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 03/17/2023.  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 develop and implement an effective method of responding to and resolving resident complaints. Findings include the following:

During an unannounced site visit on 03/16/2023 Compliance Specialist (CS) reviewed facility Grievance Procedure Policy, Resident Council Meeting minutes from 01.10.23 as well as emailed grievances. The facility policy states that a community grievance log will be kept. No grievance log was provided.

In an interview with Staff #1 (S1) it was stated that with the complete management turn over in the facility a lot of documents were not able to be located from their time in the building.

Based on interview and record review it was confirmed that the facility failed to provide assistance with bathing. Findings include the following:

During an unannounced site visit on 03/16/2023 in separate interviews with Resident #1 and Resident #2 (R1 & R2) and Staff #1 (S1) the following was stated:

·I have gone nine days without receiving a shower before.

·A resident has gone nine days without a shower before and it happens often that we go without showers.

·We recently implemented shower sheets over the past several weeks.

Compliance Specialist (CS) was able to review one completed resident shower sheet. CS was told that the rest of the completed resident shower sheets were in a staff members office that was not there, and they could not access. CS requested shower sheets be emailed as the next day when the staff was in the office. Facility did not produce anymore completed shower sheets.

Based on record review and interview it was confirmed that the facility failed to complete quarterly service plans. Findings include the following:

During an unannounced site visit on 03/16/2023 Compliance Specialist (CS) reviewed service plans that were available for staff for Resident #1- #4 (R1-R4) and found that four of four service plans were out of date, dates ranged from 02/10/2022 - 06/09/2022. CS was provided with service plans for R1-R4 and found three of four residents had out of date service plans.

In separate interviews with Staff #1 (S1), Staff #5 (S5) and Witness #1 (W1) the following was stated:

·My family member has not had a service plan since 2020.

·I have been working on getting input from the staff on residents current conditions and providing that information to the nurse for them to work in new assessments.

·We are in the process of sending out email notifications for service plan update meetings and working on trying to get service plans up to date.

Based on record review and interview it was confirmed that the facility failed to implement a service plan that reflects the resident ' s needs as identified in the evaluation. Findings include the following:

During an unannounced site visit on 03/16/2023 Compliance Specialist (CS) reviewed service plans that were available for staff for Resident #1- #4 (R1-R4) and found that four of four service plans were out of date, dates ranged from 02/10/2022 - 06/09/2022. CS was provided with service plans for R1-R4 and found three of four residents had out of date service plans. CS also found that for R1, R3 and R4, on service plan was created from an assessment several weeks old, another from a month-old assessment and the third from an assessment ten months old.

In separate interviews with Witness #1 (W1) and Witness #2 (W2) the following was stated:

·Their family member has not had a service plan since 2020.

·Their family member has had a persistent cough that the facility has not followed up with or assessed.

Based on interview, observation and record review it was confirmed that the facility failed to create and implement a policy to ensure a resident and reporting system is implemented 24-hours a day. Findings include the following:

In an interview with Witness #2 (W2) it was stated that their family member has had a new cough that has become persistent, and the facility has not been monitoring it.

During an unannounced site visit on 03/16/2023 Compliance Specialist (CS) observed Resident #2 (R2) and observed that they did have a cough and it appeared persistent throughout approximately 15-20 minutes of observation.

A review of service plan and progress notes for R2 did not reveal any noted concerns of resident cough. CS requested alert charting or monitoring for R2 and was not provided with any documentation.

Based on interview and record review it was confirmed that the facility failed to include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. Findings include the following:

During an unannounced site visit on 03/16/2023 in an interview with Staff #2 (S2) it was stated that the facility had hired a full-time nurse that was in the process of fulfilling their resignation time in their previous position, but they work on Fridays. It was stated that the previous RN left the facility on 02/14/2023.

In separate interviews with Staff #3- Staff #5 (S3-S5) the following was stated:

·I don ' t know who we would call for nursing since the nurse listed on our sheet hasn ' t been here for a while.

·I ' m not delegated to, but a staff member is coming in to administer insulin at noon who is.

