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 10/20/2022.  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 failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. Findings include:

In review of the facility's policy and procedures for reporting to APS and incident reports from August-October 2022 for Resident #1, it was determined that the facility did not notify APS for multiple resident to resident altercations and falls with injury.

The above information was shared with Staff #1 on 10/21/22, who acknowledged the findings.

In an interview on 10/20/22, Staff #1 stated that because of short staffing, the Wellness director and Wellness Coordinator have been filling in care staff shifts, and they have not been getting to the incident reports and reporting timely.

Plan of correction:

Re-training to staff regarding APS reporting requirements and what information needs to be provided. Hiring additional staff so that the Wellness Director can perform their job duties timely.

Based on interview and record review, it was confirmed that the facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent reoccurrence of abuse. Findings include:

In review of the facility ' s policy and procedures for Incident Reports and Abuse Reporting, progress notes, and incident reports from August-October 2022 for Resident #1, it was determined that the Wellness Director, Nurse, and Administrator are not reviewing the investigation, completing the review and assessment, or completing the administrator review per their policy. Follow up with staff regarding training, interventions being put in place, updating the service plans, and notifying APS of any abuse/suspected abuse and neglect is not being completed or documented. Most of the incident reports reviewed are still  " In Progress "  under the status.

The above information was shared with Staff #2 on 10/21/22, who acknowledged the findings.

In an interview on 10/21/22, Staff #1 stated that because of short staffing, management has been filling in for care staff, and they have not been getting to the incident reports to review and complete or report timely to APS.

Plan of correction:

Re-training to staff regarding incident reports, internal investigation process, and APS reporting requirements. Hiring additional staff.

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 review of Resident #1-4 ' s Service Plans on 10/20/22, it was determined that they are not being updated quarterly. Three out of the four service plans haven ' t been updated since October 2021. Resident #1 has had multiple falls and resident to resident altercations since August 2022, which have not been updated on the service plan.

On 10/20/22, CS observed that the service plans available to staff in the binders are not updated.

The above information was shared with Staff #1-2 on 10/20/22, who acknowledged the findings.

In an interview with Staff #2 on 10/20/22, they stated that the facility is behind on their quarterly updates. Their wellness director is usually responsible for updating the service plans, however, due to short staffing, they have been working on the floor as care staff and the service plans have not been updated.

Plan of correction:

Determine how many residents need quarterly updates. Facility will be hiring additional staff so that the wellness director will be free to working on their job duties assigned.

Based on interview and record review, it was confirmed that the facility failed to keep an accurate medication administration record (MAR) of all medications. Findings include:

Review of Resident #1s medication administration records (MARs) and progress notes for September and October 2022 showed multiple missed entries on the MAR for multiple medications. No staff initials or notes regarding whether or not the medication was given.

In interviews on 10/20/22, Staff #4 stated that they should be documenting the medications as they are given in the MAR. If they are refused or not given for any reason, they still initial and make a note/reason for not being given.

The above information was shared with Staff #2 on 10/20/22, who acknowledged the findings.

Plan of correction:

Facility is in contact with Consonus Pharmacy to provide a med tech pass audit and retraining for staff.

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:

Review of staffing schedules for September- October 2022, posted staffing plan, Acuity Based Staffing Tool (ABST), and service plans and progress notes for Resident #1. The wellness coordinator and wellness director are filling in as care staff regularly for call outs/staffing needs. The posted staffing plan shows that Days and Swing shifts are to have 3 care staff and 1 med tech (1 in memory care, 2 in assisted, and a shared med tech), and the NOC shift has 2 care staff and 1 med tech (1 in memory care, 1 in assisted, and shared med tech). The ABST provides the following weekly hours needed: Day 89.25, Eve 326.55, and NOC 373.7. The facility is not staffing per the ABST and the ABST does not match the posted staffing plan. Resident #1s progress notes and incident reports from January-March 2022 show multiple falls and resident to resident altercations, however, the service plans and temporary service plans have minimal interventions and instructions following these incidents. An interim service plan dated 10/05/22 states to be mindful of the resident ' s whereabouts at all times. If there is only 1 staff in the memory care, this is not always possible.

On 10/20/22 compliance specialist (CS) observed that Resident #1s service plan in the memory care binder has not been updated quarterly and is dated 10/04/21. CS observed Staff #3 assisting Resident #1 in their room while Staff #4 was passing meds in the dining room. CS observed 1 care staff in the memory care, 2 care staff in the assisted, and 1 med tech going between the two during onsite visit on 10/20/22.

The above information was shared with staff #2 on 10/24/22.

In interviews on 10/20/22, Staff #1 stated that they have had some issues with staffing and are in the process of hiring. They stated that there are 2 2-person transfers in the assisted living and 2 in the memory care. They only have 1 care staff in the memory care and if they need assistance, they will call for the med tech or other care staff from the assisted side. The wellness director and wellness coordinator are both out right now because they are covering on NOC shift this evening. Staff #3-4 stated that sometimes there is enough staff. They are not always able to get laundry done. Toileting and showers are getting done but sometimes residents will have to wait. There is only 1 care staff in the memory care and the med tech works on both sides. If they need assistance with a transfer they will call for assistance. During the day shift, management will come help out if they are busy.

Plan of Correction:

Hiring new staff, staffing per the ABST and updating the posted staffing plan. Hiring an additional wellness coordinator so that the wellness director can focus on their job duties such as service plan updates, incident report follow up, medication oversight.

Based on interview, observation and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:

Review of staffing schedules for September and October 2022, posted staffing plan, ABST, and service plan for Resident #1. The ABST provides the following weekly hours needed: Day 89.25, Eve 326.55, and NOC 373.7. The posted staffing plan shows that Days and Swing shifts are to have 3 care staff and 1 med tech (1 in memory care, 2 in assisted, and a shared med tech), and the NOC shift has 2 care staff and 1 med tech (1 in memory care, 1 in assisted, and shared med tech). The ABST and posted staffing plan do not match. Resident #1s service plan is not accurately reflected in the ABST. The ABST is showing that showers only take 5 minutes, when they report that it takes an average of 30 minutes per shower. Specific housekeeping or laundry is documented as 7 minutes on average, however, on the ABST it is being counted as 1 minute per occurrence. Resident #1-4 all have service plans that are not updated quarterly, so the ABST is also not updated quarterly with changes.

CS observed that the facility is not staffing per the ABST on 10/20/22. The posted staffing plan has not been updated with the current staffing levels from the ABST.

The above information was shared with Staff #1 on 10/24/22, who acknowledged the findings.

In an interview on 10/20/22, Staff #2 stated that the facility is using their own ABST. They just recently updated it. Staff #2 was unable to explain the ABST and how the staffing hours are calculated. Staff #2 stated they would need to check with home office as they are working on the data/calculation errors.

Plan of Correction: The facility is hiring more staff, service plans will be worked on to get updated, they will assess the ABST and make sure information is correctly entered as well as fix any calculation issues. The posted staffing plan with be updated to match the ABST.