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 04/21/2023. 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 record review it was confirmed that the facility failed to provide assistance with mobility. Findings include:
During separate interviews on 04/21/2023, Staff #1 stated that the facility has had in the past called 911 for lift assists and that they are working with their policy analyst, local fire department and the emergency service coordinator. Resident #2 (R2) stated that the facility has called 911 when they fell.
During an unannounced site visit on 04/21/2023, Compliance Specialist (CS) observed a sign posted in the med room stating effective 03/08/2023 Med Techs are required to call S1 prior to calling 911.
A review of policy and procedure for occurrence and 911 utilization and occurrence reporting policy. In the policy it states 911 should not be utilized simply for lift assistance.
On 04/21/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: S1 stated that the facility is working with the local fire department to resolve the issue.
Based on interview, observation, 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:
During separate interviews on 04/21/2023, Staff #1 stated that their current staffing levels are 1 Med tech (MT) for all shifts and 4 Caregivers (CG) for day, 3 CG for swing, and 1 for NOC. S1 stated that the facility has two 2-person transfers.
During an unannounced site visit on 04/21/2023, Compliance Specialist (CS) observed the executive director on their day off with the manager on duty passing medications on the floor because the facility was short staffed a med tech.
A review of the call light logs for Resident #1 from 2/3-2/6 and staff schedules for February and March 2023. The call lights showed one occurrence where the call light did not get answered for 41 minutes.
On 04/21/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: S1 is working on hiring more staff.