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 02/14/2023.  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 record review and interview it was confirmed that the facility failed to implement the resident's right to be given informed choice and opportunity to select or refuse service. Findings include but not limited to:

A review of Resident #1 (R1) progress notes for December 2022 and service plan dated 11/7/2022 revealed than on 12/27/2022 R1's service plan was altered to adjust incontinence care practices. Progress notes do not reflect that the resident, family or their Power of Attorney (POA) were notified of this change.

During a phone interview on 02/14/2023 Witness #1 (W1) stated that the facility changed R1's service plan without notifying them.

These findings were reviewed with and acknowlegded by Staff #1 by phone on 02/16/2023.

Facility Plan of Correction: Facility to document conversations with family in progress notes and notify of any changes as soon as possible within 72 hours or less.

Based on record review and interview it was confirmed that the facility failed to report any suspected abuse to the local Adult Protectice Services (APS) office. Findings include but not limited to:

A review of Resident #1 (R1)'s incident reports and progress notes for August 2021  revealed:

*On 08/20/2021 R1 had an unwitnessed fall with injury. Q 2 hour checks noted to be initiated. Abuse ruled out because "No staff member went into the room before the incident"

*On 08/21/2021 R1 had an unwitnessed fall with injury. There is no documentation on whether two hour checks had been provided. Abuse and neglect ruled out by "cameras were reviewed and no staff member went into apartment prior to incident." Resident was very agitated after.

*On 8/22/2021 given double dose of psychotropic. R1 experienced a decreased level of consciousness. PCP was not notified of error until 9/1/2021.

*On 8/30/2021 unwitnessed fall. encourage resident to stay in bed. 2 hour checks are mentioned again, but there is no documentation if they occurred.

None of these events were self-reported to APS.

These findings were reviewed with and acknowledged by Staff #1 by phone on 02/16/2023 who was in agreement. S1 stated they now review all incidents Monday-Friday with administrator, Resident Care Coordinator (RCC) and nurse.

Plan of correction: CS emailed copy of ODHS abuse/neglect reporting guide for review.

Based on record review and interview, it was confirmed that the facility failed to provide a service plan with written description of who shall provide the services and what, when, how, and how often the services shall be provide and date and initial changes and entries made to the service plan.

A review of the Resident #1 (R1)'s service plan dated 11/07/2022 and 02/08/2023, Resident #2 (R2)'s serices plans dated 5/4/2021 and 8/12/2021and Resident #3 (R3)'s service plan dated 1/30/2022 fail to identify who shall perform what services and when. R1's service plan dated 11/07/2022 contatains handwritten additions that are not dated or inititaled.

These findings were reviewed with and acknowledged by Staff #1 by phone on 02/16/2023.

The facility was unwilling to provide a Plan of Correction though stated they woud follow up.

Based on record review and interview, it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:

Compliance Specialist (CS) reviewed Resident #1 (R1)'s Medication Administration Record (MAR) for January 2023 which revealed that R1 did not receive a medication for nine days straight due to "waiting on delivery". R1's MAR for August 2021 revealed at least two more instances when medications were not given for the same reason. A review of R1's progress notes for these time periods did indicate any steps that were taken by staff to obtain these medications. An incident report dated 8/22/2021 revealed that R1 was given double dose of a psychotropic medication which resulted in a decreased level of consciousness.

These findings were reviewed and acknowledged by with Staff #1 (S1) by phone on 02/16/2023 who was in agreement with findings.

Plan of Correction: Facility to audit MARs and progress notes Monday-Friday for exceptions and ensure that appropriate actions taken beginning 2/17/2023.

Based on oservation, record review and interview, it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:

During an unannounced site visit on 02/14/2023, Compliance Specialist (CS) observed five caregivers (CGs) and one medication technician (MT) working the floor, which would total 42 hours. There was one additional medication technician in training on the floor.

A review of the facility's ABST updated on 2/11/2023 revealed the need for 46.79 hours on day shift.

A review of the facility's posted staffing plan stated the facility needed:

Three CGs and one MT on day shift.

Three CGs and one MT on evening shift

Two CGs and one MT on noc shift.

A review of the facility's staff schedule for February 2023 and time cards for 02/13/2023 revealed only 30 hours of care on day shift on 02/13/2023, and several days in February 2023 when only three CGs were scheduled during the day. There were five noc shifts when only one CG and one MT were scheduled.

A review of Resident #1 (R1)'s service plan dated 11/07/2022 revealed that R1 sometimes requires assistance of three people for transfers and incontinence care. a review of R1's progress notes revealed that R1 had a fall on 2/4/2023 when two staff members were assisting with incontinence care.

During interview, Staff #3 (S3) and Staff #4 (S4) stated:

*Day and swing shift are short-staffed.

*Swing shift and weekends have the worst staffing.

*There are sometimes only two CGs and one MT on day shift.

*There is only one CG sometimes on swing shift.

In an email on 02/15/2023, Staff #1 (S1) stated that the facility's "call light system is not set up to track call light usage."

These findings were reviewed with and acknowledged by Staff #1 by phone on 02/16/2023.

Plan of Correction: S1 stated that they disagreed with findings and that R1 can be changed in bed with only two people. Facility will update service plan to be reflective of need for only two people on noc shift.

Based on observation, interview and record review, it was confirmed that the facility failed to fully implement an Acuity Based Staffing Tool. Findings include but not limited to:

During an unannounced site visit on 02/14/2023, Compliance Specialist (CS) observed five caregivers and one medication technician working the floor, which would total 42 hours. There was one additional medication technician in training on the floor.

A review of the facility's ABST updated on 2/11/2023 revealed the need for 46.79 hours on day shift. The facility's ABST does not include all 22 Activities of Daily Living (ADLs). A review of the facility's posted staffing plan stated the facility needs three CGs and one MT on day shift. A review of the facility's staff schedule for February 2022 and time cards for 02/13/2023 revealed only 30 hours of care on day shift and several days when only 3 CGs were scheduled during the day.

During interview, Staff #1 (S1) stated:

*Two of the caregivers working were on light duty and unable to lift more than two pounds and would not be responsible for taking a section of residents.

*Their background is in skilled nursing so they believe they need less staff than required by skilled nursing ratios.

These findings were reviewed with and acknowledged by S1 by phone on 02/16/2023.

Plan of Correction: S1 stated that data is entered incorrectly and says that tasks are distributed incorrectly to disproportionately effect day shift. They will review and revise within two weeks. They will speak with company management to address 22 ADLs.

Based on observation, interview and record review, it was confirmed that the facility  failed to have a training program that includes methods to determine the competency of direct care staff. Findings include but not limited to:

During an unannounced site visit on 02/14/2023, Compliance Specialist (CS) observed Staff #2 (S2) passing medications unsupervised throughout the day.

During interview, S2 and Staff #3 (S3) stated:

*S2 is still in training

*A Medication Technician (MT) in training can pass medications unsupervised when the employee in training feels confident.

*S3 has been working as a MT for many months.

CS requested all training documents for S2 and S3. S2's training materials included a single page "Medication Assistant Training Check Off List" which was not signed by the trainee, and had several missing initials. There was no indication any of these skills were verified. S3's "Medication Assistant Training Check Off List" was complete and dated 1/5/2023. No other training documentation was available.

These findings were reviewed with and acknowledged by S1 by phone on 2/16/2023 who was in agreement.

Plan of Correction: Facility will have office manager complete audit of training material for existing staff within two weeks.