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 09/06/2022.  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 observation and record review it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of the residents. Findings include the following:

During an unannounced site visit on 09/06/2022 Compliance Specialist (CS) checked in at the front desk and was not instructed to screen in, nor did staff attempt to screen CS upon entering building. CS observed multiple staff members improperly wearing masks, under noses and at their chins as well as staff members not wearing masks at all.

CS reviewed screening documents for staff/ visitors and residents as well as facility policies on infection control practices. Facility was not following their own screening practices.

Above findings were shared with Staff #1- Staff #3 (S1-S3) who were in agreement.

Based on interview and record review it was confirmed that the facility failed to implement services according to service plan. Findings include the following:

During an unannounced site visit on 09/06/2022 Compliance Specialist (CS) reviewed progress notes from 11/2021 - 01/2022 and service pan for Resident #5 (R5). Service plan stated that if a meal plan is delivered to resident to set up in front of resident, effective as of 06/08/2021. Progress note dated 01/15/2022 stated that residents meal was left on counter by their sink and out of reach of resident.

CS was also provided with a copy of APS Investigation #00129583-AP-101098 dated 06/03/2021 which confirmed that an Alleged Victim (AV) went without meal assistance.

In an interview with Staff #5 (S5) it was stated that there have been a few residents that staff have left meals out of reach of resident and resident was unable to reach food.

Based on interview and record review it was confirmed that the facility failed to administer the resident' s medications as ordered by their physician. Findings include the following:

During an unannounced site visit on 09/06/2022 Compliance Specialist (CS) reviewed Medication Administration Record (MAR) for September 2021 for Resident #3 (R3), February 2022 MAR for Resident #2 (R2) and January 2022 MAR for Resident #4 (R4) which revealed all three residents did not receive multiple medications because they were unavailable.

According to Witness #1 (W1) the facility would keep running out of residents medications and residents would miss doses.

Based on interview and record review it was confirmed that the facility failed to keep an accurate Medication Administration Record (MAR). Findings include the following:

During an unannounced site visit on CS reviewed February 2022 MAR for Resident #2 (R2) which revealed multiple instances of medications being marked as refused and then being marked as not available then as refused again.

According to Witness #1 (W1) it was stated that R2 had not been observed refusing medications as it was being indicated in their MAR.

Based on interview, record review and observation it was confirmed that the facility does not have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following:

During an unannounced site visit on 09/06/2022 Compliance Specialist (CS) observed a posted staffing plan which stated:

Day Shift: 2 med techs; 4 caregivers

Swing Shift: 2 med techs; 4 caregivers

Night Shift: 1 med tech; 3 caregivers

CS reviewed four sampled residents call light logs for dates 08/29/2022 - 09/04/2022 and found two instances of call lights not being responded to timely (within 15 minutes). A review of facility's schedules for September 2021 and September 2022 revealed that facility consistently failed to staff according to posted staffing plan.

In an interview with Staff #3 (S3) it was stated that their staffing plan was two med techs on day and swing and one on NOC, four caregivers on day, three to four on swing and two on NOC. S3 was unable to communicate how their staffing plan derived from the acuity-based staffing tool.

Based on interview and record review it was confirmed that the facility failed to have an acuity-based staffing tool (ABST) to determine appropriate staffing levels. Findings include the following:

During an unannounced site visit on 09/06/2022 Compliance Specialist (CS) reviewed Resident Care Level document and Resident Assessments for four sampled residents. Resident Assessments did not address the 22 required ABST elements.

In an interview with Staff #3 (S3) it was stated that they did not create a staffing plan based off their resident acuity. S3 was unable to explain how the resident assessment addressed the 22 ABST requirements.

Findings were shared with Staff #1- Staff #3 (S1-S3).

Based on interview, observation and record review it was confirmed that the facility failed to keep all equipment in good repair. Findings include the following:

During an unannounced site visit on 09/06/2022 Compliance Specialist (CS) completed a walk through of the licensed facility floors and observed several signs for equipment being out of order, most notably on the service elevator and on washing machines/ dryers. CS also observed several stairwell lights not working.

In an interview with Staff #3 (S3) it was stated that a resident had kicked the service elevator door, breaking it and trapping resident inside. The fire department responded and had to break into the elevator.

A review of invoices revealed an invoice for Otis Service and Repair Order dated 07/28/2022 for proposed work that needed to be completed on the service elevator, but no evidence was provided that repair work was scheduled to be completed. CS was also provided with an email of repairs needing to be made/ scheduled to be done dated September 3, 2022.