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 11/15/2022. 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, observation and record review, it was confirmed the facility failed to have an effective method to respond to complaints. Findings include:
During an interview with Staff #1 (S1) on 11/15/2022 it was stated there is a resident form to fill out as well as a grievance log that tracks all complaints. These complaints are gone over monthly at a quality control meeting.
On 11/15/2022, Compliance Specialist (CS) reviewed facility Responding to Complaints policy and Resident Complaint forms, which reveal that the facility was not following its stated policy and/or responding effectively to resident complaints.
CS observed that there were no Resident Complaint forms to review in the binder. The last entry in the Grievance Log was March 2020.
The above findings were discussed with Staff #1 who was in agreement with the findings.
Facility Plan of Correction: Facility will follow their own policy and record and respond effectively to all grievances effective immediately.
Based on interview and record review it was confirmed the facility failed to provide assistance with mobility. Findings include:
A review of Resident #10 ' s (R10) service plan dated 5/17/2022 and progress notes dated 9/01/2022-11/10/2022. R10 ' s service plan states they need assistance with ambulation and mobility including eating assistance. In the progress notes on 9/10/2022 there was a note stating, noticed that residents ' dinner plate was still sitting on their counter, looks like they missed dinner last night.
On 11/15/2022, these findings were reviewed and acknowledged by S1.
Plan of Correction: The facility has a Point of Care system for all staff to sign when providing services. S1 is already in the process of implementing and informing staff how to use it correctly.
Based on interview, observation, and record review, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:
In an interview with Staff #1 (S1) on 11/15/2022, they stated that the facility is behind on their quarterly updates.
On 11/15/2022, Compliance Specialist (CS) observed that the service plans available to staff in the binders are not updated.
A review of Resident #8-11 (R8, R9, R10, and R11) service plans show that they are not being updated quarterly. The service plans stated last updated was,
·R8 dated 5/20/2022
·R9 dated 5/16/2022
·R10 dated 5/17/2022
·R11 dated 5/16/2022
On 11/15/2022, these findings were reviewed and acknowledged by S1.
POC: The facility has a Point of Care system on Point Click Care where the system will let them know when the service plans need to be updated. The Executive Director (ED) has recently hired a Resident Care Coordinator (RCC) who's first project will be to update all service plans.
Based on record review, observation and interview the facility failed to provide enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:
Compliance Specialist (CS) reviewed the following: Resident #3-5 (R3-5) service plans (SP). Progress notes from 09/23/2022-10/31/2022 and MAR from 10/01/2022-11/15/2022. Call light logs from 10/01/2022-11/15/2022. Posted staffing, staffing schedule for October 2022-November 15, 2022, and facility ABST. Shower, laundry and housekeeping schedules. Review of R3-5 SP's, progress notes and MAR reflect that residents require assistance with activities of daily living. Review of Resident #1(R1) progress notes reveled R1 had fallen and staff member from memory care came over to provide Assisted Living (ALF) care staff with two-person transfer and lift R1 off the floor on NOC shift at 5:50am on 11/15/2022. Review of staffing schedule, posted staffing and ABST reflect that the facility is not staffing to current acuity and not meeting the daily scheduled and unscheduled needs of the residents. Review of R3-5 call light log from 10/1/2022 to 11/15/2022 show multiple response times over 20 minutes, as well multiple call light response times from 1 hour to 5 hours. Shower, laundry and housekeeping schedules for R3-5 reflect residents are not receiving services as stated in their service plan and as scheduled throughout the week.
Compliance Specialist (CS) observed during site visit on 11/15/2022 garbage's overflowing, excessive amounts of dirty laundry piled in laundry baskets and some on the floor, unmade beds, dirty kitchens, and unclean bathrooms in residents' apartments. CS observed call-light response time for pull cord in bathroom to be over 14 minutes. CS observed staff walk past overflowing garbage, go re-set call light in bathroom and not inquire with resident what helped they required before taking the one bag of garbage from the floor and leaving the apartment.
In separate interviews with Staff# 1,3,4 on 11/15/2022 they stated the following:
-S1 they are aware that staff is not getting to call lights in the expected 10minute response time.
-S1 that staff does not keep a log of showers, laundry or housekeeping tasks and date performed or resident refusals.
-S3 that they don't have enough staff on the weekends or in the AM to meet the needs of our residents.
-S4 they have not had enough staffing, but they are hiring now.
