Print Inspection: 0F09

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 01/24/2023.  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 have their staffing plan posted. Findings include but not limited to:

During an unannounced site visit on 1/24/2023, Compliance Specialist (CS) was unable to locate the facility's posted staffing plan.

During interview, Staff #3 (S3) stated that the posted staffing plan went missing and they currently don't have one.

Plan of correction: Executive Director (ED) had their Business Office Manager (BOM) order a board and stand on 1/24/2023 to display their posted staffing plan and manager on duty information. Facilty to post a word document with this information by end of day 1/25/2023.

Based on interview and record review it was confirmed that the facility failed to promptly investigate all reports of abuse and suspected abuse. Findings include but not limited to:

During an unannounced site visit on 1/24/2023, Compliance Specialist  (CS) interviewed Staff #2 (S2) who reported an incident on 1/20/2023 when only one medication technician (MT) was working in the morning until a second MT arrived at 0845. S2 stated that R1 received their morning medications late because of this and that afternoon medications were held because the morning medications were late. S2 stated that no incident report was completed for this.

During separate interviews Staff #6 and #7 stated:

*R1 was moved from one side of building on 1/19/2023 but that all medications and treatments had not been moved to the appropriate cart.

*The Electronic Medication Administration Report (EMAR) was not reflective of the move on the morning of 1/20/2023.

*Only R1's morphine was moved to the other medication cart.

*S6 was working as the only MT until S7 arrived at 0845.

*S6 popped and prepared R1's medications.

*At some point during the day R1 was removed from S6's EMAR.

*S7 did not give the medications that S6 prepared for R1 until later in the morning, but was unsure of the time.

*Afternoon medications were held because the morning medications were late.

A review of Resident #1 (R1)'s Medication Administration Report (MAR) and progress notes for January 2023 revealed that R1 missed afternoon medications due to receiving morning medications late.

These findings were reviewed with Staff #3 on 1/24/2023 who confirmed that there was no incident report or investigation and that this incident was not reported to Adult Protective Services.

Plan of Correction: CS emailed DHS's Abuse Reporting and Investigation guide to Executive Director (ED). ED to in-service staff on facility' s incident report policy and abuse and neglect reporting policy beginning 1/24/2023. Incident reports and investigations to be reviewed in standup meeting daily with all pertinent staff.

Based on interview and record review it was confirmed that the facility failed  to assist resident with toileting and bowel and bladder management. Findings include but not limited to:

During an unannounced site visit on 1/25/2023, Compliance Specialist (CS) reviewed Resident #2 (R2)'s most recent service plan dated 11/17/2021 which revealed R2 needed full assistance with toileting needs and that staff were to toilet R2 up to four times per shift using a bedside commode and perform peri care after toileting. R2's progress notes for May 2022 revealed five occassions when resident was noted to have done their own peri care, was upset about not getting cleaned after a large bowel momement, was upset that staff did not respond to their call light, did not get them cleaned up, and were unable to help her fast enough.

During interview Staff #3 stated that staff are to document completed tasks on task sheets but that facility had four different Resident Care Coordinators recently so task sheets were not available for that time.

These findings were reviewed with S3 on 1/24/2023 who was in agreement.

Plan of Correction: CS emailed Acuity-Based Staffing Tool (ABST) resources to Executive Director (ED). ED will have all residents entered into ABST by 2/3/23. Resident Care Coordinator and nurse to begin auditing all service plans tomorrow 1/25/23. Facility will have all service plans updated  by 2/3/23. ED to verify task sheets are in place for staff and begin reviewing in standup meeting daily.

Based on record review and interview it was confirm that the facility failed to complete quarterly service plans. Findings include but not limited to:

During an unannounced site visit on 1/24/2023, Compliance Specialist requested the most recent service plan for Resident #2 (R2) which was dated 11/17/2021. The most recent service plan for Resident #1 (R1), taken from the facility's service planning binder was dated 9/1/2022. A review of Resident #3 (R3's) latest service plan, recevied by email on 1/25/2023 was dated 3/6/2022.

During interview, Staff #3 (S3) stated that R2 moved out of the facility in August 2022. S2 stated that they are not surprised that their service plans are out of date as the facility has had four to five Resident Care Coordinators (RCC) since they started and it is their responsibility to manage service planning meetings.

Plan of Correction: RCC and nurse to begin auditing all service plans 1/25/23. Facility will have all service plans updated  by 2/3/23.

Based on observation, interview and record review it was confirmed that the facility failed to provide care as listed in the service plan. Findings include but not limited to:

During an unannounced site visit on 1/24/2023, Compliance Specialist (CS) observed Staff # 4 and Staff #5 (S4-S5) enter Resident #1 (R1)'s room to provide incontinence care.

During interview, S4 and S5 stated that resident is totally dependent, requiring two person extensive assistance for brief changes as R1 was actively passing.

A review of R1's service plan dated 9/1/2022 indicated that staff are to assist R1 to the restroom 3-4 times per shift. No Interim Service Plans (ISP)s related to this need were available.

These findings were reviewed with Staff #3 on 1/24/2023.

Plan of correction: Resident Care Coordinator and nurse to begin auditing all service plans tomorrow 1/25/23.Facility will have all service plans updated  by 2/3/2023. Executive Director to verify task sheets are in place for staff and begin reviewing in standup meeting daily.

During an unannounced site visit on 1/24/2023, Compliance Specialist  (CS) interviewed Staff #2 (S2) who reported an incident on 1/20/2023 when only one medication technician (MT) was working in the morning until a second MT arrived at 0845. S2 stated that R1 received their morning medications late because of this and that afternoon medications were held because the morning medications were late.

During separate interviews Staff #6 and #7 stated:

*R1 was moved from one side of building on 1/19/2023 but that all medications and treatments had not been moved to the appropriate cart.

