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 07/22/24. 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
CBG:capillary blood glucose or blood sugar
CG:caregiver
CS: Compliance Specialist
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
HS:Hours of sleep
LPN:Licensed Practical Nurse
MT: Medication Technician or Med Tech
MAR:Medication Administration Record
MCC:Memory Care Community
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
RCC:Resident Care Coordinator
RN:Registered Nurse
SP:Service plan
SPT:Service Planning Team
TAR:Treatment Administration Record
Based on interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:
A review of Resident 1's service plan, dated 01/26/24 indicated the following:
·Staff would provide assistance with showers per the shower schedule;
·Trash removed daily
A review of Resident 1's Point of Care Audit Report for Bathing/Showers on Tuesday & Friday Evenings, dated 05/01/24 - 05/31/24 indicated on 05/07/24, 05/10/24 and 05/28/24 a shower was not recorded as given for Resident 1. No documentation of resident refusals was available or provided.
In an interview on 07/22/24, Staff 1 (Executive Director) stated based on the audit reports Resident 1 did not receive showers on three occasions in May 2024.
In an interview on 07/22/24, Resident 1 stated s/he has had issues with receiving care at the facility.
The facility failed to ensure the implementation of services.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.
Verbal Plan of Correction: Re-training of staff on ADLs, how to respond to residents when they refuse care and move care to next shift to be implemented on 08/01/24. Facility leadership to verify plan of Care ADLs sign-off daily, and follow up with staff.
Based on interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to ensure the service plan was reflective of the resident's needs for 1 of 1 sampled resident (# 2). Findings include but are not limited to:
A review of Resident 2's service plan, dated 05/06/24, indicated under the section ambulation/mobility the following:
·Resident 2 ambulated with a four-wheeled walker and had a cane s/he may occasionally use to support the right side of his/her body; and
·S/he was able to manage ambulation and mobility independently.
Under the section for Transfers, service plan indicated the following:
·Resident 2 was able to manage transfers independently.
Under the section Risk for Falls, service plan indicated the following:
·Falls on 06/16/24, 06/18/24 and 06/20/24;
·Resident 2 had a history of falls - s/he had four falls in the past three months on 02/11/24, 02/21/24, 02/26/24 and 03/24/24; and
·Resident had multiple falls during times when s/he attempted to get out of bed at around 6:00 am.
A review of Resident 2's incident report dated 03/24/24 indicated Resident 2 was found by med tech in the hallway/doorway of his/her room. Resident stated s/he was going to the grocery store when s/he fell.
No temporary service plans were available or provided for Resident 2 regarding interventions for falls.
In an interview on 07/22/24, Staff 1 (Executive Director) stated there could be some confusion on if all of the recorded falls are actually falls due to how Resident 2 likes to take naps on the floor, but there had not been any interventions put in place for Resident 2's falls.
The facility failed to ensure the service plan must reflect the resident's needs.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.
Verbal Plan of Correction: Administrator had input interventions on 07/22/24 which included additional housekeeping, encouraging him/her to use his/her walker and have someone help him/her tidy his/her room. Administrator was to involve case manager and behavioral support services. Was to do a root cause analysis for falls by end of week on 07/26/24.
Based on observation, interview, and record review, conducted during a site visit on 07/22/24, the facility's failure to ensure the implementation of services for 1 of 1 sampled Resident (# 1) was substantiated. Findings include, but are not limited to:
Resident 1 stated s/he struggled with receiving care. The facility was short staffed, and s/he had problems getting showers and with two person transfers.
At approximately 11:20 am, Staff 12 (CG) entered Resident 1's room to provide care (toileting assistance) to Resident 1.
Resident 1's service plan, dated 01/26/24, indicated:
-Staff will provide physical assistance with showers per the shower schedule.
-"Staff will provide physical assistance with transferring [Resident 1]. Staff to use transfer board, [Resident 1] is able to bear some weight."
The facility's Point of Care Audit Report, dated 08/01/23 through 08/31/23, and 05/01/24 through 05/31/24, indicated physical assistance for Resident 1's with bathing/showers were scheduled for Tuesday and Friday evenings.
There was no documented evidence physical assistance was provided for a shower on Tuesday, 05/28/24 as scheduled.
The facility's failure to ensure the implementation of services for Resident 1 was substantiated.
The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Nurse), and Staff 3 (Health Services Director).
The facility's plan of correction is to perform retraining of staff on ADLs, how to respond to resident when they refuse care, and moving the ADL to the next shift will commence on August 1, 2024. Plan of care ADLs sign-off will be verified daily and follow up with staff.
Based on interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to develop a service planning team that included the resident for 4 of 5 sampled residents (#s 2, 8, 9, and 12). Findings include, but are not limited to:
a.Resident 9
In an interview on 07/22/24, Resident 9 stated s/he had not been included in a service planning meeting or consulted about his/her care in about a year. S/He stated if s/he were invited to a service planning meeting s/he would like to attend.
