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 8/24/2022.  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 determined that the facility failed to ensure the implementation of services. Findings Include:

During onsite interviews on 8/24/2022 with Residents #1-2 (R1-R2). R1 stated they do not have a set shower schedule and that it has been about 3 weeks since they received a shower. R2 states for a while they were not receiving their showers on one of their scheduled days and that they usually had to remind the staff when it is their scheduled shower time. R2 also said if you miss a shower the facility does not have the ability to reschedule until your already next scheduled shower day due to there not being enough time the next day since other residents whom showers are that day need to get done.

In a separate interview with Staff #3 (S3) they confirmed R2 ' s statement about rescheduled showers.

During onsite interview on 8/24/2022 with Staff #2 (S2) they stated that the facility was unable to show who has been getting showers and who has not. S2 stated that the staff is not filling out the shower refusal log for every shift or day.

Compliance Specialist (CS) observed no showers being provided on unscheduled onsite visit on 8/24/2022.

Verbal Plan of Correction:  S2 will be retraining staff on documenting missed showers and will look at the last days showers that were not given to insure they are provided.

Based on interview and record review, it was confirmed the facility failed to carry out medications as prescribed. Findings include:

On 8/24/2022 Compliance Specialist (CS) reviewed Resident #5 (R5) medication administration records (MARs) and progress notes for February 2022 as well as the facilities policy and procedures for medication errors. CS identified that the progress notes stated that R5 ' s medication was not administered from 2/1/2022-2/8/2022 due to the change in pharmacy that was at or around 1/18/2022.

During onsite interview with Staff #6 (S6) stated s/he signs off on medication after passing it out. CS observed med tech to be pop and passing the medication throughout the facility and in the dining room.

Verbal Plan of Correction: Ongoing monitoring, look and observe for every shift and do retraining with staff members.

Based on interview and observation, it was confirmed that the facility failed to provide enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:  

During site visit on 8/24/2022 Compliance Specialist (CS) observed:

·The hallway on the second floor to have an odor

·The med tech to be popping and passing out medication

R1 to have:

·dirty clothes on

·bed not made

·stains on sheets

·still in pajamas

·in the shower there was a laundry hamper with clothes in it

·shower to be dry

·urine jars spread out throughout the apartment

·room had an odor to it

In separate onsite interviews on 8/24/2022 with Staff #1-3 and Staff #6 (S1, S2, S3 and S6) all state that the facility is short staffed. S1 stated that there should be 3 caregivers and 1 med tech working however once interviewing S3 they stated there was only 2 caregivers and 1 med tech working. S3 stated there are going to be other shifts this week where the facility will be short staffed.

In an Interview on 8/24/2022 with Resident #2 (R2) stated that:

·s/he has had to wait awhile in the dining room to get staff to take them back up to their room after meals.

·call light response times can range from a few minutes - thirty minutes or more depending on the number of staff working that day.  

·for a while they were not receiving their showers on one of their scheduled days.

·they typically have to remind the staff when it is their scheduled shower time.

·if you miss a shower the facility does not have the ability to reschedule until your already next scheduled shower day due to there not being enough time the next day since other residents whom showers are that day need to get done. Staff #3 (S3) confirmed what R2 stated in their separate interview.  

In a separate interview on 8/24/2022 with Staff #6 (S6) stated s/he feels they can pass out medications for the whole building on their own but that an average person probably could not, and s/he stated that if they had to use the medication cart and not the pop and pass method that s/he would not be able to get it all time timely.

Verbal Plan of Correction: S1 and S2 will be working on staffing and hiring. Will contact policy analyst to figure out how the staffing levels are for ABST.

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:

In an interview on 8/24/2022, Staff #2 (S2) stated that they are using the ODHS ABST, however, they were not aware that it generated a staffing plan based on amount of caregiving time indicated with the tool. S2 told Compliance Specialist (CS) that their current census is 59 residents. The staffing levels have not been fully implemented yet.

Interview with Staff #1 (S1) stated that they take the posted staffing plan down because it did not reflect the correct staffing levels created by the ABST. Staff #1 (S1) and S2 stated that their staffing schedule is 3 caregivers and 1 med tech for the shift CS was there on. Review of their ABST indicates they should be staffing at a higher level according to the hours shown.

Record review on 8/24/2022 of ODHS ABST and Service Plans of Resident #1-11. Review of the 22 ADL ' s show no residents having time put into the call light response time even though CS observed the call lights to be going off during the onsite investigation.

The above information was shared with S1 and S2 during exit conference on 8/24/2022.

Plan of Correction: The facility will speak with Policy Analyst (PA) to get further clarification on how to generate the staffing plan to be in compliance with the ODHS ABST.