revealed that training competencies were not completed and initialed until 05/17/2022.
These findings were reviewed with and acknowledged by Staff #1 on 09/07/2022 who was in agreement.
Based on record review and interview it was confirmed that the facility failed to orient staff to the resident, including the resident's service plan. Findings include but not limited to:
During an unannounced site visit on 09/07/2022 Compliance Specialist reviewed service plans available in facility's "service planning binder" which is available to all floor staff. CS noted that many of these service plans had not been reviewed or acknowledged by floor staff including those belonging to Resident #1-Resident #5. Resident #6 had no service plan. Additionally, many of the Temporary Service Plans available were only signed by 1 person.
During interview, Staff #6 stated that there is supposed to be a shift change meeting but that it has only happened one time since they started.
These findings were reviewed with and acknowledged by Staff #1 on 09/07/2022 who was in agreement.
ED to audit all service plans to confirm they are up to date, available to staff and acknowledged by 9/16/2022.