A review of the service plan binder indicated Resident 9 did not have a service plan available.
b.Resident 8
In an interview on 07/22/24, Resident 8 stated s/he had never been to a service planning meeting and had never been invited to attend one. S/He further stated s/he had never seen his/her service plan.
A review of the service plan binder indicated Resident 8's service plan, dated 02/13/24, was signed by staff members. The section for resident and family signatures lacked any signatures.
c.Resident 2
On 07/22/24 Resident 2 refused an interview.
A review of the service plan binder indicated Resident 2's service plan, dated 02/08/24, was signed by staff members. The section for resident and family signatures lacked any signatures.
d.Resident 12
Resident 12 was unavailable for interview on 07/22/24.
A review of the service plan binder indicated Resident 12's service plan, dated 01/17/24, was signed by staff members. The section for resident and family signatures lacked any signatures.
The facility failed to develop a service planning team that included the resident.
The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.
Verbal Plan of Correction: Since June when new administrator started residents and families were being included in service plan meetings. The administrator printed out old and new service plans, medications, and demographics and reviewed them all together during the service planning meeting with residents and/or family. Reception scheduled the meeting and sent the invites to administrator, nurse, RCC and family.
Based on interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed. Findings include but are not limited to:
A review of Resident 5's 04/01/23 - 05/31/23 MAR's indicated the following:
· "Check weight one time a day, Notify PCP if 5 pound weight loss or gain one time a day for monitoring for 30 Days" with a start date of 04/15/23.
·On 04/15/23, 04/16/23, 04/26/23, 04/30/23, 05/13/23 no weights were recorded and no indication of why residents weight was not obtained.
In an interview on 07/22/24, Staff 1 (Executive Director), Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) acknowledged the lack of consistency with monitoring Resident 5's weight.
The facility failed to carry out medication and treatment orders as prescribed.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 and Staff 3 on 07/22/24.
Verbal Plan of Correction: MT meeting to occur by 07/26/24 to review vitals and missed medications. The facility had been working with staff to put medications on cycle-fill.
Based on interview and record review, conducted during a site visit on 07/22/24, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled Resident (# 7) was substantiated. Findings include, but are not limited to:
Resident 7's physician order summary report, dated 01/31/23, indicated:
-Alpha-Lipoic Acid 600 mg (nerve pain), give two capsules by mouth one time a day. May increase to two capsules daily if no improvement, starting 09/06/22;
-Ferrous Sulfate 325 mg (anemia), give one tablet by mouth one time a day at bedtime starting 01/02/23;
-Omeprazole Delayed Release 20 mg (acid reflux), give one capsule by mouth in the morning starting 01/03/23;
-Suboxone Sublingual Film 2-0.5 mg (pain management), give one tablet sublingually three times a day starting 08/08/22; and
-Venlafaxine 37.5 mg (depression), give one tablet by mouth one time a day starting 08/09/22.
Resident 7's MAR, dated 01/01/23 through 01/31/23 indicated:
-Alpha-Lipoic Acid 600 mg was not administered 12 times;
-Ferrous Sulfate 325 mg was not administered five times;
-Omeprazole Delayed Release 20 mg was not administered 12 times;
-Venlafaxine 37.5 mg was not administered four times; and
-Suboxone Sublingual Film 2-0.5 mg was not administered 19 times.
Staff 1 (Executive Director), stated Resident 7 had moved out of the facility.
Resident 7 was no longer at the facility and could not be interviewed or observed.
The facility's failure to carry out medication and treatment orders as prescribed for Resident 7 was substantiated.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse), and Staff 3 (Health Services Director).
The facility's plan of correction was to hold a MT meeting this week to review vitals and missed medications. The facility has been working with staff to put medications on cycle fill. Administration and their clinical team will create an additional plan of correction.
Based on observation, interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:
No posted staffing plan was observed.
In an interview on 07/22/24, Resident 1 stated on 07/08/24 there were not enough staff to provide care timely and s/he had to wait over an hour to be assisted out of bed.
In an interview on 07/22/24, Staff 1 (Executive Director) stated generally if the facility was short staffed the management team would step on the floor to assist, and s/he recently got approval to use agency staff. S/he stated the posted staffing plan may not have been hung back up after painting the lobby, but the facility staffing plan was as follows:
·Day shift: 3 med techs and 3 to 4 caregivers;
·Swing shift: 2 med techs and 3 caregivers;
·Night shift: 1 med tech and 2 caregivers; and
·Housekeepers and dietary staff are scheduled in addition to caregivers and med techs.
Documentation to support management had assisted with resident care was requested and was not available or provided.
A review of the facility scheduled dated 07/01/24 - 07/31/24 indicated 36 of 65 shifts we staffed below the stated staffing plan.
The facility failed to have qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.
