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 04/13/2023.  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 obtain background checks on all subject individuals. Findings include but not limited to:

A review of Staff #10 (S10)'s background check documentation, provided by the facility, revealed that the background check was submitted but not returned as approved.

During interview during an unannounced site visit on 04/13/2023, Staff #1 (S1) confirmed that they did not have a completed background check for S10.

These findings were reviewed with S1 and Staff #11 on 04/13/2023.

Plan of Correction: Background checks are now completed and in-hand prior to any new hires being added to the schedule for training.

Based on interview and record review, it was confirmed that the facility failed to provide a copy of the service plan to the resident or to the resident's legal representative.

During an unannounced site visit on 04/13/2023, Compliance Specialist (CS) interviewed Staff #2 (S2) who stated that they started in August of 2022 and must not have had a care conference with Resident #6 (R6) and/or family in September 2022 as it was not documented.

A review of R6's service plan dated 09/01/2022 was not signed by any family.

These findings were reviewed with Staff #1 and Staff #11 on 04/13/2023.

Plan of Correction: Facility is now scheduling care conferences, providing service plans to residents and Power of Attorney (POA) and documenting this process.

Based on observation, record review and interview, it was confirmed that the facility failed to implement a system for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications. Findings include but not limited to:

During an unannounced site visit on 04/13/2023 Compliance Specialist (CS) observed Resident #3 (R3)'s liquid morphine bottle contained 12 ml. A review of the corresponding log for the medication indicated that it contained 14ml. CS also observed two expired medications contained in the second-floor cart.

During separate interviews Staff #1 (S1), Staff #2 (S2) and Staff #6 (S6) stated:

*All were aware of the expired medications in the second-floor cart.

*All were aware of the discrepancy in R3's liquid morphine.

*R3's missing medication had not been investigated or reported to Adult Protective Services (APS).

*There was another incident when an entire card of R3's narcotic went missing.

CS reviewed facility's narcotic shift audit record for April 2023 and March 2023 which revealed at least three occasions when the narcotic count was not completed. There were 71 occasions when the medication number was not included during the count. The April 2023 record did not have the month or year filled in.

These findings were reviewed with S1 and Staff #11 (S11) on 04/13/2023 who were in agreement.

Plan of Correction: Facility and corporate staff to review and revise current policy. Investigation to begin immediately on current missing narcotic and will report to APS. CS also reported to Clackamas County APS. Education to be provided to all Medication Technicians within 2 weeks. Facility is piloting an electronic narcotic count program in the future.

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

During an unannounced site visit on 04/13/2023, Compliance Specialist (CS) reviewed an incident report dated 09/03/2021 which revealed Resident #1 (R1) received the wrong medication. Resident #2 (R2)'s November 2022 Medication Administration Report (MAR) revealed multiple medications were not documented, not available or awaiting delivery. Resident #3 (R3)'s December 2022 MAR revealed two instances when a medication was not given because it was not available.

These findings were reviewed with Staff #1 and Staff #11 on 04/13/2023 who were in agreement.

Plan of Correction: Missed medication report to be pulled daily and Resident Care Manager (RCM) to follow up and find out why medication was missed. Next steps taken will be documented in resident record.

Based on observation, interview and record review, it was confirmed that the facility failed to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. Findings include but not limited to:

During an unannounced site visit on 04/13/2023, Compliance Specialist (CS) used Resident #1 (R1)'s call button to call staff. CS and R1 waited 27 minutes and no one responded. CS left room and found Staff #5 (S5) in the dining room. CS observed two Caregivers (CG) and one Medication Technician (MT) working on second floor and one CG and one MT working on the third floor.

During interview, R1 stated that they frequently have to wait 30 minutes for help.

During interview, S5 stated that R1's call light had been on for 28 minutes. They were unaware and had been organizing cereal for the last 10 minutes and were now setting tables. They stated that call lights should be responded to within five minutes.

During interview, Staff #3 (S3) stated that the facility has the following staffing needs for day shift:

Second floor: three CG, one MT

Third Floor: one CG, one MT

Staff #1 (S1) reported they had a person quit this morning and walk off the floor so Staff #2 and S3 would support as needed.

These findings were reviewed with S1 and Staff #11 on 04/13/2023 who were in agreement.

Plan of Correction: Facility is actively recruiting and interviewing daily. They currently have an ad on indeed. Agency is used when needed. S1 will follow up with S5 on time management and priorities.

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

During an unannounced site visit on 04/13/2023, Compliance Specialist (CS) reviewed training material for Staff #7, Staff #8 and Staff #10. All three were incomplete. S7 had no training as a medication technician (MT).

During interview, Staff #2 (S2) stated that S7 had previously worked as a MT for a different company.

A review of the facility's schedule for September 2022 revealed that S7 had worked multiple shifts as a MT.

These findings were reviewed with Staff #1 and Staff #11 on 04/13/2023 who were in agreement.

Plan of Correction: All Relias training are required prior to staff being scheduled to begin training on the floor. Facility has audited all current employees for training materials which are to be completed within 30 days.