*The Electronic Medication Administration Report (EMAR) was not reflective of the move on the morning of 1/20/2023.

*Only R1's morphine was moved to the other medication cart.

*S6 was working as the only MT until S7 arrived at 0845.

*S6 popped and prepared R1's medications.

*At some point during the day R1 was removed from S6's EMAR.

*S7 did not give the medications that S6 prepared for R1 until later in the morning, but was unsure of the time.

*Afternoon medications were held because the morning medications were late.

A review of Resident #1 (R1)'s Medication Administration Report (MAR) and progress notes for January 2023 revealed that R1 missed afternoon medications due to receiving morning medications late. Similar instances also occurred on 1/2/2023 and 1/22/2023.

These findings were reviewed with Staff #3 and Staff #8 on 1/25/2023 by phone.

Plan of Correction: Medication Technician training will be occurring today to review medication rights and training for charting within their MAR system.

Based on 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 1/24/2023, Compliance Specialist  (CS) interviewed Staff #2 (S2) who reported an incident on 1/20/2023 when only one medication technician (MT) was working in the morning until a second MT arrived at 0845. S2 stated that R1 received their morning medications late because of this and that afternoon medications were held because the morning medications were late.

During separate interviews Staff #6 and #7 stated:

*R1 was moved from one side of building on 1/19/2023 but that all medications and treatments had not been moved to the appropriate cart.

*The Electronic Medication Administration Report (EMAR) was not reflective of the move on the morning of 1/20/2023.

*Only R1's morphine was moved to the other medication cart.

*S6 was working as the only MT until S7 arrived at 0845.

*S6 popped and prepared R1's medications.

*At some point during the day R1 was removed from S6's EMAR.

*S7 did not give the medications that S6 prepared for R1 until later in the morning, but was unsure of the time.

*Afternoon medications were held because the morning medications were late.

A review of Resident #1 (R1)'s MAR for January 2023 stated "MEDS GIVEN ON TIME-LATE ENTRY' on 1/20/2023 while a progress note on that date revealed that afternoon meds were missed due to morning meds being late.

These findings were reviewed with Staff #3 and Staff #8 by phone on 1/25/2023.

Plan of Correction: Medication Technician training will be occurring today to review medication rights and training for charting within their MAR system.

Based on observation, interview and record review it was confirmed that the facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident. Findings include but not limited to:

During an unannounced site visit on 1/24/2023 Compliance Specialist observed four caregivers (CG) and two medication technicians (MT) working on the floor.

During separate interviews Staff #3 - Staff #4 (S3-S4), Staff #6-#7 (S6-S8) stated:

*The facility needs five CGs and two MTs on day and swing shift and two CG and 1 MT on noc.

*There is not enough staff on NOC shift.

*When we come in in the morning residents have not been changed all night.

*Sometimes I am the only one working.

*The facility is not using an Acuity-Based Staffing Tool (ABST).

*Staffing levels are determined by the task sheets and feedback from staff.

*We have not used task sheets since October.

A review of the facility's time cards for 1/2/2023, 1/20/2023 and 1/22/2023  revealed that the facility only had three people working on swing shift on 1/2/2023,  five people working on day shift on 1/20/2023, one person working on noc shift on 1/20/2023, three people working on swing shift on 1/22/2023 and two people working on noc shift on 1/22/2023.

A review of the Resident #1 (R1)'s Medication Administration Record (MAR) and progress notes for January 2023 revealed occasions on 1/2/2023, 1/20/2023 and 1/22/2023 when medications were late and medications were not given due to the previous dose being given late.

A review Resident #2 (R2)'s most recent service plan dated 11/17/2021 revealed R2 needed full assistance with toileting needs and that staff were to toilet R2 up to four times per shift using a bedside commode and perform peri care after toileting. R2's progress notes for May 2022 revealed five occasions when resident was noted to have done their own peri care, was upset about not getting cleaned after a large bowel moment, was upset that staff did not respond to their call light, did not get them cleaned up, and were unable to help fast enough.

The facility did not have their staffing plan posted. No ABST records were available for review.

These findings were reviewed with S3 on 1/24/2023.

Plan of Correction: Compliance Specialist emailed ABST resources to Executive Director (ED) at their request. ED will have all residents entered into ABST by 2/3/23.  ED to verify task sheets are in place for staff and begin reviewing in standup meeting daily.

Based on observation, interview and record review it was confirmed that the facility failed to fully implement an Acuity Based Staffing Tool. Findings include but not limited to:

During an unannounced site visit on 1/24/2023 Compliance Specialist (CS)observed four caregivers (CG) and two medication technicians (MT) working on the floor.

During separate interviews Staff #3 - Staff #4 (S3-S4), Staff #6-#8 (S6-S8) stated:

*The facility needs five CGs and two MTs on day and swing shift and two CG and 1 MT on noc.

*There is not enough staff on NOC shift.

*When we come in in the morning residents have not been changed all night.

*Sometimes I am the only one working.

*The facility is not using an Acuity-Based Staffing Tool (ABST).

*Staffing levels are determined by the task sheets and feedback from staff.

*We have not used task sheets since October.

A review of the facility's time cards for 1/2/2023, 1/20/2023 and 1/22/2023  revealed that the facility only had three people working on swing shift on 1/2/2023,  five people working on day shift on 1/20/2023, one person working on noc shift on 1/20/2023, three people working on swing shift on 1/22/2023 and two people working on noc shift on 1/22/2023.

The facility did not have their staffing plan posted. No ABST records were available for review.

These findings were reviewed with S3 and S8 by phone on 1/25/2023.

Plan of Correction: Compliance Specialist emailed ABST resources to Executive Director (ED). ED will have all residents entered into ABST by 2/3/23.