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 12/27/2022.  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, including events overheard or witnessed by observation. Findings include:

In interviews on 12/27/22, Staff #2-4 stated that paper incident reports are being filled out for staff as an incident occurs. Staff will then send it to the administrator who will report abuse or neglect. Staff #1 stated that staff will call and let them know about incidents and they will tell them if it is reportable. Staff #5 stated that if there is a fall, it is documented in the progress notes, incident report and family and physician will be informed. Higher up staff will call APS.

CS reviewed of the facility's policy and procedures for incident reports, reporting abuse and neglect, and Resident #1-3s service plans, completed incident reports and progress notes for December 2023. Resident #1 has an incident report dated 12/16/22 that reports an unwitnessed fall involving another resident (both are memory care residents). Incident report states that the Resident #1 was sitting in their wheelchair when the other resident was trying to get the resident out of the chair. Resident #1 slipped onto the floor. No other documentation or follow up regarding how abuse or neglect was ruled out or whether or not this was reported to APS. Incident Report has a status of incomplete with no review or updated of service plan. Resident #2 (memory care resident) has 6 incident reports for December 2022 reporting unwitnessed falls and all of the statuses are documented as  " incomplete "  with no review and update to resident's care plan as needed by the HSD. An incident report on 12/15/22 reported that resident  "complaints that only his/her bottom hurt because of his/her sores. They had reopened " . No detailed investigation done to rule out abuse or neglect and nothing documented about reporting to APS. Another incident on 12/15/22, Resident #2 was found on the floor and was yelling  " the other guy left him/her "  Resident was agitated and refused vitals to be checked. No other documentation regarding investigation to rule out abuse or neglect or reporting to APS.

The above information was shared with Staff #1 on 01/09/23 via email.

Based on interview and record review, it was confirmed that the facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. Findings include:

In separate interviews on 12/27/22, Staff # 2-4 stated that if a resident had orders to monitor meals, they would document that on the MAR. They do not have any concerns about this. Staff #5 stated that if there is a fall or an incident, an incident report would be filled out, it would be documented in the progress notes, the nurse would need to evaluate the resident for changes and alert charting would be done.

CS reviewed Resident #1-3s service plans, progress notes for December 2023, medication administration records (MAR) for January 2023, incident reports for December 2022, and policy and procedures for incident reports and change of condition and monitoring. Resident #1 and Resident #2 both had falls document in incident reports for December 2022, without any assessments documented, interventions put in place, or alert charting in the progress notes. No temporary or permanent updates to the service plans were made. Resident #2 has notes in the incident reports about a bed alarm but nothing documented in the service plan or progress notes about when this was implemented.

The above information was shared with Staff #1 on 01/09/22 via email.

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:

In an interview on 12/27/22, Staff #1 stated that the facility has changed ownership on 12/01/22 and they are now using the state ABST. Their current census is 44, however, they do need to make some updates with recent changes.

CS observed that the facility is staffing per their current staffing plan and ABST during walkthrough on 12/27/22.

CS reviewed staffing schedules for December 2022, posted staffing plan, and service plans for Residents #1-3. CS determined that there are a total of 43 residents listed on the ABST with 3 residents that have incomplete information filled out and 1 resident that didn't have any information filled out at all.

The above information was shared with Staff #1 on 12/27/22, who acknowledged the findings.

Plan of correction: Facility to finish updating the ABST and update their posted staffing plan with any changes. Admin has an ABST call on 12/28/22 regarding their ABST.

Based on interview and record review, it was confirmed that the facility failed to provide records to the Department upon request. Findings include:

CS requested documents from the facility for an investigation on 12/27/22 and did not receive them. Reviewed emailed requests dated 12/30/22, 01/06/23, and 01/09/23 following up on the requests for documentation still needed. The facility is not providing documentation timely upon request.

Per phone conversation with Staff #1 on 01/03/23, they stated they would get the documents sent right away and did not see the email from 12/30/22 with the deadline of 01/02/23. On 01/04/23 Staff #2 called CS to ask what documents were requested again and stated they would have them ready for pickup ASAP. On 01/06/22, CS emailed and called the facility and was told the documents would be available for pickup before 3:30pm. Documents were again not ready.

The above information was shared with Staff #1 via email on 01/09/23.