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 03/01/2023. 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 the facility failed to provide personal and other laundry services. Findings include:
During separate interviews on 03/01/2023, Witness #1 (W1) and Resident #1 (R1) stated that housekeeping services have not been done in a while.
A review of Resident #1-3 (R1, R2, and R3) service plan, resident council notes for 02/21/2023, and the housekeeping checkoff binder for February 2023. The housekeeping binder showed that housekeeping had only been completed 2 out of the 4 weeks in February for all residents. The individual check off sheet for R2 showed that their bed sheets had not been washed all month. The review of their service plans stated all 3 residents are to received weekly housekeeping services.
On 03/01/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: The facility has hired a new housekeeper and will do training on housekeeping and completing housekeeping sheets.
Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include:
During separate interviews on 03/01/2023, Staff #1-4 (S1, S2, S3 and S4) stated that their current staffing levels are 1 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift.
During an unannounced site visit on 03/01/2023, Compliance Specialist (CS) observed 1 MT and 2 CG working.
A record review of the posted staffing plan, staff schedule for February 2023, resident roster, Resident #1-3 (R1, R2 and R3) service plans, progress notes, and the breakdown of their care on the facility ' s ABST. The exported data in the ABST showed 40 of the 49 residents entered in the tool to not have been evaluated quarterly with last updated dates ranging from 07/08/2022-12/18/2022. Matching the roster with the ABST showed that Residents #3-6 (R3, R4, R5 and R6) had not been entered into their tool. R3 moved into the facility on 02/15/2023, R4 moved in on 02/04/2023, and R5 and R6 moved in on 02/23/2023.
On 03/01/2023, these findings were reviewed and acknowledged by S1.
Based on interview, observation, and record review it was confirmed the facility failed to keep clean all interior and exterior materials and surfaces. Findings include:
During separate interviews on 03/01/2023, Witness #1 (W1) and Resident #1 (R1) stated that housekeeping services have not been done in a while. Staff #1 and 4 (S1 and S4) stated that Resident #3 (R3) is a newer resident and the belongings stacked in the hallway by their room belonged to R3.
During an unannounced site visit on 03/01/2023, Compliance Specialist (CS) observed many boxes of belongings stacked in a hallway.
A review of Resident #1-3 (R1, R2, and R3) service plan, resident council notes for 02/21/2023, and the housekeeping checkoff binder for February 2023. The housekeeping binder showed that housekeeping had only been completed 2 out of the 4 weeks in February for all residents. The individual check off sheet for R2 showed that their bed sheets had not been washed all month. The review of their service plans stated all 3 residents are to received weekly housekeeping services. R3 service plan showed R3 moved into the facility on 02/15/2023.
On 03/01/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: The facility has hired a new housekeeper and will do training on housekeeping and completing housekeeping sheets. S4 stated that they will call R3 ' s power of attorney to remove the belongings from the hallway.