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 10/13/2022. 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, record review and interview it was confirmed that the facility failed to update Service plans quarterly. Findings include but not limited to:
During an unannounced site visit on 10/13/2022, Compliance Specialist (CS) observed multiple binders of service plans available to staff. Service plans were available for each of the sampled residents, Resident #1-Resident #3 (R1-R3).
A review of R1-R3's service plans revealed that R1's was last updated and printed on 12/31/2021 and R2's on 6/29/2022.
During interview, Staff #2 (S2) stated that the facility had just hired and trained two new Resident Care Coordinators and are trying to catch up and get back on track.
These findings were reviewed with and acknowledged by Staff #1 and Staff #7 on 10/13/2022.
Facility Plan of Correction: Facility has just hired two new Resident Care Coordinators. All service plans to be updated and meetings held with residents and families within 30 days.
Based on observation and interview it was confirmed that facility failed to comply with masking requirements. Findings include but not limited to:
During an unannounced site visit on 10/13/2022, Compliance Specialist (CS) observed several staff members wearing masks inappropriately, with their mouth and nose exposed, within close proximity to other staff members and residents.
These findings were reviewed with and acknowledged by Staff #1 and Staff #7 on 10/13/22022.
Facility Plan of Correction: In-service on masking policy to occur by end of week.
Based on observation, interview and record review it was confirmed that the facility failed to keep an accurate MAR. Findings include, but not limited to:
During an unannounced site visit on 10/13/2022, Compliance Specialist (CS) heard Staff #4 (S4) say to Staff #3 (S3), "[Resident #2 (R2)] missed their big orange pill. I just found it."
CS observed pill in a cup on a dining table at approximately 0910.
A review of R2's Medication Administration Record (MAR) indicated this medication was given at 0705.
During interview, Staff #3 reported that they took the pill upstairs to resident between 0900 and 0930 and observed him take it at this point.
These findings were reviewed with and acknowledged by Staff #1 and Staff #7 on 10/13/2022.
Based on observation, interview and record review it was confirmed that the facility failed to visually observe residents take medications. Findings include but not limited to:
During an unannounced site visit on 10/13/2022, Compliance Specialist (CS) heard Staff #4 (S4) say to Staff #3 (S3), "[Resident #2 (R2)] missed their big orange pill. I just found it."
CS observed pill in a cup on a dining table.
During interview S3 stated that R2's wife will take and give meds as R2 is very confused.
A review of R2's service plan printed on 10/11/2022 indicated that staff are to dispense R2's medications 1x daily. A review of facility's "leave order" board does not include R2.
These findings were reviewed with and acknowledged by Staff #1 and Staff #7 on 10/13/2022.
Facility Plan of Correction: In-service to occur to medication administration policy and need to observe resident take medications by end of week.
Based on interview and record review it was confirmed that the facility failed to ensure hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.
During an unannounced site visit on 10/13/2022, Compliance Specialist (CS) took temperature in Resident #4 (R4's) bathroom sink which was 108 degrees.
A review of facility's Water Temp documentation dated 10/7/2022 revealed multiple temperatures outside of the acceptable range.
During interview Staff #6 reported that a plumbing company has been out to the facility and believes that cold water is entering the system at an unknown origin. S6 is aware of the problem and is in the process of ordering shower cartridges to help.
These findings were reviewed with and acknowledged by Staff #1 and Staff #7 on 10/13/2022.
Facility Plan of Correction: Interim Admin will approve purchase of shower cartridges today for maintenance director to order.