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 8/23/2022.  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, observation and record review, it was confirmed that the facility failed to provide general housekeeping services. Findings include:

On 08/23/22, Compliance Specialist (CS) observed Resident #1s (R1) apartment and bathroom and found the floor had debris and stains on the carpets. Bathroom appeared to be clean aside from the sink having a small ring of yellow around the drain.

In review of R1s service plan and facility ' s Uniform Disclosure Statement (UDS), R1 should be getting weekly housekeeping done. CS requested the housekeeping schedule and documentation of completed housekeeping duties, however, the facility does not have a schedule at this time and does not have a system in place to audit/ensure the cleaning is being completed via documentation.

The above information was shared with Staff #1.

Interviews with Staff #1 on 08/23/22 stated that residents get their apartments cleaned weekly from housekeeping and the care staff empty trash and do spot cleaning daily. Staff # 2-3 stated that they don ' t have a schedule on paper that the housekeeper keeps track of, and documents completed tasks on. They just had a discussion this morning about getting one created. Staff # 2 stated that they clean the rooms Monday-Thursday and clean common areas on Fridays. R1s cleaning day is on Wednesdays.

On 08/16/22, Witness #1 reported that the facility is not cleaning the resident's room.

Plan of Correction:

Facility is creating a weekly Housekeeping schedule and a checklist for the housekeeper to document when they complete their tasks. Supervisor will review these completed sheets to ensure that they are getting done. They are working on getting the carpet removed from the resident's room.

Based on interview and record review, it was confirmed that the facility failed to provide assistance with oral care. Findings include:

Reviewed Resident #1s service plan, TSPs, progress notes, and flowsheets from Point Click Care (PCC) for August 2022. On PCC there are only 2 days documented under oral care completed. No documentation of refusals in the progress notes either. The facility is not documenting completed oral care, or not providing assistance as listed.

The above information was shared with Staff #1 on 08/23/22, who acknowledged the findings.

In separate interviews with Staff #1 and #4 on 08/23/22, they stated that staff are supposed to be documenting completed care or refusals in PCC, however, this is not always getting done. Staff #1 stated that R1 refuses oral care frequently and staff are supposed to make multiple attempts, including change of face if refusals continue. They are supposed to notify MT or RN so they can document and notify family to see if they can get them to do oral care.

Facility plan of correction:

Reminders to staff to document completed ADLs in PCC. This will be a topic at change of shift and meetings.

Based on interview and record review, it was confirmed that the facility failed to ensure adequate professional oversight of the medication and treatment administration system. Findings include:

Reviewed Resident #1s Medication Administration Records (MAR) and progress notes for August 2022. MAR lists a PRN medication to give as needed with no BM in 3 days, however, the facility is not tracking the resident ' s bowel movements. Unable to determine how the staff can tell when the resident hasn ' t had a bowel movement in 3 days if they are not tracking it.

The above information was shared with Staff #1 who acknowledged the findings.

In separate interviews on 08/23/22, Staff #1 and #4 stated that they are monitoring bowels on the MAR if there is a doctor ' s order. Resident #1 doesn ' t have an order for bowel monitoring. Staff #1 stated that normally they would just ask the resident if they had a bowel movement or needed it, however, this is a memory care.

Plan of correction:

The facility will add bowel monitoring to the MAR so they can track whether or not the resident needs the PRN medication.