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 01/30/2023. 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 interview and record review it was confirmed that the facility failed to administer medications as ordered by their physician. Findings include the following:
During an unannounced site visit on 01/20/2023 Compliance Specialist (CS) reviewed the April 2022 Medication Administration Record (MAR) for Resident #4 (R4) as well as their Chart Notes for the same period. CS found that all evening medications after 5pm on 04/19/2022 were left blank on the MAR, there is no indications in either the Pass Notes or in R4 ' s chart notes as to why medications were not administered. There was also an instance of a PRN medication with specific parameters marked as given on 04/08/2022 and there are no indications on the MAR, in Pass Notes or in Chart Notes that the parameters were met in order to administer medication. A review of R4 ' s bowel program it appears that Staff #7 (S7) marked on three occasions that the monitoring program had not started on two of those instances were on 04/05 and 04/11/2022 even though on prior dates staff were performing the bowel program.
In an interview with Witness #1 (W1) it was stated that the facility was not following R4 ' s bowel protocol correctly and that they are making medication errors.
Based on interview and record review it was confirmed that the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include the following:
During an unannounced site visit on 01/20/2023 Compliance Specialist (CS) reviewed the facility ABST for Resident #3 and #5 (R3 & R5) against each residents current service plan. CS found inconsistencies between service plans and ABST questions for both R3 and R5. CS reviewed the facility ABST and found that it is not being updated quarterly or with resident change of condition in accordance with rule.
In an interview with Staff #2 (S2) it was stated that the acuity tool answers includes the activities worker and time residents will spend in group activities. S2 and Staff #1 (S1) also confirmed that their staffing plan was not consistent with what the acuity tool states they should be staffing at.
Facility Plan of Correction:
The facility will be going through the ABST to ensure that only caregiving/MT duties are included in the time and that they are using their ABST to create the staffing plan for the facility
Based on interview and observation it was confirmed that the facility failed to provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area; and have a minimum rinse temperature of 140 degrees Fahrenheit. Findings include the following:
During an unannounced site visit on 01/20/2023 Compliance Specialist (CS) observed the soiled linen room, there was no way to check the rinse temperature on the washing machine. CS observed the regular detergent that was being used in the was process.
In an interview with Staff #3 (S3) it was state that the chemical disinfectant isn ' t used because they had issues with it not dispensing properly and therefore, they use regular detergent.
Facility Plan of Correction:
The facility will be looking for a chemical disinfectant supplier for use in their soiled linen process as they are unable to confirm water temps of at least 140 degrees.