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 09/08/2022. 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 observation, interview and record review it was confirmed that the facility failed to assist the resident in performing all activities of daily living, on a 24-hour basis with toileting assistance. Findings include but not limited to:
During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) heard Resident #4 (R4) screaming from behind a closed door in their room. CS was unable to locate a staff member for some time. CS checked on resident to verify safety and resident was yelling and requesting a brief change stating that they were messy and wanted to get up. CS found Staff #5 (S5) and requested assistance for resident.
During separate interviews, Staff #4 (S4) and S5 stated that staff are very busy and do not have time to help with hygiene, showers, or toileting as much as residents need. Neither could say if R4 had assistance with brushing their teeth.
A review of R4's service plan dated 08/12/2022 revealed resident requires physical assitance with grooming/personal hygiene.
A review of Resident #1 (R1's) shower sheets revealed that resident did not receive a shower between 08/11/2022 and 08/22/2022.
A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers and 1 Med Aid for a total of 24 hours of care on day shift.
These findings were reviewed with and acknowledged by Staff #1-Staff #3 (S1-S3) on 09/08/2022 who were in agreement.
Facility Plan of Correction: Facility continue attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.
Based on record review and interview it was confirmed that the facility failed to ensure the implementation of services. Findings include but not limited to:
A review of Resident #1 (R1)'s service plan dated 08/12/2022 revealed that R1 is to be weighed every Monday. Compliance Specialist requested documentation of weights from Staff #1-Staff #3 (S1-S3) who were unable to produce these records.
During interview, S1-S3 indicated that the weights had not been entered.
Facility Plan of Correction: Facility to resume daily standup meeting which has not occurred in several weeks. Clinical meeting to occur immediately following standup. MAR Audit to occur daily, verify weight put into vitals each Monday.
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:
A review of Resident #2's MAR, progress notes and narcotic log for September 2022 revealed that resident missed a dose of a psychotropic medication on 09/02/2022 and that no exceptions or refusals were documented.
These findings were reviewed with and acknowledged by Staff #1-Staff #3 on 09/08/2022 who were in agreement.
Facility Plan of Correction: Inservice to occur on documenting refusals and missed-medications on 09/09/2022. Administrative team to resume clinical meeting on a daily basis and conduct MAR/charting audits.
Based on record review and interview it was confirmed that the facility failed to keep an accurate MAR. Findings include but not limited to:
A review of Resident #2 (R2)'s MAR for September 2022 revealed that resident missed multiple doses of a medication on 09/01/2022 and 09/02/2022 however the narcotic log revealed that those doses were given.
These findings were reviewed with and acknowledged by Staff #1-Staff #3 on 09/08/2022 who stated that the staff member likely signed them out from the narcotic book and forgot to document they were given on paper MAR.
Facility Plan of Correction: Inservice to occur on documenting refusals and missed-medications on 09/09/2022.
Based on record review and interview it was confirmed that the facility failed to offer non-pharmacological interventions prior to administration of PRN psychotropic medications. Findings include but not limited to:
A review of Resident #2 (R2) MAR for August and September 2022 revealed that R2 is utilizing PRN psychotropic medications for which there are no interventions in place.
These findings were reviewed with and acknowledged by Staff #1-Staff #3 on 09/08/2022 who were in agreement.
Facility Plan of Correction: RN to add interventions by end of day 09/08/2022. PRN psychotropic audit to occur by end of the following week.
Based on observation, interview and record review it was confirmed that the facility failed to assist the resident in performing all activities of daily living, on a 24-hour basis with toileting assistance. Findings include but not limited to:
During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) heard Resident #4 (R4) screaming from behind a closed door in their room. CS was unable to locate a staff member for some time. CS checked on resident to verify safety and resident was yelling and requesting a brief change stating that they were messy and wanted to get up. CS found Staff #5 (S5) and requested assistance for resident.
During separate interviews, Staff #4 (S4) and S5 stated that staff are very busy and do not have time to help with hygiene, showers, or toileting as much as residents need. Neither could say if R4 had assistance with brushing their teeth.
A review of R4's service plan dated 08/12/2022 revealed resident needs physical assistance with grooming/personal hygiene.
A review of Resident #1 (R1's) shower sheets revealed that resident did not receive a shower between 08/11/2022 and 08/22/2022.
A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers and 1 Med Aid for a total of 24 hours of care on day shift.
These findings were reviewed with and acknowledged by Staff #1-Staff #3 (S1-S3) on 09/08/2022 who were in agreement.
Facility Plan of Correction: Facility continue attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.
Based on record review, observation and interview it was confirmed that the facility failed to adopt and implement an ABST.
Findings include but not limited to:
A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers (CGs) and 1 Med Aid (MA) for a total of 24 hours of care on day shift.
During an unannounced site visit on 09/08/2022, Compliance Specialist (CS) observed two caregivers and one MA working during the day shift.
These findings were reviewed with Staff #1-Staff #3 on 09/08/2022 who were in agreement.
Facility Plan of Correction: Facility continue attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.
Based on observation and interview it was confirmed that the facility failed to keep all equipment in good repair. Findings include but not limited to:
During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) observed the facility scale in an activity room, dismantled and tucked into a corner.
Staff #1 and Staff #2 were unable to make the scale work at that time and were in agreement that scale was not working.
Facility Plan of Correction: Scale was fixed prior to exit on 09/08/2022.