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 observation and interview, it was confirmed that the facility failed to ensure that each residential care and assisted living facility is licensed, maintained, and operated as a separate and distinct facility. Findings include but not limited to:
During an unannounced site visit on 1/30/2023, Compliance Specialist (CS) observed Staff #1 (S1) receive a phone call from an Assisted Living Facility (ALF) staff member requesting assistance with a fall that occurred in the ALF. S1 left the memory care unit to assist in the ALF, leaving only Staff #2 (S2) on the floor in the memory care.
During interview, S1 stated that the ALF needed assistance with the fall. They also stated that in December 2022, they worked as a medication technician in the ALF and the memory care during the same shift.
These findings were reviewed with S4 and S6 on 1/30/2023.
Plan of Correction: Facility to review and audit the ABST for accuracy. They will provide education to staff on separate facilities and in-service on proper channels for communication in the event of an emergency.
Based on observation, record review and interview, it was confirmed that the facility failed to employ a full-time administrator scheduled to be on-site in the facility at least 40 hours per week. Findings include but not limited to:
During an unannounced site visit on 1/30/2023, Compliance Specialist observed Staff #4 (S4) onsite who was acting as administrator.
A review of the Oregon Health Licensing Office records revealed that S4 is not a licensed administrator.
During interview, Staff #1- #2 (S1-S2), Staff #4 (S4) and Staff #6 (S6) stated:
*S4 is the new administrator.
*S6 was the administrator for both the memory care and the ALF
*S4 is working on getting their license.
*S4 has support from ALF ED and corporate Administrator.
*Their regional director currently holds the administrator license for the building, but they are not here full time.
These findings were reviewed with S4 and S6 on 1/30/2023.
Plan of Correction: S4 is in training and has completed most of the necessary coursework. They will be scheduling their test as soon as possible for licensing. Current Administrator in training has support from ALF ED as well as corporate administrator.
Based on observation, interview and record review, it was confirmed that the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:
During an unannounced site visit on 1/30/2023, Compliance Specialist (CS) observed Staff #1- Staff #2 (S1-S2) working in the memory care unit for the noc shift. At around 0510 S1 was called by an Assisted Living Facility (ALF) staff member to help with a fall that occurred. S1 left to assist ALF staff, leaving only S2 on the memory care unit.
During interview, S1, S2 and Staff #3 (S3) stated:
*There are eight residents that require two person assist for transfers.
*They would be unable to evacuate the building in the event of a fire or emergency.
*There was an occasion in December 2022 when there was only one Medication Technician (MT) for the whole building and that MT worked both the ALF and the Memory Care on the same shift.
*Family members get their food handler cards to help feed residents.
*There are five residents who require 1:1 assistance with eating.
*It is common on Sundays for there to only be two caregivers (CGs) and one medication technician (MT) on swing shift.
A review of the facility's posted staffing plan revealed the need for:
Day: three CG and two MTs
Swing: three CG and one MT
Noc: one CG and one MT
These findings were reviewed with Staff #4 and Staff #6 on 1/30/2023.
Plan of Correction: Technical assistance was provided by CS on how to input data into ABST for residents who require two person assistance. Facility will audit and update their ABST with this information. Facility is implementing an on-call phone number to help with call-outs and staffing. They are actively hiring staff.
Based on observation, interview and record review, it was confirmed that the facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:
During an unannounced site visit on 1/30/2023, Compliance Specialist observed two staff members, Staff #1- Staff #2 (S1-S2) working in the memory care unit for the noc shift. At around 0510 S1 was called by an Assisted Living Facility (ALF) staff member to help with a fall that occurred. S1 left to assist ALF staff, leaving only S2 on the memory care unit.
During separate interviews, S1, S2 and Staff #3 (S3) stated:
*There are eight residents that require two person assistance for transfers.
*They would be unable to evacuate the building in the event of a fire or emergency.
*There was an occasion in December 2022 when there was only one Medication Technician (MT) for the whole building and that MT worked both the ALF and the Memory Care on the same shift.
*Family members get their food handler cards to help feed residents.
*There are five residents who require 1:1 assistance with eating.
*It is common on Sundays for there to only be two caregivers (CGs) and one medication technician (MT) on swing shift.
A review of the facility's posted staffing plan revealed the need for:
Day: three CG and two MTs
Swing: three CG and one MT
Noc: one CG and one MT
A review of the facility's ABST revealed that that 22 of the resident's ABST profiles had not been reviewed or updated since June 2022. Resident #3 (R3)'s profile had not been updated since 10/28/2022. A review of Resident #3 (R3)'s progress notes revealed that they returned from the hospital on 1/20/2023 and newly required the use of a hoyer lift for all transfers. The need for two person assistance with the hoyer was not reflected in the ABST. A review of Resident #4 (R4)'s care plan revealed he/she required two person assistance for transfers, which was not reflected in the ABST and had not been reviewed or updated since 06/15/2022.
During interview, Staff #4 and Staff #6 were unable to explain how two staff members could safely evacuate residents from the facility. They were also unable to demonstrate how the need for two people with transfers was accounted for in the ABST.
These findings were reviewed with S4 and S6 on 1/30/2023.
Plan of Correction: Technical assistance was provided by Compliance Specialist on how to input data into ABST for residents who require two person assistance. Facility will audit and update their ABST with this information. Facility is implementing an on-call phone number to help with call-outs and staffing. They are actively hiring staff.