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 11/15/2022. 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 provide 3 daily nutritious, palatable meals to the residents, including fresh fruits and vegetables. Findings include:
Compliance Specialist (CS) reviewed the menu for 11/13/22-11/19/22, requested food temperature logs, and food meeting minutes. The kitchen staff are not logging the food temperatures and they have not had any recent food meetings with the residents. There wasnt any fresh fruit listed on the menu for 11/15/22.
In an interview with Staff #1 on 11/15/22, they stated that they do have concerns about the food quality and food sanitation in the kitchen. The staff are taking food temperatures; however, they have not been documenting them. They need a lot of training and cleaning to be done in the kitchen. They just had a new dining director start about 3 or 4 days ago.
Witness #1 reported that the facility has no concerns for the food quality they are putting out. The other day breakfast was rubber scrambled eggs, a piece of toast, and a prepackaged Danish and the resident is diabetic.
The above information was discussed with Staff #1 on 11/15/22.
Plan of correction:
The facility will be working with the dining manager and staff on training and documenting food temperatures.
Based on interview and record review, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:
CS reviewed Resident #2 ' s Service Plan dated 10/06/22 and it was determined that they are not being updated quarterly. Resident #2 moved in on 04/13/22 and only had the one service plan update since move in.
The above information was shared with Staff #1 on 11/15/22, who acknowledged the findings.
In interviews with Staff #1 and #4 on 11/15/22, they stated that they are aware that the facility has been behind on the service plans, and it is part of their condition that they are working on.
In a phone interview with Witness #1 on 11/17/22, they stated that they never had a service plan update since Resident #1 moved in. They have requested the information, but nothing was given to them.
Plan of correction:
Facility is working on getting all resident service plans updated.
Based on interview, observations, and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:
CS reviewed the posted staffing plan, Acuity Based Staffing Tool (ABST), service plans and progress notes for Resident #1-2, and call light response times for 10/22/22-10/23/22. There were multiple call light response times between 20-39 minutes. The ABST does not have all of the residents, or their information entered into the tool.
CS observed the call light monitor on 11/15/22 and observed a call light going off at 11:32am which was not responded to for 28 minutes.
In separate interviews on 11/15/22, Staff #1-4 stated that they are not always staffed per the posted staffing plan. They try to use agency staff and they have requested assistance from the Nurse Crises Team. Staff #1 stated that office staff and the nurse have been working the floor to cover shifts. They just lost their business office manager yesterday, and the new administrator has been out. Staff # 2-3 stated that there is not enough staff. Residents are not getting toileted enough, hospice residents are not getting enough attention, showers are not getting done on swing shift, and call lights are taking a long time to get to.
The above information was discussed with Staff #1 on 11/15/22.
Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:
CS reviewed posted staffing plan, ABST, and service plans and progress notes for Resident #1-2. The ABST is not updated with all the residents listed on the census. Resident # 2 does not have accurate care needs entered on the ABST per their service plan dated 10/06/22. 49 out of the 57 residents are entered into the ODHS ABST.
CS observed that the facility has 5 staff members working on the floor (including staff from nurse crises team) on 11/15/22. The nurse was not at the facility as they worked the NOC shift the night before. CS observed a call light going off at 11:32 am that was not responded to until 28 minutes later.
The above information was shared with Staff #1 on 11/15/22, who acknowledged the findings.
In an interview on 11/15/22, Staff #1 stated that there are currently about 57 residents in the assisted living facility. They have been working on ABST and updating service plans per their condition.
Based on interview and record review, it was confirmed that the facility failed to issue 30-day written notification to the resident or residents ' legal representative and follow the Oregon Administrative Rules when requesting an involuntary move out from the facility. Findings include:
Compliance Specialist (CS) reviewed Resident #2s service plan dated 10/06/22, Progress notes for June-November 2022, and Resident Evaluations/Assessments from June-September 2022, email and 30-day move out notice dated 11/15/22. Nothing was documented about interventions that were taken with family or discussions regarding finding placement for Resident #1 due to the facility not being able to provide care. Resident moved in on 04/13/22 and there wasn ' t a quarterly service plan update until 10/06/22 even though behaviors were being documented in the progress notes back in June 2022. Nothing noted by the facility about providing additional care for the residents safety until placement can be found.
In separate interviews on 11/15/22 with Staff #1 and 4, stated that they were not aware of any move out notices being issued, however, they have only been at the facility for a couple of days and the administrator is out.
In a phone interview on 11/17/22 with Witness #1, they stated that they had a meeting with the interim administrator and new administrator on 10/28/22. At this meeting they were told that Resident #1 needed memory care placement and they didn ' t have any open rooms in the memory care so they would need to immediately take the resident home or pay for 24-hour care as they couldn ' t provide the care for them. They did not give them a written 30-day move out notice. Witness #1 stated that they contacted a lawyer who told them that the facility cannot evict without notice, so they declined to take the resident home. They have recently found placement on their own at a memory care for the resident in December. Up until this point, the facility had communicated with the family regarding behaviors and needing memory care, but they were never given an updated service plan or a move-out notice.
Plan of correction:
Facility emailed a 30-day move out notice to the policy analyst on 11/15/22 and left a message to go over it.