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 8/31/2022. 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 observation it was confirmed the facility failed to provide household services. Findings include:
During onsite interview on 8/31/2022 with Resident #1 (R1) they stated they should be getting housekeeping services every Friday, however, the facility has gone a month without housekeeping services because there wasn ' t anyone doing that job. R1 stated that as of this week the facility has hired a housekeeper.
During onsite interview on 8/31/2022 with Staff #1 (S1) stated they recently hired a housekeeper and have switched washing linens back to housekeeping. S1 stated that there was a 3-week time where there was no housekeeper and services were missed. S1 also stated that the facility maintenance personal tried to do some cleaning during the absences of a housekeeper. Staff #4 (S4) stated that showers regularly get missed and room tidies do not get done.
During site visit on 8/31/2022 Compliance Specialist (CS) observed two rooms that looked dirty and to have debris on the ground looking like the room had not been swept or vacuumed for a long period of time. CS observed multiple dirty dishes outside residents ' apartments.
Verbal Plan of Correction: The facility has hired a new housekeeper and will allow for the cleaning schedules to go back to the original days and all tasks will be provided.
Based on interview, observation, and record review, it was confirmed the facility does not have enough staff to meet the scheduled and unscheduled needs of the residents.
Findings include:
Record review for site visit on 8/31/2022 of the staff schedule for August 2022, timecards for August 15th-16th, the posted staffing plan and call light logs from 8/22/2022-8/26/2022. Review of the call light logs reveal 169 times where the call lights exceed a 16-minute response time. Out of the 169 times 10 of them exceeded an hour with the longest response time being 1:58:42 wait time. Review of the staff schedule shows multiple days where they were understaffed.
Compliance Specialist (CS) observed 2 caregivers (CG) and 2 med aides (MA) to be on duty during site visit on 8/31/2022, which does not reflect the posted staffing plan or the ODHS ABST.
During separate onsite interviews on 8/31/2022, Staff #1 (S1) stated that there was a 3-week time where there was no housekeeper and services were missed. Staff #4 (S4) stated that showers regularly get missed and room tidies do not get done. S4 stated that there was a day in the beginning of the month were there was only one CG working who felt overwhelmed. Resident #2 (R2) stated it can take over 20 minutes to respond to call lights.
Verbal Plan of Correction: S1 and S2 have hired a few open positions and will continue to hire/train staff members and are working on their turnover.
Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:
Interview with Staff #1(S1) and Staff #2 (S2) on 08/31/2022 stated the facility is using their own ABST. S2 stated they could provide print outs of the ABST including sample residents showing the 22 ADLs used. Two email attempts made to S2 on 09/06/2022 for documentation to be provided no later than end of day 09/06/2022. Documentation of the ABST has not been provided as of 09/09/2022.
Based on interview and observation it was confirmed that the facility failed to keep all interior materials and surfaces clean. Findings include:
During onsite interview on 8/31/2022 with Resident #1 (R1) they stated they should be getting housekeeping services every Friday, however, the facility has gone a month without housekeeping services because there wasn ' t anyone doing that job. R1 stated that as of this week the facility has hired a housekeeper.
During onsite interview on 8/31/2022 with Staff #1 (S1) they stated that there was a 3-week time where there was no housekeeper and services were missed. S1 also stated that the facility maintenance personal tried to do some cleaning during the absences of a housekeeper. Staff #4 (S4) stated that showers regularly get missed and room tidies do not get done.
During site visit on 8/31/2022 Compliance Specialist (CS) observed two rooms that looked dirty and to have debris on the ground looking like the room had not been swept or vacuumed for a long period of time. CS observed multiple dirty dishes outside residents ' apartments.
Verbal Plan of Correction: The facility has hired a new housekeeper and will allow for the cleaning schedules to go back to the original days and all tasks will be provided.