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 03/28/2023. 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 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:
A review of the facility's security camera footage revealed an incident on 2/18/2023 in which Resident #1 (R1) is being assisted in eating by Staff #7 (S7). Staff #6 (S6) can be seen assisting Resident # 3 (R3). R1 choked, subsequently passing away while all other residents can be observed, still seated in the dining room.
During an unannounced site visit on 3/18/2023, Compliance Specialist (CS) observed the noon meal service. CS observed Staff #5 (S5) providing assistance with eating to Residents #2 (R2)- R3 from 1204 to 1240.
Duing interview S5 and S7-Staff #8 (S8) stated:
*R1 required assistance with eating lasting 20-30 minutes.
*R2 and R3 required assistance with eating lasting about 30-40 minutes.
*R1 took 2-3 people to get up in the morning.
*Sometimes there is only 1 Med Tech (MT) and 1 Caregiver working in Happy Valley neighborhood.
*There are currently five residents in Happy Valley neighborhood that require assistance with eating.
*On 2/18/2023 The MT on shift was floating between Happy Valley neighborhood and another neighborhood and was not in Happy Valley Neighborhood at the time the incident began.
A review of the facility's staff schedule for February 2023-March 2023 revealed instances in which only 1 MT and 1 CG were scheduled in Happy Valley neighborhood including: 3/2/2023, 3/3/2023, 3/4/2023, 3/18/2023. No caregivers were scheduled on 3/6/2023.
CS attempted to call Staff #4 (S4) twice and emailed once on 3/30/2023, with a follow up phone call and email on 3/31/2023 to review findings. CS was told on 3/31/2023 by Staff #10 (S10) that no management, including Executive Director, Assistant Executive Director, RN, LPN or business office was available and were unsure when management staff would be in.
These findings were reviewed with and acknowledged by S4 on 3/31/2023.
Plan of Correction: Happy Valley neighborhood will always have one medication technician and two caregivers for day and swing shift. The medication technician will no longer float between houses for this neighborhood. Happy Valley will have its own medication room to be implemented immediately.
Based on observation, interview and record review it was confirmed that the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include but not limited to:
During an unannounced site visit on 3/18/2023, Compliance Specialist (CS) observed the noon meal service. CS observed Staff #5 (S5) providing assistance with eating to Residents #2- Resident #3 (R2-R3) from 1204 to 1240.
During interview S5 and Staff #7-Staff #8 (S7-S8) stated:
*Resident #1 (R1) required assistance with eating lasting 20-30 minutes.
*R2 and R3 required assistance with eating lasting about 30-40 minutes.
*R1 took 2-3 people to get up in the morning.
*Sometimes there is only 1 Med Tech and 1 Caregiver working in Happy Valley neighborhood.
*There are currently five residents in Happy Valley neighborhood that require assistance with eating.
A review of R1-R3's ABST profiles revealed the following:
R1 was allocated 2 minutes for assistance with eating 35 times per week.
R2 was allocated 7 minutes for assistance with eating 21 times per week.
R3 was allocated 3 minutes for assistance with eating 21 times per week.
A review of the facility's Staff Acuity Summary for 2/14/23 revealed the need for 15.28 hours of care (2.25 staff) in Happy Valley. A review of the facility's Staff Acuity Summary for 3/28/23 revealed the need for 17.63 hours of care (3 staff).
A review of the facility's staff schedule for February 2023-March 2023 revealed instances in which only 1 MT and 1 CG were scheduled in Happy Valley neighborhood including: 3/2/23, 3/3/23, 3/4/23, 3/18/23. No caregivers were scheduled on 3/6/23.
CS attempted to call Staff #4 (S4) twice and emailed once on 3/30/2023, with a follow up phone call and email on 3/31/2023 to review findings. CS was told on 3/31/2023 by Staff #10 (S10) that no management, including Executive Director, Assistant Executive Director, RN, LPN or business office was available and were unsure when management staff would be in.
These findings were reviewed with S4 on 3/31/2023.
Plan of Correction: S4 will audit all residents, starting with those who need assistance with eating and adjust times to be reflective of needs. S4 will have caregivers verify time accuracy. This process will be completed within 30 days.