Interview with Resident #3,5-7 (R3,5,7) on 11/15/2022 they stated the following:
-R3 housekeeping does not come every week, they only clean the bathroom and mop kitchen floor and vacuum. No one changes my bed. They didn't do my laundry last week. When they do my laundry it comes back not completely dry. We had a meeting last month with Administrator and my Case Manger to update my service plan because I was not receiving assistance and it has not improved.
-R5 that they wait long periods of time for help when they call for help. Sometimes they leave me on the commode for a long time before coming back.
-R7 staff tells us there is not enough people to help. Sometimes they don ' t get weekly cleaning and laundry done, sometimes laundry comes back wet still and just tossed in the basket. Staff is not good about answering call lights right away.
Interview with Witness #1 on 11/15/2022 stated that the facility has been very short staffed and not meeting residents current care needs. They have brought this to the attention of the Executive Director.
On 11/15/2022, these findings were reviewed with and acknowledged with S1.
Based on record review, observation and interview, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:
Compliance Specialist (CS) reviewed the following: ABST, posted staffing, Residents #3-5 (R3-5) service plans (SP) and staffing schedules for October 2022-November 15, 2022. The facility is currently not staffing to acuity ABST does not include all current residents in the facility. Review of R3-5 and R8-11 SP's showed dates out of compliance for quarterly review and ADLS do not reflect current residents care needs. Current staffing does not meet ABST required 24 hours staffing plan and residents daily scheduled and unscheduled care needs. Review for 11/15/2022 ABST current acuity required 6 care staff for day shift, facility current staffing for day shift was 3 caregivers and 2 med-techs (understaffed by 1 care staff according to ABST). ABST census on 11/15/2022 52 for Assisted Living (ALF), reported current ALF census was 56 on this date. The posted staffing plan shows that Day and Swing shifts are to have 3 care staff and 1 med tech (1 in memory care (MC), 2 in ALF, and a shared med tech), and the NOC shift has 2 care staff and 1 med tech (1 in MC, 1 in ALF, and shared med tech). The ABST and posted staffing plan do not match. The ABST does not include all current residents in facility and review of service plans for R3-5 showed dates out of compliance for quarterly review and ADLS do not reflect current residents care needs. R5 service plan (SP) is not reflected in the ABST at all. R5 SP states moved in 07/12/2022, reflects a high level of care needs and is a two-person Hoyer lift for all transfers. Further review of R8-11 SP reflect out of compliance for quarterly review. R4 SP is not reflected accurately in ABST. SP shows R4 requires assistance transferring out of bed each morning this is reflected as 0 mins in ABST, SP shows R4 requires assistance in dressing ABST reflects 0 mins and SP shows R4 requires mouth care, nail and foot care that are reflected as 0 mins in ABST. R3 SP was reviewed on 11/07/2022 but not updated in ABST to reflect the residents higher care needs. Current staffing does not meet ABST required 24 hours staffing plan and residents daily scheduled and unscheduled care needs.
CS observed that the facility is not staffing per the ABST on 11/15/2022. The posted staffing plan has not been updated with the current staffing levels from the ABST.
In an interview on 11/15/2022, Staff #1 stated that the facility is using ODHS ABST tool. They have not updated the tool in about a month and have not removed residents that have moved out or added new residents that moved in. S1 stated that they thought they were using ABST correctly, but they had not been.
On 11/15/2022, these findings were reviewed with and acknowledged by S1.
Plan of Correction:
Immediately Interim ED is hiring more staff. Updating service plans and will assess the ABST and make sure information is correctly entered as well as fix any calculation issues. The posted staffing plan will be updated to match the ABST.
Based on interview and observation it was confirmed the facility failed to keep all interior and exterior materials and surfaces and all equipment necessary for the health, safety and comfort of the residents clean and in good repair. Findings include:
During an interview on 11/15/2022, Staff #1 (S1) stated that the elevator plaster has been damaged multiple times in the past few weeks. S1 stated that the H-vac unit was being repaired on the roof that day.
During an unannounced site visit on 11/15/2022, Compliance Specialist (CS) observed;
·A hole in the plaster of the elevator, roughly the size of a hand, which left an uncleanable surface.
·A ladder on the third floor going up to the attic behind a door the residents can access with no signs up for precautionary measures.
·Dirty dishes and Styrofoam boxes in the hallways.
On 11/15/2022, these findings were reviewed and acknowledged by S1.
Plan of Correction: Facility maintenance will put a plastic wheelchair guard in the elevator and will place precautionary signs up when working on areas of the building.