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 observations, interviews, and record review it was confirmed the facility is not providing a daily program of social and recreational activities. Findings include:
Review of the facility posted activities calendar for October 2022 and for the time of the visit reveal the facility is scheduling activities for residents.
During tour of facility on 10/19/2022 Compliance Specialist observed that the facility was not providing the posted activity at the time of visit. Compliance Specialist observed a resident in the activity room working on a puzzle independently. There was no organized activity taking place in the activity room.
Interview with Staff # 2 on 10/19/2022 who stated that the staff member responsible for activities is currently working as a caregiver and the posted activities are not taking place. Staff # 2 further states that the facility is not providing the materials for the posted activities.
Interview with Staff # 1 on 10/19/2022 who acknowledged the findings.
Facility Correction Plan: None provided.
Based on interview and record review it was confirmed the facility is not completing service plans quarterly after the resident moves in. Findings include:
Review of Resident # 3 Service plan dated 03/30/2022 reveals the facility is not updating the service plan quarterly. The service plan should have been updated in 06/2022 as it's next quarterly review.
Interview with Staff # 1 on 10/19/2022 who acknowledged the findings.
Facility Correction Plan: Facility will ensure that service plan for Resident # 3 is updated and that all service plans are updated quarterly.
Based on observations, interviews, and record reviews it was confirmed the facility failed to have sufficient staff to meet resident needs. Findings include:
During tour of facility Compliance Specialist observed that there is a resident that is residing on the first floor of the facility. There are no other residents residing on this floor and there is no care staff assigned to work on the first floor of the facility. The first floor of the facility is locked and you need a code to exit the first floor. The first floor is a distinct and segregated area from the second floor.
Interview with Staff # 1 (S1) on 10/19/2022 who states that there is a resident living on the first floor of the facility and no care staff are scheduled to work on that floor. S1 further stated that the first floor is a locked floor and a code is needed to go from the first floor to the second floor.
Interview with Staff # 2 (S2) on 10/19/2022 who states that there are no group activities being done in the facility due to not having enough staff to do the activities. S2 further stated that the staff person who is the activities director is working as a caregiver during the site visit.
During tour of facility on 10/19/2022 Compliance Specialist observed that the scheduled activities were not taking place.
Review of facility posted staffing plan reveals that the facility is staffed with 2 caregivers and 1 med tech during day shift and 1 caregiver and 1 med tech during night shift. Review of facility Acuity Based Staffing Tool on 10/19/2022 reveals the faciltiy should be staffed with a total of 9 care staff a day. Based on the staffing plan the facility is only staffed with 5 care staff a day.
Facility Correction Plan: Facility hired new staff which should be starting in the next couple of days and will continue to hire until staffing levels are met. Resident that is living in the first floor will be moved to the second floor.
Based on interview and record review it was confirmed that the facility failed to have an Acuity Based Staffing Tool that accurately reflected the resident population and their needs. Findings include the following:
During an unannounced site visit on 10/19/2022 Compliance Specialist (CS) reviewed the facilities Acuity Based Staffing Tool (ABST) against the facilities current resident roster and found 1 resident in the acuity tool that was no longer on the resident roster . CS reviewed the most current service plans for Resident #3 and Resident #4 (R3 & R4) against the facility ABST for both residents and inconsistencies were identified between each residents' service plans and their ABST questions. Service plans indicated that R3 and R4 have non-drug interventions in place for behaviors but the ABST indicates that no time is used for this activity.
In an interview with Staff #1 (S1) on 10/19/2022 it was stated that they had not updated their ABST in over a month.
Correction Plan: Facility will update ABST and update staffing plan to meet ABST staffing levels.