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 04/03/2023. 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 record review and interview, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:
A review of Resident #2 (R2) service plan showed that the facility did not update quarterly. The service plan is dated 12/31/2022.
On 04/19/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: S1 will update service plan to reflect resident's current needs.
Based on interview, observation, and record review it was confirmed 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 04/03/2023, Resident #5 (R5) stated call lights take a long time for staff to respond especially during meals times.
During an unannounced site visit on 04/03/2023, Compliance Specialist (CS) entered the facility at 10:30 AM and did not observe any med techs or caregivers until 11:30AM.
A review of the staff schedule for February and March 2023, call light logs from 03/20/2023-3/24/2023, and the acuity-based staffing tool (ABST). The call light log showed 12 occurrences where they call lights exceed the facility's 10-minute response time, with 2 exceeding 20 minutes. Both schedules show multiple days were the facility had open shifts not filled. The facility ABST is not updated correctly, not showing the correct staffing levels reflective of all resident's needs.
On 04/03/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: Not provided.
Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include:
During separate interviews on 04/03/2023, Staff #1-3 (S1, S2, and S3) stated that their current staffing levels are 1 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift.
During an unannounced site visit on 04/03/2023, Compliance Specialist (CS) observed 1 MT and 2 CG working.
A record review of the posted staffing plan, staff schedule for February- March 2023, resident roster updated on 04/01/2023, Resident #1-2 (R1 and R2) service plans dated 12/31/2022 and 02/24/2023, progress notes from 01/03/2023 - 04/03/2023, and the breakdown of their care on the facility's ABST. R2 service plan had not been updated quarterly. The exported data in the ABST showed 38 of the 45 residents entered in the tool to not have been evaluated quarterly with last updated dates ranging from 07/08/2022-01/02/2023. Matching the roster with the ABST showed that the ABST has 45 residents entered in the tool while the resident roster has 48 residents listed.
On 04/03/2023, these findings were reviewed and acknowledged by S1.
Based on record review and interview, the facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned. Findings include:
During separate interviews 04/03/2023, Staff #1 (S1) stated that competencies should have been verified by a med tech and a nurse, as per their policy.
A review of training records for Staff #3-5 (S3, S4 and S5) revealed that S4 hired on 03/21/2023 did not complete the safety and health program which includes reporting protocols, accident prevention plan, OSHA requirements, employee focused- resident safe handing, proper body mechanic/safe transfers and the use of a camel.
On 04/03/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: Not provided.
Based on interview and record review it was confirmed the facility failed to provide records to the Department upon request. Findings include:
Compliance Specialist (CS) requested documentation from the facility for an investigation conducted on 04/03/2023 and did not receive them. Reviewed email request dated 04/05/2023 following up on the request for additional documentation to Staff #1 (S1). The facility did not provide the documentation requested. On 04/19/2023 CS informed S1 about documentation not being provided upon request.
Plan Of Correction: S1 will be providing documentation upon site visit.