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 11/15/2022. 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, record review and interview, it was confirmed that the facility the failed to keep clean all interior and exterior materials and surfaces necessary for the health, safety, and comfort of the resident. Findings include but not limited to:
During an unannounced site visit on 11/15/2022, Compliance Specialist (CS) observed Resident #1 (R1)'s room which was cluttered with clothes, books and at least two old meal containers, as well as electronic cords that present a tripping hazard for resident. R1's bed was piled with things and unusable. The recliner and carpet both had dark soilage spots and carpet was fraying in places.
A review of R1's service plan revealed that care staff are to pick up R1's trash daily and to declutter the apartment as R1 allows.
During interview, R1 stated that they want to declutter the apartment and that staff help is needed for this.
During interview, Staff #2 stated that they had just cleaned R1's apartment the day before.
During interview Staff #1 stated that the elevator plaster has been damaged multiple times in the past few weeks.
These findings were reviewed with and acknowledged by Staff #1 and Staff #10 on 11/15/2022.
Plan of Correction: Facility to implement Point of Care documentation in Point Click Care. Staff to be educated on this procedure within two weeks. Administrator will audit missed charting.
Based on record review and interview it was confirmed that the facility failed to perform resident evaluation before the resident moves into the facility. Findings include but not limited to:
During an unannounced site visit on 11/15/2022 Compliance Specialist reviewed Resident #2 (R2)'s progress for January 2022, Service Plan initiated on 1/06/2022 and a CBC Level of Care Evaluation dated on 1/06/2022 which revealed R2 moved into facility on 01/03/2022. The facility was unable to provide any evidence that resident was evaluated or a care plan was initiated prior to move-in.
During interview, Staff #1 stated that they would hope pre-move-in evaluation was completed but they could not find any documentation.
These findings were reviewed with Staff #1 and Staff #10 on 11/15/2022.
Plan of Correction: New nursing staff to be trained on this during training and company facility admission checklist to be utilized for all new move-ins.
Based on record review and interview it was confirmed that the facility failed to complete resident's service plan before the resident moves into the facility. Findings include but not limited to:
During an unannounced site visit on 11/15/2022 Compliance Specialist reviewed Resident #2 (R2)'s progress for January 2022, Service Plan initiated on 01/06/2022 and a CBC Level of Care Evaluation dated on 01/06/2022 which revealed the R2 moved into facility on 01/03/2022. The facility was unable to provide any evidence that resident was evaluated or a care plan was initiated prior to move-in.
During interview, Staff #1 stated that they would hope pre-move-in evaluation was completed but they could not find any documentation.
These findings were reviewed with Staff #1 and Staff #10 on 11/15/2022.
Plan of Correction: New nursing staff to be trained on this during training and company facility admission checklist to be utilized for all new move-ins.
Based on interview and observation, it was determined the facility failed to comply with masking requirements. Findings include but not limited to:
During onsite visit on 11/15/2022 Compliance Specialist (CS) observed Staff #6 (S6) and Staff #8 (S8) wearing their surgical masks underneath their noses.
These findings were reviewed with and acknowlegded by with Staff #1(S1) and Staff #10 on 11/15/2022.
Plan of Correction: Facility to provide education to staff and post signage my time clock on masking requirements within one week.
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:
During an unannounced site visit on 11/15/2022, Compliance Specialist reviewed Resident #1 (R1)'s Medication Administration Record (MAR) and progress notes for July 2022 which revealed that 7/12/2022-7/14/2022 R1 missed and/or received the wrong dose of a medication.
During interview, Staff #1 stated that this incident was a self-report incident to Adult Protective Services (APS) for the error.
These findings were reviewed with and acknowledged by Staff #1 and Staff #10 on 11/15/2022.
Plan of Correction: All Med Techs have been re-trained on common med errors. This training to occur annually. Root cause analysis to be conducted after any med error.
Based on observation, record review and interview, it was confirmed that the facility the failed to keep clean all interior and exterior materials and surfaces necessary for the health, safety, and comfort of the resident. Findings include but not limited to:
During an unannounced site visit on 11/15/2022, Compliance Specialist (CS) observed a hole in the plaster of the elevator, roughly the size of a hand, which left an uncleanable surface. Additionally, CS observed Resident #1 (R1)'s room which was cluttered with clothes, books and at least two old meal containers, as well as electronic cords that present a tripping hazard for resident. R1's bed was piled with things and unusable. The recliner and carpet both had dark soilage spots and carpet was fraying in places.
A review of R1's service plan revealed that care staff are to pick up R1's trash daily and to declutter the apartment as R1 allows.
During interview, R1 stated that they want to declutter the apartment and that staff help is needed for this.
During interview, Staff #2 stated that they had just cleaned R1's apartment the day before.
During interview Staff #1 stated that the elevator plaster has been damaged multiple times in the past few weeks.
These findings were reviewed with and acknowledged by Staff #1 and Staff #10 on 11/15/2022.
Plan of Correction: Facility to implement Point of Care documentation in Point Click Care. Staff to be educated on this procedure within two weeks. Administrator will audit missed charting. Wheelchair guard to be added to elevator.