Based on interview and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to develop and implement a written policy prohibiting the falsification of records for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:
Staff 1 (RN) stated s/he had worked at the facility for two weeks and was not aware of any altered interim service plans. S/he stated the Compliance Specialist should speak with the Regional Director of Operations.
Staff 1 attempted to call the Regional Director of Operations and s/he did not answer.
The facility was unable to provide documentation for Resident 5.
Adult Protective Services provided LCU with Resident 5's interim service plans, dated 03/19/24, 12/20/24, and 12/24/24.
A review of Resident 5's interim service plans, completed by a previous RN, revealed staff signatures had been scanned and copied across all three documents.
It was determined the facility failed to implement a written policy that prohibits the falsification of records.
The preliminary findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/20/24.
1. Based on interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to update service plans quarterly for 2 of 3 sampled residents (#s 2, and 3). Findings include, but are not limited to:
Resident 2's care plan, dated 04/09/24, indicated the next evaluation due date was 07/08/24.
Resident 3's care plan, dated 04/08/24, indicated the next evaluation due date was 07/07/24.
In an interview on 08/20/24 at 1:30 pm, Staff 1 (RN) acknowledged that care plans were out of date and that they were working on updating the care plans with the Resident Care Coordinator.
In interviews on 08/20/24, Staff 2 (Bus. Office Mgr.) and Staff 4 (Caregiver) each stated care plans were not being updated quarterly.
Residents 2 and 3 were unavailable for interview.
The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings.
It was determined the facility had failed to update service plans quarterly.
Verbal Plan of Correction: No plan of correction was provided by the facility.
2. Based on observation, interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to update service plans quarterly for 2 of 3 sampled residents (#s 2, and 3). Findings include, but are not limited to:
Resident 2's care plan, dated 04/09/24, indicated the next evaluation due date was 07/08/24.
Resident 3's care plan, dated 04/08/24, indicated the next evaluation due date was 07/07/24.
In an interview on 08/20/24 at 1:30 pm, Staff 1 (RN) acknowledged that care plans were out of date and that they were working on updating the care plans with the Resident Care Coordinator.
The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings.
It was determined the facility had failed to update service plans quarterly.
Verbal Plan of Correction: No plan of correction was provided by the facility.
Based on observation, interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to have direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. Findings include, but are not limited to:
On 08/20/24, upon entering the facility at 12:09 pm, there were no staff at the front desk or in either office. Compliance Specialist (CS) waited in the lobby for over 25 minutes before s/he was acknowledged by staff.
The facility's census was 38.
The facility's posted staffing plan indicated:
Day shift: three caregivers and two med techs;
Swing shift: three caregivers and two med techs; and
Night shift: two caregivers and one med tech.
On 08/20/24, two caregivers and one med tech were observed working the day shift.
On 08/20/24, Staff 1 (RN) stated there had been constant staff shortages and the facility did not currently have an administrator for the building. Staff 1 further stated some resident's care needs were not being met timely and care plans were not being updated quarterly.
During separate interviews, Staff 2 (Business Office Manager) and Staff 4 (Caregiver) stated there had been constant staff shortages.
On 08/20/24 a strong smell of urine was present in the hallway near the nurses station. There was debris and trash on some of the floors, dirty clothes in unsampled resident rooms, beds not made, and trash cans had not been emptied that day.
The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings.
It was confirmed the facility had failed to have qualified direct care staff sufficient in number to meet the 24 hour scheduled and unscheduled needs of residents.
Verbal plan of correction: No plan of correction was provided by the facility.
Based on observation, interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to fully implement an acuity-based staffing tool (ABST). Findings include, but are not limited to:
The facility's posted staffing plan indicated:
Day Shift: 3 Caregivers, 2 Med Techs;
Swing Shift: 3 Caregivers, 2 Med Techs; and
Noc Shift: 2 Caregivers, 1 Med Tech.
On 08/20/24, two caregivers and one med tech were observed working the day shift. This did not match the posted staffing plan of three caregivers and two med techs.
In an interview on 08/20/24 at 1:30 pm, Staff 1 (RN) stated s/he had started her position a couple of weeks ago and had not had a chance to access the facility's ABST. Staff 1 was unsure what ABST the facility used.
During the site visit the facility was unable to access their ABST, despite attempts to contact the Regional Director.
A review of the facility's Oregon Department of Human Services ABST on 08/22/24 indicated all 38 residents had been entered into the ABST. The facility's ABST did not match the posted staffing plan.
The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings.
It was confirmed the facility had failed to fully implement an Acuity Based Staffing Tool.