·I haven ' t seen the new nurse, but I heard they were coming in to the facility in the next couple of days.

·All of our delegated staff were delegated to by the previous nurse

·I was delegated to by Staff #6 (S6) who used to be the RN here, but the new RN hasn ' t come in to do delegations

CS reviewed the facility delegations binder and found that all the delegations were from the previous RN that separated employment from the facility on 02/14/2023.

Based on observation, interview and record review it was confirmed that the facility failed to establish and maintain infection prevention control protocols. Findings include the following:

In an interview with Staff #10 (S10) it was stated that there is a resident that has opened wounds that bleed and weep and they do not allow staff to care for their wounds and spreads bodily fluids throughout the building.

During an unannounced site visit on 03/16/2023 Compliance Specialist (CS) observed staff walking throughout the facility without masks on and multiple staff with masks down under their noses or masks at their chins. CS observed resident with open wounds with blood on them walking throughout the building and observed the floor outside of their room was sticky with a strong odor of urine.

A review of resident progress notes revealed an incident where a resident defecated in a public space in the facility.

Based on interview and record review it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include the following:

In separate interviews with Witness #3 - #4 (W3 & W4) and the following was stated:

·A resident missed their insulin medication all day because no staff on site were delegated to administer it.

·Multiple residents missed their morning medications because staff were having issues with the computer system

During an unannounced site visit on 03/16/2023 Compliance Specialist (CS) reviewed 01/2023 and 02/2023 Medication Administration Records (MARs) and progress notes for Resident #1- #5 (R1-R5). CS found entries of medications not given on time or at all due to medications not being in cart, insulin not being given with no explanation, or the wrong number of units given.

Based on observation and interview it was confirmed that the facility failed to ensure all medications administered by the facility are stored in locked containers in a secured environment. Findings include the following:

During an unannounced site visit on 03/16/2023 Compliance Specialist (CS) completed a walkthrough of the facility and attempted to find the med tech. CS found the door to the med room unlocked, when CS entered they found the med room unattended and med carts unlocked.

CS shared findings with Staff #1 (S1) who acknowledged findings.

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

During an unannounced site visit on 03/16/2023 in an interview with Staff #9 (S9) it was stated that there is only one caregiver working on the assisted living floors and that they are on light duty.

Compliance Specialist (CS) observed only one caregiver on the assisted living floors working at the time of initial walkthrough, med tech appeared to be on break and there was a housekeeper working.

A review of staff schedule for the month of March 2023 revealed that there was only one light duty caregiver scheduled for the morning of 03/16/2023 and one med tech. CS reviewed call light logs for Resident #1 and #2 (R1 & R2) for 02/24-02/26/2023 and 03/03-03/05/2023 and found 11 calls exceeding 30 minutes of 58 total pages, seven of those 11 calls exceeded an hour.

Based on interview and record review it was confirmed that the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include the following:

During an unannounced site visit on 03/16/2023 in an interview with Staff #1 (S1) it was stated that they did not have access to the ODHS website in order to implement the state ABST and that they had made a request to the department to gain access to the website.

Compliance Specialist (CS) reviewed the email chain started 03/14/2023 from the Director of Memory Care, a separate licensed facility, to Quality Metrics and Acuity requesting access to the facility through the ABST portal. The administrators were denied access on 03/16/2023 due to no SDS 0566 (Facility Administrator of Record Change) form on file for either requested administrator. Facility was unable to provide any other ABST documentation.

Based on interview and observation it was confirmed that the facility failed to keep all equipment necessary for the health, safety, and comfort of the resident clean and in good repair. Finding include the following:

During an unannounced site visit on 03/16/2023 Compliance Specialist (CS) observed the facility's bus and observed several broken items on both the interior and exterior of the bus, including a broken seat belt.

In separate interviews with Staff #1 and Staff #8 (S1 & S8), Resident #1 and Resident #2 (R1 & R2) the following was stated:

·The bus lift is not working, wheelchair bound residents cannot use it for outings or medical appointments

·The bus lift has been working intermittently

·There is a broken seat belt in the front row

·We just received approval to get the facility bus serviced to get anything fixed that needs to be fixed on it