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 10/26/2022. 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 record review it was confirmed that the facility/staff failed to immediately notify the local Department office of any incident of abuse or suspected abuse. Findings include the following:
During an unannounced site visit on 10/26/2022 Compliance Specialist (CS) reviewed Resident Occurrence Reports for the month of September. CS found five occurrences of unwitnessed falls with injury that had not been reported to the local department.
In an interview with Staff #1 (S1) it was stated that they were unaware that unwitnessed falls with injury for residents that are unreliable narrators are reportable instances.
Facility Plan of Correction:
S1 will ensure that all reportable instances are reported to APS moving forward.
Based on observation and record review it was confirmed that the facility failed to have a daily program of social and recreational activities. Findings include the following:
During an unannounced site visit on 10/26/2022 Compliance Specialist (CS) reviewed facilities Uniform Disclosure Statement (UDS) revealed that the facility will have six hours of structured activities every day. CS reviewed posted activities schedule dated 10/21/22 which did not include six hours of activities. CS received a copy of the facility's weekly activity calendar for October 2022; calendar did not consistently have six hours of structured activities scheduled.
CS observed the posted sign dated same day as visit which did not have any activities listed. CS observed activities began for the day at 1 o'clock, but there did not appear to be a schedule or structure for the activities occurring.
Based on interview and record review it was confirmed that the facility failed to have qualified direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include the following:
During an unannounced site visit on 10/26/2022 Compliance Specialist (CS) reviewed facilities staffing schedule for September and October 2022, payroll details for 09/25-10/01/2022 and facility Acuity Based Staffing Tool (ABST). September and October schedules had several instances where facility was not staffed to facility ABST. Facility payroll details for 09/25-10/01/2022 also indicate facility was staffing under ABST at the time.
In an interview with Staff #1 (S1) it was stated that they took a state training and afterwards realized that the facility was not staffing appropriately for their ABST and then increased their staffing to match their ABST.
Based on interview and record review it was confirmed that the facility failed to have qualified direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include the following:
During an unannounced site visit on 10/26/2022 Compliance Specialist (CS) reviewed facilities staffing schedule for September and October 2022, payroll details for 09/25-10/01/2022 and facility Acuity Based Staffing Tool (ABST). September and October schedules had several instances where facility was not staffed to facility ABST. Facility payroll details for 09/25-10/01/2022 also indicate facility was staffing under ABST at the time.
In an interview with Staff #1 (S1) it was stated that they took a state training and afterwards realized that the facility was not staffing appropriately for their ABST and then increased their staffing to match their ABST.
Facility Plan of Correction:
The facility is currently staffing to their ABST, staffing was corrected by the time of CS ' s time of site visit.
Based on interview and record review it was confirmed that the facility failed to have a training program that includes methods to determine competency of direct care staff. Findings include the following:
During an unannounced site visit on 10/26/2022 CS requested demonstrated competencies and checklists for Staff # 4 - Staff #6 (S4-S6). All three staff had completed Caregiver ADL Skills Checklist and Observations completed, but two of three were not completed within 30 days of hire. 2 of 3 required Medication Technician Skills Checklists and Observations of Medication Pass and 1 of 2 was not completed within 30 days of hire.
In an interview with Staff #1 (S1) it was stated that they had been working on the training program and was working through staff files to ensure checklists were completed and working through completing checklists for all staff including more senior staff members. S1 acknowledged findings.
Facility Plan of Correction:
S1 is in the process of working through staff files and ensuring that their training files are complete and implementing a training program the meets state requirements.