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 01/11/2023. 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 interview and observation it was confirmed the facility failed to post a copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. Findings include:
During separate interviews on 01/11/2023, Staff #1-2 (S1 and S2) acknowledged the survey was not posted and have been working to retrieve the documents required to be able to display the survey.
During an unannounced site visit on 01/11/2023, Compliance Specialist (CS) observed no posted copy of the most recent re-licensing survey conducted in January 2021. CS did observe the memory cares re-licensure survey binder to be in the Executive Directors office incomplete.
On 01/11/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: S1 has reached out to get all documents needed and will put re-licensure survey on display as soon as the documents are given to them.
Based on interview and record review it was confirmed the facility failed to provide services to assist the resident in activities of daily living including toileting, showering, and dressing. Findings include:
During an interview on 01/11/2023, Staff #3 (S3) stated that showers are missed and not rescheduled due to lack of staffing. S3 stated there should be 3 Caregivers (CG) and 1 Med tech (MT) working on 01/11/2023 however they are short staffed with only 2 CG and 1 MT.
A review of the shower schedule and the staff log of the completed or refusals from 12/07/2022-12/31/2022 revealed multiple occurrences where showers were not marked as completed or refused indicating to CS the shower was not giving.
On 01/11/2023, these findings were reviewed and acknowledged by S1 and S2.
Plan of Correction: The facility will have in-service with staff and will need to re look at their ABST to get correct staffing levels. S1 stated that they will be getting a different sign off sheet to better understand who has not received showers and who still needs them.
Based on interview, observation, and record review it was confirmed the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include:
During separate interviews on 01/11/2023, Staff #3 (S3) stated that showers are missed and not rescheduled due to lack of staffing. S3 stated that staff calling out or the facility being short staffed happens often. S3 stated there should be 3 Caregivers (CG) and 1 Med tech (MT) working on 01/11/2023 however they are short staffed with only 2 CG and 1 MT. Staff #2 (S2) stated that they were filling in for the 3rd CG.
During an unannounced site visit on 01/11/2023, Compliance Specialist (CS) observed 2 CG and 1 MT on the floor. CS observed S2 not providing care during the time CS was in the building.
A review of the posted staffing plan and the shower schedule and the staff log of the completed or refusals from 12/07/2022-12/31/2022. The shower log revealed multiple occurrences where showers were not marked as completed or refused indicating to CS the shower was not giving. The posted staffing plan states that here should be 3 CG and 1 MT working during day shift.
On 01/11/2023, these findings were reviewed and acknowledged by S1 and S2.
Plan of Correction: The facility will work on ensuring there are the correct number of staff on the floor and showers are being provided.
Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include:
During separate interviews on 01/11/2023, Staff #2 (S2) stated the following,
-They were unaware the residents 22 activities of daily living (ADL's) needed to be completed in the ABST before the resident moves in.
-Resident #2-3 (R2 and R3) moved in a week or two ago.
-They were filling in for the 3rd CG.
Staff #3 (S3) stated the following,
-Showers are missed and not rescheduled due to lack of staffing.
-Staff calling out or the facility being short staffed happens often.
-There should be 3 Caregivers (CG) and 1 Med tech (MT) working on 01/11/2023 however they are short staffed with only 2 CG and 1 MT.
During an unannounced site visit on 01/11/2023, Compliance Specialist (CS) observed 2 CG and 1 MT on the floor. CS observed S2 not providing care during the time CS was in the building.
A record review of the Posted Staffing Plan, and the shower schedule and the staff log of the completed or refusals from 12/07/2022-12/31/2022, Resident #1 (R1) Service Plan and progress notes, the facility ' s ABST, the breakdown of care for R1-R3 on the ABST. resident #2-3 were not entered into the tool until CS entered the building. R2-3 service plans show R2 moved in on 01/01/2023 and R3 moved in on 12/22/2022. The shower log revealed multiple occurrences where showers were not marked as completed or refused indicating to CS the shower was not giving. The posted staffing plan states that here should be 3 CG and 1 MT working during day shift. The breakdown of R2-3 22 ADLs on the facility ' s ABST shows their hours are incomplete and not entered into the tool indicating their needs are not being reflected correctly.
On 01/11/2023, these findings were reviewed and acknowledged by S1 and S2.
Based on interview and record review it was confirmed the facility failed to fully implement the Condition. Findings include:
During separate interviews on 01/11/2023, Staff #1-2 (S1 and S2) stated they did not know about condition placed on the building or the mandatory reporting until 01/10/2023.
A review of the facility ' s condition for their Acuity Based Staffing Tool (ABST) and an email correspondent from the facility first report to the Corrective Action Coordinator (CAC) for ABST condition. The condition states there was a notice of impending condition on 11/04/2022 from a violation stemming from evidence collected from the Licensing Complaint Unit on 09/07/2022. The condition was effective on 11/29/2022 with reporting requirements every two weeks starting on 12/13/2022. The email correspondent does show the facility reporting to the CAC and the CAC acknowledging the facility has missed the last two reporting dates.
On 01/11/2023, these findings were reviewed and acknowledged by S1 and S2.
Plan of Correction: The facility is now aware of needing to report and has started reporting as of 1/10/2023.