Facility Verbal Plan of Correction: The facility had received approval to use agency staff and would be staffing with agency staff to meet the staffing plan.
Based on observation, interview, and record review, conducted during a site visit on 07/22/24, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of residents was substantiated. Findings include, but are not limited to:
The facility's Acuity-Based Staffing Tool (ABST) generated staffing hours requiring minimums of six direct care staff on day shift, five direct care staff on swing shift, and two direct care staff on night shift. There were two residents whose care needs were not accounted for in the tool.
The facility did not have a posted staffing plan.
Staff 1 (Executive Director) stated the facility's staffing plan was three Med Techs (MTs) and three to four Personal Care Assistant (PCA/CG) on day shift, two MTs and three CGs on evening shift, and one MT and two CGs on night shift and on 07/08/24, the facility was short staffed, so Staff 1, Staff 3 (Health Services Director), and Staff 2 (Nurse) all worked the floor.
On 07/22/24 there were three CGs and two MTs working the floor on day shift.
A facility staff schedule, dated 07/01/24 through 07/22/24, indicated the facility was not staffing according to ABST generated minimum staffing requirements for 21 instances on day shift, ten instances on swing shift, and six instances on night shift.
Staff 5 (MT) stated when s/he was working at the facility, the facility was "short" on "in-house" staff.
The facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of residents was substantiated.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, and Staff 3.
Facility's plan of correction: Facility has since received approval to utilize agency staff and will continue to fill scheduling gaps with agency staff.
Based on observation, interview and record review, conducted during a site visit on 07/22/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool for 2 of 4 sampled residents (# s 3 and 14). Findings include, but are not limited to:
A.Resident 3
A review of facility resident roster and ABST indicated Resident 3 was not entered into the tool.
In an interview on 07/22/24, Staff 1 (Executive Director) stated Resident 3 had moved in on 12/31/22.
B.Resident 14
A review of facility resident roster and ABST indicated Resident 14 was not entered into the tool.
In an interview on 07/22/24, Staff 1 stated Resident 14 moved in on 06/17/24.
There was no posted staffing plan available.
A review of the stated staffing plan and 07/01/24 - 07/31/24 staff schedule indicated the facility was not staffed according to the staffing plan on 36 of 65 shifts.
In an interview on 07/22/24, Staff 1 stated the RCC or the RN were responsible for updating the ABST.
The facility failed to fully implement and update an acuity-based staffing tool.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Delegation Support Nurse) and Staff 3 (Health Services Director) on 07/22/24.
Based on observation, interview and record review, conducted during a site visit on 07/22/24, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 3 of 3 sampled residents (#s 2, 3, and 14). Findings include, but are not limited to:
The facility utilized the ODHS ABST. Residents 3 and 14 were not entered into the tool, the facility had no staffing plan posted, and the facility was not consistently staffing to the levels indicated by the tool.
The facility's ABST generated staffing hours requiring minimums of six direct care staff on day shift, five direct care staff on swing shift, and two direct care staff on night shift.
There were three Caregivers (CG) and two Med Techs (MT) working the floor on day shift.
Staff 4 (Community Relations Director) stated the facility's census was 68.
Staff 1 (Executive Director) stated either the Resident Care Coordinator (RCC) or Staff 3 (Health Services Director) updated the ABST and the staffing plan was three MTs and three to four CGs on day shift, two MTs and three CGs on evening shift, and one MT and two CGs on night shift.
A facility staff schedule, dated 07/01/24 through 07/22/24, indicated the facility was not staffing according to the required staffing levels for 21 instances on day shift, ten instances on swing shift, and six instances on night shift.
Staff 5 (Med Tech) stated when s/he was working at the facility, the facility was "short" on "in-house" staff.
During interviews, Staff 2 (Nurse) and Staff 3 (Health Services Director) stated regarding Resident 2's care needs, Staff brought breakfast, performed safety checks, assisted with dressing, and assisted with bathing three times weekly.
Interventions for fall prevention identified in Resident 2's service plan, dated 05/06/24, were not captured in his/her ABST profile.
Residents 2, 3, and 14 were unavailable for interview.
The facility's failure to fully implement and update an ABST was substantiated.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, and Staff 3.
Based on interview and record review, conducted during a site visit on 07/22/24, the facility's failure to document they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 3 sampled staff (# 15) was substantiated. Findings include, but are not limited to:
Staff 1 (Executive Director) stated s/he identified training as an area of the facility that needed improvement.
Facility records for Staff 15 indicated s/he did not have a Health/Medication Competency Checklist, and his/her basic Competency Checklist for Passing Medications was incomplete.
The facility's failure to document they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised was substantiated for Staff 15.
The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Nurse), and Staff 3 (Health Services Director).
The facility's plan of correction included scheduling several caregiver trainings. Staff 1 will ensure all staff complete the trainings starting August 1, 2024. Staff 1 has completed an audit of the facility's training records to ensure staff have completed all required trainings.