The findings of the on-site investigation, conducted 12/03/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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, conducted during a site visit on 12/03/23, it was confirmed the facility failed to update service plans quarterly and have them available to staff for 3 of 4 sampled residents (#s  1, 4 & 7). Findings include, but are not limited to:

In an interview on 12/03/23, Staff 1 (Concierge) stated resident service plans are located in the chart room for staff to review.

Resident 1's service plan was not available for review in the service planning binder that was available to staff.

A review of Resident 4' s service plan indicated the quarterly evaluation last occurred on 10/11/22.

A review of Resident 7' s service plan indicated the quarterly evaluation last occurred on 06/11/23.

The facility failed to update service plans quarterly and have them available to staff.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Life enrichment Director) and Staff 4 (Vice President of Operations) on 12/03/23.

Verbal Plan of Correction: Staff 4 will complete an audit of all service plans and get all out of date service plans updated and create a schedule to ensure service plans stay up to date moving forward and be completed within 30 days.

Based on observation and record review, conducted during a site visit on 12/03/23, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled residents (#3). Findings include, but are not limited to:

Resident 3's service plan was reviewed and did not indicate when or how often Resident 3 was to receive housekeeping services.

Resident 3's room was observed on 12/03/23. Next to his/her bed there was discoloration and dark staining on the carpet and the room had a pervasive foul odor.

The findings were reviewed with and acknowledged by Staff 2 (Life Enrichment Director) and Staff 4 (Vice President of Operations) on 12/03/23.

It was confirmed the facility failed to ensure the implementation of services.

Verbal plan of correction: Staff 4 to review all apartments normal housekeeping schedule, audit service plans for housekeeping, and ensure they are all on schedule. A deep clean of Resident 3's carpet was completed on 12/04/23.

Based on observation, interview and record review, conducted during a site visit on 12/03/23, it was confirmed the facility failed to have an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. Findings include, but are not limited to:

On 12/03/23, multiple signs were observed in the chart room with a nurse's name and phone number listed for staff to contact.

A call was place to the nurse listed, who reported s/he had not worked in the facility since August 2023.

During separate interviews, Staff 1 (Congierge/Receptionist) and Staff 5 (MT) stated they were unsure who the nurse was for the facility and did not have a phone number to contact a nurse.

The findings were reviewed with and acknowlegded by Staff 2 (Life Enrichment Director) and Staff 4 (Vice President of Operations) on 12/03/23.

The facility failed to include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.

Verbal plan of correction: Facility had an RN Consultant and facility was attempting to recruit and hire a nurse. Facility ensured RN Consultant contact information was readily available to any staff who need it on 12/03/23.

Based on interview and record review conducted during a site visit on 12/03/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 resident (# 7). Findings include, but are not limited to the following:

A review of Resident 7's June 2023 MAR indicated Resident 7 did not receive three of four doses of his/her Klor-Con between 06/03-06/05/23. The medication exceptions report indicated the resident was out of refills and waiting on a new order.

A review of facility faxes indicated Resident 7's pharmacy was faxed at 6:51 pm on 06/03/23 noted resident was out of refills and to please send as soon as possible. Physician orders dated 06/08/23 indicated Resident 7 was to take Klor-Con two tablets by mouth twice daily with food.

In an interview on 12/03/23, Resident 7 stated s/he had issues with receiving his/her medications in the past, but no issues currently with medications.

In an interview on 12/03/23, Staff 2 (Life Enrichment Director) stated Resident 7's daughter picked up the medication for resident.

The findings of the investigation were reviewed with and acknowledged by Staff 2 and Staff 4 (Vice President of Operations) on 12/03/23.

The facility failed to carry out medication orders as prescribed.

Verbal plan of correction:  Re-training with medications staff about when to re-order medications in a timely manner to ensure they have an adequate stock by end of the week.

Based on interview and record review, conducted during a site visit on 12/03/23 and by phone on 12/08/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

During a phone interview on 12/08/23, Staff 4 (Vice President of Operations) stated the facility's expectation is that staff respond to call lights in 5-10 minutes.

A review of Resident 4's call light log for 11/26/23-12/03/23 revealed one occasion when Resident 4's call light was not responded to for over 30 minutes.

During a phone interview on 12/08/23, Resident 4 stated occasionally s/he waits for over 30 minutes or his/her call light to be answered.

It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of Resident 4.

Verbal plan of correction: An in-service on timely response to call lights, calling for back up when unable to respond timely to be done by end of 12/15/23. Staff 4 will begin reviewing call light times in facility's daily stand up meeting.

Based on observation, interview and record review, conducted during a site visit on 12/03/23, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings, include, but are not limited to:

The facility had an active ABST condition ALFCD22-01076 with the following  imposed care staff mandates:

Day: 3 Caregivers 2 Med Techs

Evening: 3 Caregivers 2 Med Techs

Night: 2 Caregivers 1 Med Techs

The facility's posted staffing plan was observed and reviewed on 12/03/23, and noted the following care staff.

Day: 3 Caregivers 2 Med Techs

Evening: 3 Caregivers 2 Med Techs

Night: 1 Caregiver 1 Med Tech

Interviews with Staff 1 (Conceirge) Staff 2 (Life Enrichment Director) and Staff 5 (MT) on 12/03/23 confirmed the facility was staffing in accordance with their staffing mandate, and that the posted staffing plan was not accurate.

The facility failed to update their posted staffing plan to be consistent with their imposed ABST condition and staffing mandate.

Verbal plan of correction: The facility would posted an accurate staffing plan by 12/04/23.