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 07/12/2022. 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 develop and implement a written policy that prohibits the falsification of records. Findings include the following:
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) reviewed facility internal investigation for Resident #1 (R1) dated 02/24/2022 which states " Med tech did not administer medication that they signed off as administered on 02/22/2022 and 02/23/2022 as the medication was awaiting refill. RN was auditing medication administration records and found the error on the same day it occurred, and conversation was had with med tech. " A review of R1 ' s Medication Administration Record (MAR) for the month of February 2022 revealed that after the medication error was discovered on 02/24/2022 two other staff members incorrectly marked medication as administered while the facility was still awaiting refill. A review of facility Policy on Medication Errors and Medication Records did not reveal any area preventing the falsification of records.
According to Witness #1 (W1) this is a systemic issue and R1 ' s medication was incorrectly signed off as administered when the medication was not available. The above findings were discussed with Staff #1 (S1) who was in agreement.
Based on observation and interview it was confirmed that the facility failed to assist residents with toileting/incontinence care. Findings include the following:
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) observed an unsampled resident walking the common area hallway that was soiled through their pants before staff attempted to assist resident with incontinence care. After staff assisted resident with brief change there was no attempt made to change residents soiled pants. CS observed resident in the same soiled pants over an hour after they were assisted with their brief change.
In an interview with Staff #4 (S4) it was stated that they were unaware of staff doubling up on briefs during NOC shift, but they do have a few residents that are heavy soilers, but they use mattress pads to catch any excess fluids. The above findings were shared with Staff #1 (S1) who acknowledged findings.
Based on interview and record review it was confirmed that the facility failed to assist with showers/bathing. Findings include the following:
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) reviewed records for Resident #2 (R2) which revealed an Interim Service Plan date 02/22/2022 stating resident has not had a shower in over a month. A review of R2 ' s service plan revealed that staff are to provide assistance with showers, initiated on 11/11/2021.
According to Witness #2 (W2) it was stated that showers are not getting done for weeks.
Based on interview, observation and record review it was confirmed that the facility failed to provide services as listed in the service plans. Findings include the following:
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) observed Staff #8 (S8) provide a solo assist to Resident #4 (R4) into their bed.
CS reviewed R4 ' s service plan dated 06/12/2022 which revealed resident requires assistance of two during transfers.
In an interview with Staff #1 (S1) it was stated that S8 knows R4 very well and does transfer the resident alone.
Based on record review and interview it was confirmed that the facility failed to identify and monitor a resident experiencing a change of condition. Findings include the following:
During an unannounced site visit on 07/12/2022 in an interview with Staff #1 (S1) it was stated that Resident #2 (R2) had a lot of falls and that they thought they were doing what they could to implement fall preventions, but upon further questions R2 was unable to tell Compliance specialist (CS) what new interventions facility was implementing as resident experienced changes in condition.
CS reviewed service plan dated 06/06/2022 for R2 as well as progress notes, interim service plans and internal investigations from 01/2022 - 07/12/2022 for R2. Record review revealed instances of resident service plan not being followed prior to resident experiencing several falls as well as instances where interim service plans were not created or implemented timely and resident experienced cluster falls without proper staff intervention due to lack of interim service plans.
Based on interview and record review it was confirmed that the facility failed to carry out medication orders as prescribed. Findings include the following:
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) reviewed facility internal investigation for Resident #1 (R1) dated 02/24/2022 which states " Med tech did not administer medication that they signed off as administered on 02/22/2022 and 02/23/2022 as the medication was awaiting refill. RN was auditing medication administration records and found the error on the same day it occurred, and conversation was had with med tech. " A review of R1 ' s Medication Administration Record (MAR) for the month of February 2022 revealed that after the medication error was discovered on 02/24/2022 two other staff members incorrectly marked medication as administered while the facility was still awaiting refill.
According to Witness #1 (W1) this is a systemic issue and R1 ' s medication was incorrectly signed off as administered when the medication was not available. The above findings were discussed with Staff #1 (S1) who was in agreement.
Based on interview and record review it was confirmed that the facility failed to have a licensed administrator and failed to comply with administrator requirements. Findings include the following:
In separate interviews with Staff #1 (S1) and Witness #3 (W3) it was stated that Staff #13 (S13) was the facility administrator and that they had been the administrator at least since the winter either late 2021 or early 2022.
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) reviewed the Health Licensing Office' s website and completed a license search for S13 who was identified as the facility administrator. S13 did not have a long-term care administrator's license.
Based on interview and record review it was confirmed that the facility failed to have a licensed administrator and failed to comply with administrator requirements. Findings include the following:
In separate interviews with Staff #1 (S1) and Witness #3 (W3) it was stated that Staff #13 (S13) was the facility administrator and that they had been the administrator at least since the winter either late 2021 or early 2022.
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) reviewed the Health Licensing Office' s website and completed a license search for S13 who was identified as the facility administrator. S13 did not have a long-term care administrator's license.
Based on record review, interview and observation it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled need of the residents. Findings include the following:
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) reviewed facility staff schedules for May, June and July 2022, facility posted staffing plan, and facilities Acuity Based Staffing Tool (ABST). Review revealed across all three months facility has consistently staffed under their minimum staffing hours per their posted staffing plan. CS reviewed July staff schedule against facilities ABST which revealed facility is substantially understaffed according to the residents scheduled and unscheduled needs. The facility is staffing at approximately a quarter of the staff their ABST is stating that they need to meet the residents needs.
In an interview with Staff #3 (S3) it was stated that they sometimes only have 4 staff working the floor and they are barely able to meet residents needs with 6 staff working.
CS observed staff unable to locate residents in the facility, staff improperly transfer a resident, staff unable to locate residents assistive devices and not try to locate them as well as a resident fully soiled and visible through their clothing before staff assisted them with incontinence care.
Based on interview and record review it was confirmed that the facility failed to ensure that the Acuity Based Staffing Tool (ABST) was updated regularly and that the facility has a staffing plan that is based on the ABST. Findings include the following:
During an unannounced site visit on 07/12/2022 Compliance Specialist (CS) reviewed the facility ABST and found two residents listed that were no longer residents of the facility and one resident was listed in a different hallway than they resided in at the time of site visit. A review of the staff schedule for the month of July 2022 revealed that the facility did not have enough staff scheduled to meet the needs of the residents according to the ABST.
In an interview with Staff #1 (S1) it was stated that they did not believe that the facility was generating a staffing plan based on the ABST and S1 was unable to explain how the facility had enough staff to meet the needs as shown in the ABST. S1 acknowledged findings.